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                                                                                MEDICINE, Page 77

The Private Pain of Prostate Cancer


It is killing more and more older men. Will early screening
with blood tests make a difference?

By CHRISTINE GORMAN - With reporting by David Bjerklie/New York
and David S. Jackson/San Francisco


    If there is a single leading reason why middle-age men
dread going to the doctor, it is the prostate examination.
Routinely recommended for those 50 and over, the procedure calls
for a physician to insert a gloved finger into the rectum to
probe the chestnut-size prostate gland, which is near the
bladder and produces some of the fluids in semen. But however
uncomfortable and embarrassing the exam may be, it could be a
lifesaver. The rate of prostate cancer in the U.S. has been
steadily rising over the past several years. It strikes 1 in 11
American males and kills more than 30,000 annually. Prostate
cancer ranks second only to lung cancer as the most deadly
malignancy in men.

    No one knows why the disease is spreading. The aging of
the American population only partly explains the increase. No
one knows why the cancer develops less often in Asians than in
Americans or Europeans. Perhaps a low-fat diet plays a role in
prevention. No one knows why black Americans suffer and die from
prostate cancer more frequently than do white Americans.

    But doctors are hopeful that they can force the death rate
back down -- through earlier and better detection and
treatment. The effort begins this week and next, as the
Schering-Plough pharmaceutical company, based in New Jersey,
sponsors free prostate screenings all over the U.S. An estimated
half a million American men will allow themselves to be poked,
prodded and bled in hopes of being reassured of their good
health or of spotting trouble before it gets serious. In
addition to the rectal exam, men can undergo a new blood test
that measures levels of a protein called prostate-specific
antigen. If pres ent in large quantities, PSA may signal
malignancy. The goal is to detect cancer while it is still
confined to the prostate and therefore more likely to be
curable. Men can call the American Cancer Society at
800-ACS-2345 for a listing of local screening sites.

    As worthy as the goal may be, however, the effectiveness
and value of the mass screening are matters of dispute within
the medical community. One-third of the tumors picked up by the
rectal exam are already inoperable. Yet the PSA blood test is
also far from infallible. It misses at least 20% of
malignancies and can often give an indication of cancer where
none exists. Furthermore, prostate cancers are not all the same;
many grow so slowly that they do not need to be treated at all.
A man could easily die of something else before his prostate
condition proved fatal. If millions of men 50 and older take the
blood test, some doctors fear that a great deal of unnecessary
treatment will take place.

    Whatever the merits of this particular type of mass
screening, there are strong reasons to believe that early and
accurate detection of prostate cancer can prolong life. When the
disease has not spread beyond the prostate, 95% of men survive
for at least five years. For half the men in whom the cancer has
metastasized, life expectancy is two to three years. Moreover,
techniques for surgically removing the prostate -- the standard
treatment for the cancer -- have improved dramatically. Just a
few years ago, the operation usually caused impotence and
incontinence because it damaged nerves in the area. But by using
a nerve-sparing operation developed by Dr. Patrick Walsh at the
Johns Hopkins Hospital, doctors can prevent those side effects
in most patients.

    With the progress in detection and treatment has come a
wave of publicity about this very private kind of cancer, which
was once rarely talked about. Many prominent men, from ABC News
chief Roone Arledge to musician Frank Zappa, have revealed that
they have the disease. Others, like Kansas Senator Robert Dole,
who underwent an operation for early prostate cancer last
December, are actively encouraging men 50 and older or with a
family history of the illness to get tested and become familiar
with the warning signs: frequent or difficult urination, blood
in the urine, painful ejaculation or continuous lower-back pain.

    A major element of the controversy over early detection is
the test for PSA, a protein that is produced by the prostate
and is believed to play a role in preventing semen from
coagulating. High levels of PSA in the blood indicate an
enlarged prostate, which is common in older men and is only
sometimes the result of cancer. Research studies show that 20%
to 25% of men with a PSA level between four-billionths and
ten-billionths of a gram per milliliter of blood harbor a cancer
in their prostate.

    Unfortunately, even a low PSA level is no guarantee of
good health. "A third of the men I operate on have PSAs less
than 2.8," says Walsh. "So the idea that if your PSA is low,
you don't have cancer, is wrong. But if you have a negative
rectal examination and a low PSA, you probably don't have
prostate cancer."

    Everyone agrees that PSA tests should be given in tandem
with rectal exams. But what if the tests seem to contradict
each other? It is not unusual to have a PSA level in excess of
four-billionths of a gram per milliliter and a rectal exam that
reveals nothing. In that case, the next step might include
further observation, an ultrasound exam or even a biopsy, a
procedure in which bits of tissue are removed from the prostate
and examined under a microscope. Should men with high PSA levels
undergo expensive, anxiety-producing biopsies year after year
to make sure they do not have cancer? Not necessarily. More
important than the absolute level of PSA may be the change in
levels over time. A dramatic rise is more likely to indicate the
presence of cancer. A steady high level may suggest nothing more
than an enlarged prostate.

    Although doctors have found the PSA test helpful in
spotting small prostate cancers, there is no guarantee that
early detection is beneficial. The test may be turning up the
less troublesome tumors and not ferreting out the killer
cancers. Researchers are working on ways to improve the blood
test. And the National Cancer Institute is launching a $97
million study to investigate whether early diagnosis translates
into longer lives. But the results will not be available for
another 16 years.

    Until then, physicians and their patients will have to use
their own judgment. Because prostate cancer runs in some
families, men with affected relatives may want to take fewer
chances with a high PSA level. For others, the best approach may
simply be to wait and see. Rather than treat the diagnosis as
an immediate call to action, or ignore the problem altogether,
they will need to follow the situation closely with frequent
examinations.

    That kind of restraint will not be easy. Over the past
several decades, much of American medical practice and public
expectation has been geared toward the idea that if someone has
cancer, it should be treated without delay, observes Dr. Gerald
Chodak, a urologist at the University of Chicago. But as blood
tests and biopsies detect ever smaller cancers, physicians and
patients will have to make more sophisticated decisions about
treatment.

    It does not make sense for everyone to be tested --
particularly patients who are within 10 years of the end of
their expected life-spans. "The perfect example is an
86-year-old guy I just saw in my office," says Chodak. Another
doctor had found an elevated PSA level in the patient. "He went
for a biopsy, and he's got prostate cancer. Now, this guy is not
going to benefit at all from his diagnosis. The last thing I
would do for an 86-year-old guy is test him."

    But for every anecdote about over treatment, there is one
about saving a life. "Five years ago, I would not tell a man who
came into my office to have a PSA test," says Dr. Perinchery
Narayan, chief of urology at the Veterans Affairs Medical Center
in San Francisco. "I would say, `Let's do a digital rectal exam,
and if everything's fine, we'll do another next year.' Today
when any man 50 or older comes into my office, I'll sit down
with him and tell him about prostate cancer and advise that he
get a PSA test." For too long, there were no options left by
the time prostate cancer was diagnosed. Used wisely, the PSA
test is an opportunity to improve the odds of survival.