Prostate Prognosis
New treatments improve the survival rates for this most common male cancer

September 26, 2004

Studies show that men with prostate cancer who get active in treatment decisions increase their chances of living a longer and more comfortable life. The choices are complex, the side effects hard to foresee. And the stakes are life and death.

Think of four men or boys you care about. Give it some thought – guys you love. Perhaps your dad makes the cut, your son or brother; maybe your best man or best friend. Now, add yourself to the list. So there are the five of you, all excellent dudes, everything to live for – and one of you will get cancer of the prostate. That’s the stat. During his lifetime one of every five American men will develop prostate cancer, a disease without symptoms until it’s too late to cure.

Bummer. So why is Stan Rosenfeld smiling? And where does he get the audacity to say being diagnosed with prostate cancer – the second most common cause of cancer death in men (following lung cancer) – ranks with some of the best news of his life?

“That’s simple,” he says. “If I hadn’t found out early, I wouldn’t have had the chance to make the kinds of informed treatment decisions that today make it possible for me to be alive so I can hand out these to strangers in grocery stores.” Rosenfeld hands me a brightly colored business-sized card. One side: “You are reading this card because … I care about you! Flip side: “I want you to be around for a long time, so please get the facts about prostate cancer from your doctor now!”

Rosenfeld has his work cut out for him, given that Marin County has California’s highest rate of disease. The longtime Fairfax resident says he’s optimistic because prostate cancer trends are on the side of health. “Now it’s true that the incidence of the disease is up in Marin but there’s every reason to believe this is because more people are getting tested,” Rosenfeld says. “At the same time, prostate cancer deaths in Marin are down compared with the California urban population as a whole, and the most plausible hypothesis is early diagnosis and treatment.”

The trend is national. “Cure rates are definitely improving,” says Greenbrae urologist Gary Grossfeld, a nationally recognized leader in prostate cancer treatment. “Men are being diagnosed at earlier stages, more favorable stages, and as a result there are more treatment options available to them, ranging from surgery to radiation, hormone therapy to observing and monitoring with no specific treatment given unless the cancer begins to show signs of advancing or causes symptoms.” American prostate cancer deaths are expected to fall below 29,000 this year, down from 35,000 a decade ago. Grossfeld attributes the decrease in mortality rates to “a more aggressive testing and screening program, leading to diagnosis and treatment of more favorable disease.” The American Cancer Society estimates that 184,500 new cases will be discovered nationally this year.

Found only in men, the prostate is a gland about the size of a walnut. It sits in front of the rectum, under the bladder, and behind the base of the penis. The prostate surrounds the upper part of the urethra, the tube that dispatches urine and semen. The cells that comprise the gland grow and stay healthy because of the influence of male hormones, such as testosterone. (Ironically, testosterone also causes prostate cancer cells to grow.) As men age, the prostate can expand to the size of a peach, impeding urination and causing bladder or kidney problems.

The big diagnostic leap forward of the past two decades was the development of a simple test for prostate specific antigen (PSA), a protein whose blood level signals changes in the prostate. Generally, PSA readings above 4 are a cause for apprehension, but research in the mid-1990s showed that normal PSA levels may vary based on age. “For men in their 40s or early 50s, a PSA level over 2.5 will lead me to repeat the test to see what’s going on,” Grossfeld says. Men in the 70s may have a normal reading at 5.5 or 6.” Many doctors place more stock in the trend of successive measurements than any absolute value.

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Obscuring the picture, not all men with prostate cancer have high PSA levels, and high readings frequently don’t designate cancer. If a second test confirms a high reading, doctors more often than not order a biopsy. When that sequence led to a prostate cancer diagnosis for Rosenfeld in 1997, his doctor recommended immediate surgery. Then 59, he decided against surgery, and started looking into his options.

“I must have spent a thousand hours on the Internet,” he recalls. “After getting second, third, and fourth opinions from doctors around California, I began looking closely at the long-term cure rates of the various treatments, in addition to the side effects. I built myself a little chart, a matrix that tried to balance what was known about the cure rates, not just out at four and five years because all the treatments are similar, but more out at ten and fifteen years. Basically I was looking for a cure.”

During his research period, Rosenfeld underwent hormone therapy, a treatment strategy widely used to lower levels of the male hormone, testosterone. Within a month, his testosterone level dropped to virtually nothing – effectively to the amount of testosterone that a woman would have in her body. The main side effect was, well, hot flashes.

“My wife said, ‘Well, finally now you understand and sympathize.’ And every woman in your life says, ‘Aha! Now you know.’ An interesting thing about the loss of libido, ironically, is that in a way you don’t care. But you do have to remember the other person in your life, and I did, and it worked out well.”

Patti Breitman, Stan’s wife, says the experience brought them closer. “We had simultaneous hot flashes – not many couples can make that claim,” she laughs. “But not all prostate cancer treatment effects your sexual performance. In those cases where treatment does have that impact, it creates greater intimacy because it forces you to communicate. A lot of couples I know have better sex in terms of fulfilling desires – you have to be more creative when you can’t do things the way you’ve always done them. That leads to nice surprises and better intimacy.”

By reducing testosterone levels and temporarily stopping the cancer in its tracks, Rosenfeld was able to keep sorting his options without having to worry about the cancer progressing.” When he finally clarified for himself that he could live with minor side effects, Rosenfeld’s matrix pointed to surgery – radical prostatectomy – as the best chance for a cure that would last at least 20 years. The side effects have been minimal. He feels he made the right choice.

