What Edward Kaps calls his ”double whammy” began one day in 1978 when he was taking his annual physical exam. Out of the blue, the physician announced that Kaps had a nodule on his prostate gland. A biopsy showed that it was cancerous.
Kaps had become one of the legion of men whose lives are distorted, and sometimes destroyed, by this small, pesky gland that is an essential part of the male reproductive apparatus but which routinely goes haywire in middle age.
For Kaps, who had experienced no symptoms, the news hit with sledgehammer force. Over the next two months, he was obliged to spend five days a week undergoing radiation treatments. But the harsh regimen seemed worth it. At the end of 42 treatments, he was free of cancer. Or so he thought.
Some years passed, and then in May of 1988, when he was nearing retirement as labor relations director for the Electromotive Division of General Motors, he was told during another routine examination that the cancer had returned.
”You talk about devastation,” says Kaps. ”I went into a shell for more than a year.”
Kaps was lucky. His doctor recommended surgical removal of the prostate, and today, as far as anyone can tell, he is tumor-free, having once again dodged the bullet.
But thousands of men are not so fortunate. This year, an estimated 34,000 Americans will die of prostate cancer, which exacts a death toll among men second only to that of lung cancer. More than 130,000 new cases of the disease will be reported-10,000 more than in 1990-and 60 percent of these tumors will have spread to the point that they are no longer curable.
Prostate cancer strikes one in every ten males. Though it is a slow-growing condition, it is also silent and insidious, often producing no symptoms until the malignancy is well-established. Blacks are more
susceptible, as are those with a family history of the disease, but it can strike any man over the age of 40 in any ethnic, racial or sociological group. Were cancer the only threat posed by the prostate, the picture would be disconcerting enough. But the gland need not become cancerous to cause mischief. Large numbers of men over the age of 40 endure the ill effects of a condition called benign prostatic hyperplasia (BPH) in which the prostate enlarges and begins choking off the flow of urine. The results range from minor inconvenience to urinary blockage, infection, even death.
The lone function of the prostate is to make a key component of semen, the fluid that carries the sperm out of the body during sexual climax and nurtures the sperm on their way to the egg. It is an important but one-dimensional job.
Why should such a minor body part cause such disproportionate misery?
Because of its unfortunate location.
The prostate is tucked away in the depths of the abdomen, where it wraps itself around the urethra, the tube that drains the bladder. This placement allows prostatic fluid to be pumped into the urethra during the muscular contractions that accompany orgasm.
But nature, normally a flawless engineer, goofed when it designed the prostate. First of all, it inexplicably made the gland sensitive to its own environment. Testosterone, the very hormone responsible for masculinity, seems to promote the growth of prostate cancer.
Once a malignancy gets a foothold, it can expand considerably without detection because the gland is surrounded by little adjacent tissue.
More than half of all men over the age of 60 have enlarged prostates and by the age of 80, the figure climbs to 80 percent. Although only about half of those affected complain of serious symptoms, the complaints can be severe. Symptoms of BPH can include frequent urination, a weak stream, difficulty in starting to urinate, a sudden pressing need to void, a sense that the bladder is still partly full after relieving oneself and interruption of the stream.
It would seem to be a discouraging picture. But there is good news. After decades of frustration, medical science is making encouraging progress in diagnosing and treating disorders of the prostate.
The most exciting development in years has been the arrival of a new test for prostate cancer, the so-called PSA test.
PSA stands for prostate-specific antigen. In the late 1970s, researchers at Roswell Park Cancer Institute in Buffalo discovered that the prostate produces PSA, a protein that liquefies the semen and which can be found in measurable amounts in the bloodstream. It was soon learned that the quantity of PSA in the blood tends to correlate with the size of the prostate. Simply put, a bigger prostate, such as one distended by a tumor, exudes more PSA.
The result has been an easy, relatively inexpensive blood test that can help indicate the presence of prostate cancer. It supplements the traditional method of assessing the prostate, the so-called digital rectal examination. For generations, physicians have inserted a gloved finger into the rectum and palpated the prostate, which can be felt through the wall of the colon. The problem is that the test misses many tumors. Moreover, by the time a tumor is big enough to be noticed, the cancer may be advanced, having spread beyond the prostate to bone and other tissue. At this point, the illness can only be slowed down. It cannot be cured.
While the PSA test is far from perfect, it has significantly increased the ability of doctors to detect prostate malignancies, often in the early stages when they are much more treatable.
”PSA has allowed us to almost double the number of cancer diagnoses that we made in the past,” says Charles McKiel, Jr., chairman of urology at Rush Medical College. Whereas, prior to the PSA test, almost 90 percent of the men who were found to have cancer were in a late phase of the disease and beyond hope of cure, today the figure has dropped to 60 percent, ”a dramatic change that can be attributed to PSA,” McKiel says.
The overall worth of the PSA test is still being debated. Because benign enlargement and even prostate infection can also raise PSA levels, the test yields a number of false positives. Worse, it can produce false negatives, in which normal PSA levels mask an underlying cancer.
To enhance the test`s accuracy, doctors rely on a formula based on a man`s age, the size of his prostate as determined by rectal exam and the expected level of PSA for a man in that category. If the prostate is producing more PSA than a gland of that size should, cancer is a distinct possibility.
