Got Prostate?

When you hear the devastating news that you have cancer of the prostate, a small gland the size of a plum found in men below the bladder, it can be difficult to decide which of many treatment options are right for you. But the choice is vital: The prostate is responsible for making 10–30 percent of a man’s semen and is involved in sexual performance and urination. When it malfunctions, it can cause a variety of health problems, from infection to severe back pain. The worst is prostate cancer.

Dealing with “prostate” is often the first significant experience many black men have with the medical system. No wonder our decisions on how to handle it are often grounded in fear or mistrust and tend to be made with little or no information. A 2003 study by researchers at Oxford University shows that a man diagnosed with cancer is unlikely to research his options and more likely to do as radio host and motivational speaker Les Brown admits he did (see page 29): unquestioningly follow his doctor’s advice—because, as Brown says, the patient mistakenly thinks the “doctor knows best.”

Each treatment—from hormone therapy to radiation to surgery/outright removal—has a different set of benefits and risks. Yet because men panic and do what the diagnosing doctor says, many will think of questions to ask only after they’ve already undergone a treatment and are dealing with its side effects. By then it is usually too late to pursue a different strategy.

Men also act out of another fear: impotence. They may do whatever the doctor says because they fear that if they don’t, the condition will keep them from getting an erection. But prostate disease doesn’t cause impotence—the treatments do. They can damage the veins or nerve pathways to the penis, making it difficult or impossible for a man to get it up (for each treatment’s impotence risk, see page 31).

After their initial diagnosis, most men actually have plenty of time to consider treatment options. Unlike many other cancers, prostate cancer generally progresses relatively slowly. Michael Barry, MD, chief of general medicine at Massachusetts General Hospital, found in 2004 that more men die with prostate cancer than of it because some tumors are small and grow very slowly, never endangering the man’s life. Grace Lu-Yao, PhD, of Robert Wood Johnson Medical School, conducted a study that found that the great majority of prostate patients are going to die of something else, and that a large number do well with no initial treatment and indeed with no treatment long term. In fact, according to the National Cancer Institute, almost every man diagnosed with lung cancer dies of it, but only 226 out of every 100,000 men over the age of 65 with prostate cancer die of prostate cancer. While options will vary according to your circumstances, you should follow this three-step approach to obtaining appropriate treatment as soon as your screening test comes back positive.

Step 1. Assess the Situation
The process of being diagnosed with prostate cancer differs for every man. So when any screening test comes back positive, ask lots of questions. Among the most important: What additional tests or procedures do I need to determine definitively whether I have cancer? You may need as many as three tests, generally in this order: a digital rectal exam (DRE), a prostate-specific antigen (PSA) blood test and a biopsy, where a sample of tissue is removed and examined. Usually these are performed by your primary-care physician or a urologist, who specializes in problems of the urinary and reproductive systems. Sometimes test results are inconclusive and need repeating.

Always take a family member or friend when you get the results of a biopsy—the information can be overwhelming. That person should be willing to be your ongoing “treatment partner,” able to act as your second set of eyes and ears, ask questions, review information with you and accompany you on subsequent doctor
visits. Any time you must attend an appointment alone, always take a notebook or tape recorder.

A biopsy that’s positive for cancer returns “scored” and “staged,” assessments of the seriousness of the condition.

The cancer “score,” on what is known as the Gleason Scale, reflects how likely it will grow quickly and spread:
2–4 mildly aggressive
5–7 moderately aggressive
8–10 very aggressive

The cancer is assigned to one of four “stages” based on how much is present and how far it has spread:
Stage I: Early cancer that is too small to feel when the doctor examines your prostate.
Stage II: The doctor can feel the tumor, but it is contained inside your prostate gland.
Stage III: The cancer has spread to nearby tissues.
Stage IV: The cancer has spread to the lymph nodes, bones, lungs or other areas in the body.

Step 2: Get a Second Opinion
Ask your primary physician, urologist or cancer specialist (in the event you’re sent to one immediately) how long you have to make your decisions. Getting a second opinion from another doctor is critical for obtaining the best care. Don’t worry about upsetting your initial doctor: Second opinions are a crucial and expected part of the medical process. Doctors can interpret data differently, tend to be most knowledgeable about the treatments they’ve been trained to perform, and may even appreciate the perspective additional opinions bring. If you have been told your diagnosis is serious, time may be an issue and you may need to make a quicker decision. Seeking a second opinion after a prostate cancer diagnosis can sometimes mean the difference between radical surgery and what is called “watchful waiting”: aggressively monitoring your condition before you settle on a treatment option.