And that includes his decision to start a weekly support group at Marin General Hospital for prostate cancer survivors – a regular place to ask their questions and share their ongoing discoveries. “Prostate cancer is a very personal disease, and in the support group you can never tell a man what’s right for him. Because everybody has a different take on the side effects of various treatments. Is potency more important than anything in his life, or not? Is he willing to use various aids to help in intimacy with his spouse? How life-changing might it be if he has a little bit of incontinence?”

The support group is comprised of doctors, lawyers, business executives, tradesmen, teachers, and builders – several in the age range of Tom Brokaw’s “greatest generation.” As a recent meeting got underway, a spirit of solidarity reminiscent of comrades in arms filled the room. Clearly these are men who share a common battle against and invisible enemy, and they mean to come out on top. At the same time, it’s readily apparent how little in common the group as a whole has with the classic stereotype of World War Two men – you know, the type who go silent when the conversation turns personal, guys who dutifully accept their disposability as part of a hierarchy not of their choosing. To the contrary, in terms of the vast array of medical issues connected with prostate cancer this group is proactive, strategic, smart, informed, and steadfastly committed to the proposition that they are responsible for making fully informed choices about their treatment and its consequences.

Several men talked about the importance not only of getting multiple medical opinions, but getting them from different institutions. “It’s not that you assume any given medical center is wrong,” says Joe Marinno of San Rafael, whose diagnosis of prostate cancer earlier this year was based on two extremely high PSA scores and a series of biopsies. “It’s really more a matter of getting outside the different institutional categories that invariably characterize different medical centers.”

By following his own advice, Marinno learned that he has lymphoma of the stomach, a condition that takes priority over the slower growing prostate cancer.  “Whether or even whether the stomach cancer would have been detected at the first medical center is an open question,” he says. “The main thing I say to men is: Get screened regularly beginning at age 50. Every man should get a digital rectal exam. It’s not entirely comfortable, but it’s not painful, either. If irregularities are felt, the next step should be a PSA test – and if necessary, a biopsy. Chances for recovery and longevity are very good, when the disease is detected and treated in its early stages.”

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Who’s most at risk, and how can prostate cancer be prevented? Since little is known about what causes prostate cancer, it’s not easy to be categorical about how to prevent it. There’s no doubt the risk of developing the disease increases with age. More than 75 percent of all prostate cancers are diagnosed in men over the age of 65. People with a family history of the disease are at higher risk, along with African Americans, who are urged to get their first screening at age 45. Native American men are at very low risk.

Some evidence indicates that obesity and a diet rich in animal fats may play a role in the disease. Last year, Dr. Dean Ornish reported that his notably strict regimen – restricting fat to 10 percent of total calories, three hours of exercise a week plus meditation and support-group meetings — lowered PSA levels by 6.5 percent in an initial group of subjects over three months.

“The Ornish study is very provocative,” says Gary Grossfeld. “But they were very dramatic interventions that caused relatively small changes between the two groups. In most cases, what’s good for your heart also shows promise in reducing prostate cancer risk. That includes exercise, weight reduction, limiting animal fat and dairy foods in particular, eating fresh fruit and vegetables, lycopene, which of which tomatoes, watermelons, and ketchup are excellent sources. There are clinical trials currently underway to evaluate the potential benefits of supplementing your diet with vitamin E and selenium.

Taking personal responsibility for lifestyle changes makes obvious good sense – witness the growing willingness of men to get early screening for prostate cancer is nothing short of remarkable, compared with the disease’s past shrouding in embarrassed silence about “the plumbing.” At the same time, there are some who believe it’s no less urgent to ask tough questions that go beyond personal lifestyle, to our collective way of life.

A study reported in the 2002 issue of Environmental Health Perspectives reviewed a wide selection of experimental evidence from animals showing that exposure to endocrine-disrupting compounds in early development can cause cancer and/or increase sensitivity to cancer-causing agents later in life.

The article notes that few human studies have been built upon this understanding. Most human epidemiological research into cancer risk from contaminant exposures examines chemical levels only at the time of diagnosis or afterward. The authors argue that this approach neglects the period of developmental sensitivity to exposures that animal studies have identified.

Of course, given that the risk of prostate cancer becomes more prevalent with age, rising rapidly after age 50, it’s not unreasonable that so much of the research on prostate cancer risk factors and causes has concentrated on conditions during adulthood. But the study raises the disturbing possibility that the conditions for prostate cancer, even the initiation of the cancer itself, may begin much earlier in life. The evidence comes from numerous sources:

·  Autopsies of men dying from other causes have revealed microscopic evidence of prostate cancer in a significant percentage of men as young as 30-39 years of age.          

· Signs of abnormal prostate growth are evident even earlier, as a condition called prostatic intraepithelial neoplasia (PIN) was discovered in 9 percent of 20-29 year olds.

· Animal experiments show that adult prostate characteristics can be altered dramatically by conditions experienced by the fetus in the womb, including shape, size and sensitivity to hormonal stimulation.

Researchers Birnbaum and Fenton, who conducted the study, maintain that these changes in animals can be caused at extremely low levels of exposure by extremely common contaminants, levels to which virtually all Americans are exposed. No one yet knows how relevant these animal experiments are to prostate health in people. They say it’s time to begin asking different questions:

"Could we be trying to correlate exposure and effect at the wrong time? If it is prenatal, or early life stage, exposure that is critical to disease susceptibility, why are we measuring environmental chemicals in people once they have developed … cancer? The critical exposure window may have been much earlier."

Stan Rosenfeld says he spends much of his time thinking about the degree to which his sons’ susceptibility to prostate cancer may be inherited. His wife Patti Breitman raises similar questions about our legacy to our grandchildren. “You want to protect the next generation and they can learn from us. There’s a Chinese saying: ‘Waiting until you have symptoms of a disease in order to treat it is like waiting until you’re thirsty before you start digging.’”

Keith Thompson