Two recent studies have solidified the case for PSA testing. In 1981, researchers at Washington University School of Medicine in St. Louis, led by William Catalona, reported that PSA testing allowed them to detect more prostate cancers earlier than if they had used the rectal examination exclusively.
The Catalona team first reviewed a group of 274 men who had received a rectal exam alone and were found to have suspicious lumps. Among these men, a biopsy of the prostate, in which a needle device removes a bit of tissue for analysis, turned up 36 cases of prostate cancer. The key finding was that 24 of these men, or 67 percent, had advanced cancer by the time they were diagnosed.
The investigators then recruited some 10,000 men over the age of 50, none of whom had complained of prostate trouble before submitting to the study. The men were screened with a PSA test; if they had levels of PSA above four nanograms per milliliter of blood (a concentration suggesting a tumor), they were given a biopsy.
The first round of testing flagged 244 cases of prostatic cancer, and only 86 of the men, or 35 percent, had tumors that had spread beyond the prostate. A later round of screening, performed on those who passed the first test, identified 46 more individuals with cancer, but a mere 13 of them, or 29 percent, had advanced cases.
Early detection is critical. If the cancer is still confined to the prostate, the condition can be cured either by radiation or surgical removal of the gland. Either way, the five-year survival rate approaches 90 percent.
Furthermore, if surgery is necessary, the smaller the tumor, the less likely are the dreaded side effects, incontinence and impotence. With a small tumor, surgeons can employ the so-called ”nerve-sparing” operation in which one or both of the two nerves that control penile erection need not be severed. In such cases, and where the patient is under age 70, impotence can be restricted to no more than 20 to 30 percent of cases. Incontinence, meanwhile, is an outcome these days only 2 to 5 percent of the time.
But if the cancer has spilled beyond the prostate, things become more problematic. Chemotherapy is not effective. The primary treatment is to banish testosterone from the body either by administering the female hormone estrogen or other drugs-or by surgical removal of the testes. The measures will slow the disease down by anywhere from two to eight years, ”but eventually it breaks through and there is no effective treatment after that,” McKiel says. For all its promise, the PSA test is not currently viewed as a feasible mass screening tool, to be performed, for example, on all men over 40.
”It`s not accurate enough to be part of a routine physical,” McKiel says. ”It would yield too many false positives that would have to be followed up.” By the time the patient submitted to an ultrasound examination, to visualize the gland, and a biopsy to evaluate it, the $30 to $150 cost of a basic PSA test would balloon to many hundreds of dollars.
Instead, he and many others recommend that all men over 50 get a one-time PSA test to provide a base-line reading. Then, if a man comes into the office with a prostate complaint, or his doctor finds something amiss on a rectal exam, a PSA test can be given and the results compared with the earlier finding.
Anthony Schaeffer, chairman of urology at Northwestern University Medical School, agrees that mass PSA screening is counterproductive. ”For a screening test to work, it must say, `Yes, you have the disease, no you don`t.` PSA can`t do that.”
But unlike McKiel, Schaeffer believes a PSA test should be part of a man`s yearly physical. ”We recommend it for men over 40 with a family history of prostate cancer, and for everybody else over 50.”
The Journal of the American Medical Association, in an editorial last April, called PSA testing ”one of the most significant advancements in the field of prostate cancer in recent times,” and urged that ”the most complete evaluation of the prostate gland is achieved when both (digital rectal examination) and serum PSA are used together.”
As PSA testing begins to revolutionize the diagnosis of prostate cancer, so is urology broadening its array of weaponry against the aggravation of benign prostatic hyperplasia.
The ”gold standard” treatment continues to be surgical removal of the offending part of the prostate, the inner segment that is cramping the urethra. This operation, known as transurethral resection of the prostate, or TURP, makes use of a slender hose with a loop on the end that is inserted through the urethra and shreds away surrounding tissue like a continuous coal mining machine.
”You don`t remove the whole gland,” Schaeffer notes. ”It`s like an apple, you just take out the core.”
But TURP has its drawbacks. A small number of patients become incontinent. Almost all of them will lose the ability to ejaculate, the semen backing up into the bladder during orgasm instead of taking its normal path out of the penis.
The prospect of infertility, plus the general trauma of TURP, has caused scientists to come up with a menu of alternatives. They include:
– Transurethral incision of the prostate, in which two small cuts are made in the gland, causing it to split and ease its stranglehold on the urethra. The trauma of the procedure is less than that of TURP, and it has a vastly lower incidence of retrograde ejaculation.
– Laser removal of tissue, in which a laser is introduced into the urethra on the end of a catheter. The focused beam singes prostate tissue, causing it to sluff off. But the procedure only works on smaller prostates, and its long-term effectiveness is in doubt.
– Microwave treatment in which a probe is introduced through the urethra and heats prostate tissue to 113 degrees, causing it to melt away while cooling the urethra itself to avoid damage. The procedure, developed in France, is still experimental but has proven very successful in early trials here.
– Drug treatments. Some urologists are trying alpha-blockers that relax the smooth muscle tissue of the prostate and cause the gland to loosen its grip on the urethra. Others are trying shrinking agents such as the newly approved drug Proscar, which prevents testosterone from stimulating the gland`s growth. Initial reports indicate the drug can produce improvement in a third of patients, but trials are continuing.