In some cases, doctors disagree on whether cancer is even present. If this happens, have each doctor explain how they reached their conclusions. Also ask them to confer with each other to see if they can agree on one approach. If you are worried that the doctors might be cronies, schedule a consultation with a medical oncologist, a cancer treatment specialist who does not perform radiation or surgery but can oversee the treatment given by other specialists.

Step 3: Pick a Treatment Strategy
Prostate cancer treatment is not “one size fits all.” You should choose the best treatment for you with the help of your family and one or more doctors. These may include: a urologist; a medical oncologist, a cancer specialist who administers chemotherapy and hormone therapy, and who may coordinate treatment given by other doctors; a surgical oncologist, who performs surgeries to remove cancerous growths or tumors; and a radiation oncologist, who treats cancer with radiation. The doctors should always consider the grade and stage of your cancer, your age and general health, and your values and feelings about the potential benefits and harm of each option. Here are your alternatives, from most to least invasive. For more treatment-decision tools, contact the American Cancer Society (cancer.org or 800.ACS.1234).

SURGERY
The surgical removal of the entire prostate gland is called a radical prostatectomy, where an incision is made either below the navel or below your rectum. Evidence shows that men who opt for this surgery may have a better chance for long-term survival than those who choose other options. Since surgery has the longest track record for keeping men cancer-free, it remains the treatment of choice of most men. Of course, the more of the cancer doctors can get out of your body, the greater your chances are of survival. Success also depends on the age of the patient and factors like whether he received hormone therapy prior to surgery or additional therapies such as radiation therapy either prior to or after the surgery.

Unfortunately, because surgery can damage nerves involved in erection, it also has the greatest risk of impotence and problems with bowel function. After surgery, it can take two years or longer to recover, although some men recover sooner. Two newer surgical methods offer greater precision to minimize nerve damage:

Laparoscopic surgery allows the surgeon to make several tiny incisions, the size of keyholes, to remove the prostate.

Robotic procedures let surgeons operate with the help of mechanical “arms” while they watch on a video screen.

Advantages to surgical options:
•    All cancer cells growing in the prostate are removed.
•    If the cancer hasn’t spread beyond your prostate, you have a 90 percent chance of living at least 10 years afterward.
Disadvantages:
•    As with any major surgery, there is a chance of complications such as infection, pneumonia, blood clots and other problems, as well as the possibility of death.
•    Impotence due to nerve damage is common.
•    You may have stress incontinence, which means you can’t hold your urine flow when there’s increased bladder pressure—when you sneeze, cough, laugh or lift, or even simply when standing or walking.
•    Even without a prostate, cancer can appear in other parts of your body. It is impossible to know if any of the cancer cells spread outside of the prostate before it was removed.

RADIATION
Radiation therapy uses high doses of radiation to treat cancer. It is most effective when prostate cancer has not spread beyond the prostate gland or has spread only to nearby tissues, or as an option to help shrink the tumor or to reduce symptoms when a cure is not possible.

Radiation is also used for men who cannot have surgery because of their age, health or personal choice. Five to eight years after treatment, survival rates for radiation therapy are equal to those of surgery when treatment is for cancer that has not spread beyond the prostate. There are two types of radiation therapy:

External beam radiation: The radiation is focused on the prostate gland from outside the body—like getting an X-ray, but for a longer time. Treatments are generally given five days a week for about six to eight weeks on an outpatient basis. Each treatment appointment takes about 15 minutes, with most of this time for preparation.
Seed implants: This treatment, called brachytherapy, involves placing radioactive seeds or pellets (about the size of a grain of rice) in or near the prostate tumor and leaving them there permanently. After several weeks or months, the radioactivity level of the implants eventually diminishes to nothing. The seeds then remain in the prostate, with no lasting effect.

Advantages:
•    Major surgery can often be avoided.
•    Rates of sexual problems such as erectile dysfunction (ED) and urinary problems are very low.
•    No hospital stay
•    No anesthesia risk
Disadvantages:
•    Impotence may develop up to two years later in some patients and can be a permanent side effect.
•    If the prostate cancer doesn’t respond, the cancer cannot be retreated with radiation.
•    Bowel function may not return to normal after treatment is complete.
•    Since nerves that help a man have an erection are right next to the prostate, radiation may damage them.

