Prostate Cancer Presents Tough Choices

Published by Contra Costa Times

Posted on Sun, Sep. 19, 2004

By Stephen Daniels, M.D., and Julie Freestone, M.S.

As a police officer, Bill had a physical each year. At 48, he never worried about prostate cancer, or the rectal examination and blood test, the PSA, that had recently become part of his physical.

So Bill was surprised when his PSA was 8 (normal is 4 or less) and he needed a biopsy. He and his wife were stunned and scared when the biopsy came back positive for prostate cancer.

Bill discovered that the diagnosis of prostate cancer brought confusing and frightening choices, and that finding information wasn't easy. Thankfully, information has become more available since Bill's diagnosis. Useful Web sites include: www.4npcc.org, www.prostatepointers.org/prostate, www.ahrq.gov/clinic/uspstfix.htm, and www.cancer.org.

These Web sites suggest questions to ask your doctor. Some also provide information about treatment options, and as important, give ways to contact other people with the same illnesses, fears and choices, so you can discuss the pros and cons of your options. Other patients share your urgency because it's their cancer, too.

Bill and his wife learned that there was no "right" way to treat prostate cancer. Sixteen percent of men develop prostate cancer in their lives, but it is usually slow-growing, and only 3 percent die of it. Thus it's possible to overtreat, causing unnecessary side effects. Radical prostatectomy, the surgical removal of the whole prostate gland, is considered the most thorough treatment, but it can cause impotence and incontinence.

By the time he met with his urologist, the prostate specialist, Bill knew he didn't want to risk the possible side effects of the radical prostatectomy the urologist planned.

At the time of Bill's diagnosis, more than five years ago, the other treatment options, including external beam radiation and brachytherapy, the implanting of radioactive seeds, were considered experimental, so he had to be persistent with his doctor and HMO. Bill also reviewed other treatment options, including hormonal therapy and watchful waiting. More recently, cryotherapy, or the freezing of the prostate gland and its cancer, has become a treatment option.

Bill's new urologist acknowledged that because Bill's cancer had been detected early, brachytherapy might be as effective a treatment as prostatectomy, and probably with fewer side effects.

Another difficult choice that confronts most men is whether to take the PSA test in the first place. In men 50 and over, 15 percent will have elevated PSA levels, but fewer than one-third of those will turn out to have prostate cancer. Some will have unnecessary biopsies, which can be uncomfortable and cause complications.

And 25 percent to 30 percent of men with normal PSA results actually turn out to have prostate cancer, despite their normal test results. When offered the choice, though, most men take the PSA test, even though it isn't perfect.

It's been more than five years since Bill received treatment for his cancer, and he's doing well. He has missed only one day of work, shortly after the seed implants, and has no problems with incontinence or impotence. He and his wife believe the PSA test and cancer treatment saved his life.

Prostate cancer presents men with difficult and confusing choices. By investigating their illness thoroughly and carefully in consultation with their physicians, however, they can make informed and reasonable decisions.

Daniels practices family medicine at the Pittsburg Health Center. Freestone is communications officer for Contra Costa Health Services.