Magazine article Newsweek

Men's Health: Prostate Cancer's Difficult Choices: A Look at Six Different Treatment Options That Many Men Must Face

Magazine article Newsweek

Men's Health: Prostate Cancer's Difficult Choices: A Look at Six Different Treatment Options That Many Men Must Face

Article excerpt

Byline: Karen Springen and Jerry Adler

It is what God gave men instead of breasts: a complex piece of reproductive equipment whose usefulness declines over time, in proportion to its tendency to malfunction. The prostate, a walnut-size gland sitting athwart the urethra, in front of the rectum, produces fluid that propels and accompanies sperm on its epic voyage outside the body. As men age, it can become enlarged, sometimes to the size of a peach, interfering with urination and causing bladder or kidney problems; it is prone to develop tumors, which may spread to the bladder, lymph nodes or bones. Prostate cancer is the second most common form of cancer in men (after skin cancer) and the second most common cause of cancer death (after lung cancer). While it may progress so slowly that some patients live with it for years and end up dying of something else, once it spreads to the bones it is incurable and--like many cancers--can be excruciatingly painful. "Everybody talks about the painful last year of life for prostate cancer," says Peter Albertsen, a urologist at the University of Connecticut. "It is a horrendous death."

But it is a death that's on a steady decline. Deaths from prostate cancer are expected to fall below 29,000 this year, according to the American Cancer Society--down from 31,500 in 2001 and about --35,000 as recently as 1993. (Women's deaths from breast cancer, by comparison, over the same decade will go from 43,000 to a projected 39,800.) The prostate decrease is a tribute to better diagnosis and treatment; in comparison to lung cancer, for example, the risk factors for prostate cancer are mostly either unknown or unavoidable. Age is the main one; the incidence is one in 53 for men in their 40s and 50s, but one in seven for men 60 to 79. People with a family history of the disease are at higher risk, as are African-Americans (perhaps because darker skin produces less protective vitamin D in response to sunlight) and farmers (possibly the result of occupational exposure to herbicides). Some evidence suggests that obesity and a diet rich in animal fats may contribute to the disease, and lycopene, a substance found in tomatoes, may be protective--but it strikes plenty of lean, fit, health-conscious men as well. Vasectomies, bicycling and sex (or abstinence) don't seem to make much of a difference, one way or the other.

In diagnosis, the big breakthrough of the last 20 years was the development of a simple test for prostate specific antigen (PSA), a protein whose blood level reflects changes in the prostate. As a rule of thumb, PSA readings above 4 are cause for concern, although the cutoff varies by age; a reading higher than 2.5 may be suspicious for a man in his 40s, and many doctors believe the trend of successive measurements is more significant than the absolute value. (Complicating the picture, not all men with cancer have high PSA levels, and high readings often don't indicate cancer--leading some researchers to question the test's usefulness; page 64) If a high reading is confirmed on a second test, doctors typically order a biopsy. Cancer cells, if present, are rated on the Gleason scale from 1 to 10, with the higher numbers indicating a more aggressive and dangerous tumor.

It's then up to the man, and his doctor, to decide on a course of treatment--which can be among the most nerve-racking choices in modern medicine (as New Yorkers recall from the public agonizing of former mayor Rudolph Giuliani when his cancer was diagnosed in 2000). The range of treatments is wide, the side effects unpredictable and often unpleasant--and the stakes are, literally, life or death. In older men whose cancer is progressing slowly doing nothing may be the best solution. Bearing in mind that no one decision is right for everyone, NEWSWEEK spoke to six men who took six different approaches to their diseases, and are living now with the consequences. The alternatives were:

RADICAL PROSTATECTOMY: The removal of the prostate through conventional open surgery is the gold standard against which other treatments are measured. …

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