CRYOTHERAPY
The newest treatment for prostate cancer is cryotherapy. This strategy involves freezing and then thawing the tissues of the prostate gland, dehydrating and destroying the cells using a minimally invasive surgical procedure. Almost 98 percent of patients who are treated with cryotherapy are cancer-free after one year, and 95 percent are still alive at the five-year mark.

Advantages:
•    Freezing triggers antibodies that destroy cancer cells.
•    Effective when radiation fails
•    Can be used if you are not healthy enough for surgery
•    Little loss of blood from procedure

Disadvantages:
•    New treatment, so not a lot is known about long-term effectiveness
•    Few urologists are trained to perform it.
•    Not effective in late-stage prostate cancer
•    Temporary impotence

CHEMOTHERAPY
Chemotherapy is a drug treatment that is used to try to kill cancer cells or to stop them from spreading. This treatment is an option for men whose prostate cancer has spread (metastasized) to other parts of the body, or for those who have used hormone therapy (see below) to slow the growth of their cancer. Chemotherapy drugs are usually injected into the blood, after which they travel around the body, attacking cancer cells wherever they find them.

Advantages:
•    Reduces the odds of your cancer returning if taken after another treatment for prostate cancer, such as surgery or hormone therapy(see below)
•    Slows the spread of cancer
•    Can be used in combination with hormone therapy
•    Relieves pain if cancer has spread to bones
Disadvantages:
•    Weakens immune system and increases chance of infections
•    Often causes nausea and vomiting
•    Weight loss frequently occurs.
•    Tingling and loss of sensation in hands and feet

HORMONE THERAPY
Hormone therapy starves cancer cells by slowing or stopping the production of the male hormone testosterone, which is vital to the growth and function of a normal prostate, but which automatically feeds cancer cells because it cannot distinguish between them and healthy cells. A series of injections is given every three, four, six or 12 months. While hormone therapy causes prostate cancer to shrink in 85 to 90 percent of advanced prostate cancer patients, it does not cure the disease. In addition, the effects last only between 24 and 36 months.

Advantages:
•    Causes tumors to shrink
•    Slows the growth of cancer
•    Lowers PSA count
Disadvantages:
•    Decreased sex drive
•    Swelling or tenderness of the chest tissue
•    Constipation or diarrhea
•    No or decreased appetite

CLINICAL TRIAL
A clinical trial is a research study where you are given drugs or treatments not yet approved by the FDA for prostate cancer. These treatments are experimental and sometimes may involve you getting a placebo (sugar pill) and not the actual drug, so before signing up it is important to ask if you are receiving treatment or just being observed. Many clinical trials divide the patients in two groups, with one receiving the actual drug or treatment and the other receiving a sugar pill, in order to compare the results.

Advantages:
•    Access to leading doctors in the field of prostate cancer research
•    Possible benefit from drugs or treatments that are not available to other patients
Disadvantages:
•    You may receive a treatment that has no benefit.
•    Since your treatment is unapproved, you may experience unknown side effects.

COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM)
Many people are turning to natural herbs and supplements to treat their health problems, including prostate cancer. While ongoing National Institutes of Health research suggests that specific nutrients, such as Vitamin E, may ward off cancer, no CAM treatment has yet been proven to treat or cure prostate cancer. What’s more, it’s not always easy to tell which products may be unsafe, interact negatively with other medications or affect your overall cancer, so it’s best to talk with your doctor or naturopath before taking any dietary or herbal product. Keep in mind that supplements and herbs are not approved by the FDA for treatment of cancer.

Advantages:
•    May help alleviate the side effects of cancer treatments, such as nausea, pain and fatigue
Disadvantages:
•    They may interfere with how well other medicines you are taking work in your body.   

WATCHFUL WAITING
Many prostate cancers are small and grow slowly. If this is your diagnosis, it may not be necessary to treat your prostate cancer. In watchful waiting, you obtain no treatment, but you should see your doctor every three to six months for a PSA and digital rectal exam. If there continues to be no sign that the cancer is growing, you may continue to forgo treatment. The best candidates for watchful waiting are older men whose tumors are small and slow-growing, as indicated by low scoring and low stage, since most men with prostate cancer die of something else.

Advantages:
•    No recovery issues or complications found in other treatments
Disadvantages:
•    Prostate cancer can grow and spread outside the prostate before your next doctor’s visit.

For more information on these strategies, contact the National Cancer Institute (800.422.6237 or cancer.gov/cis).

WILL YOU STILL BE ABLE TO GET IT UP?
The risks of impotence vary according to the procedure; surgery and radiation pose the greatest threat. If you choose surgery, studies show that rates of impotence range from less than 15 percent to more than 80 percent, depending on your age and the experience of the surgeon. While radiation causes less impotence, surgery has better survival rates beyond 10 years.

Hormone therapy won’t cause impotence, but it may change your sexual desire by eliminating testosterone, a hormone that controls male sex drive. Most times this can be treated with medication for erectile dysfunction.

Chemotherapy might affect your ability to get and keep an erection, but this is usually temporary. You’ll usually regain your sexual function within a few weeks of ending treatment.

Success rates of such erectile dysfunction drugs as Viagra are higher in younger prostate patients and work better if you do not have a history of cigarette smoking, hypertension, high cholesterol and coronary artery disease. Also, don’t be surprised if you and your doctor have a different idea of what counts as an erection. As you make your way back to full sexual strength, talk to your urologist about your options for penile rehabilitation therapy. This involves an implant or a pump to help achieve an erection and is used in men who don’t respond to oral medication for impotence.

FINDING THE RIGHT DOCTOR
So you’ve been diagnosed with prostate cancer and decided on a form of treatment. What next?

1. Contact the National Cancer Institute (cancer.gov or 800.4CANCER) to learn their recommendations for the best cancer centers in your area.
2. Once you’ve found a center, call them or visit their website to find out which doctors specialize in your chosen prostate cancer treatment.
3. Ask how many of those treatments each doctor has performed. Remember, the more the better. According to a study published last August in the Journal of the National Cancer Institute, the more experienced the surgeon, the less likely the patient was to have a prostate cancer recurrence.
4. Once you’ve chosen a specialist, check with your health insurance company to find out if he/she is in your health care provider network. For more information, contact the American Cancer Society at cancer.org or 800.ACS.2345.

HOW I DID IT: LES BROWN
The speaker and radio host shares his journey with prostate cancer and treatment.

Eleven years ago, I was on top of the world: the leading motivational speaker on the planet and host of the No. 1 radio program in New York. In 1996, I challenged my African-American male listeners: I would get a PSA screening test for prostate cancer if they did. The media was full of stories about black men and prostate cancer, so it seemed a cool thing to do.

Little did I know that the life I’d be saving was my own.

My PSA result was 10.5 (normal is less than 4.0). After a biopsy, the doctor said I had cancer and my prostate should be removed right away if I wanted to live. I was stunned! That doctor scared me half to death. (It never occurred to me to seek a second opinion to see if his diagnosis was accurate. Instead, I jumped straight to finding the best treatments.)

My attorney’s husband, a Howard University cancer specialist, told me about another option to surgery: radiation treatment using seed implants in the prostate. It seemed like it would have the least effect on my sex life. I resumed working in a matter of days. Other than a little discomfort, I bounced right back. To my surprise and relief, I never had any problems with my sex life after the treatment.

A month or so later, tests showed I was cancer-free. The doctor reviewed my records with me, and I realized that after all I had gone through, there had never been a firm diagnosis of cancer. This was overwhelming. I couldn’t believe it. The word cancer is the most feared medical diagnosis for any man. I was shocked! I hadn’t known how to pursue the conversation or ask the right questions when I was diagnosed by my primary-care doctor. I hadn’t understood the importance of second opinions. I felt I had been a victim of racism.

Right away I decided to educate myself about prostate cancer. I talked to every medical doctor and holistic expert I could find. Now that I knew everything I should have known before I had the PSA test, I wanted to make sure that I eliminated the environment in my body that made me prone to cancer. The experts I spoke with helped me customize a plan that involved a healthy diet, herbal supplements and vitamins, stress management and regular exercise, which I still follow.

Now I know I should have had a health advocate (family member or friend) with me when I got my test and screening results. You know, when it’s your body they are talking about, you just cannot hear with a clear mind.

THE CELEBRITY TREATMENT
Prostate cancer affects men from all walks of life. Check out this list of famous black men and how they handled their treatment:

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