The prostate puzzle

One of the most frightening — and perplexing — diseases any man over 50 can encounter: prostate cancer.

It affects one in eight Canadian men; its incidence in 1997 was higher than breast cancer and, after lung cancer, it’s the second most common cause of death from cancer in men. One third of those diagnosed with prostate cancer will die of it, and treatment can frequently result in impotence and/or incontinence.

"Prostate cancer," writes Dr. John Hoey, editor-in-chief of the Canadian Medical Association Journal, "is about fear, sex, indignity and death."

But there is a positive side. Post-mortem examinations of men past 80 show 70 per cent have malignant cells in their prostates — in effect, they had prostate cancer, but it probably didn’t affect them.

As doctors are fond of saying: "You’re more likely to die with prostate cancer than of the disease."

But we all may be able to rest easier. Although the incidence of prostate cancer was climbing by an alarming 12 per cent in the early 1990s — perhaps because of better detection following prostate specific antigen (PSA) screening — it peak in 1997 and may be declining. Some studies indicate death rates are also declining.

It confounds all the expectations we — and particularly men — have of medical science. We have something wrong with us, we expect the doctor to find it and fix it — like a mechanic fixing a leaky muffler.

Nothing so simple with prostate cancer. The vaunted PSA test, introduced in Canada in 1986, can indicate prostate cancer — but is also likely to give a false reading. And when a biopsy (putting a tiny sample of the organ under the microscope) confirms prostate cancer, doctors are often uncertain whether surgery, radiation, hormone treatment, a combination of the above — or doing nothing at all — is the best course of action.

Never was there a disease — except perhaps breast cancer — that called for greater involvement on the part of patients, their spouses and loved ones. Because the incidence of prostate disorder increases with age, it’s vitally important that men past 50 — and the women in their lives — learn as much as they can about the functions and potential malfunctions of this mysterious organ.

About half of men over 50 experience a benign swelling of the prostate which is mostly an inconvenience: As the collar tightens around the urethra it restricts the flow of urine, explaining why we older men spend an inordinate amount of time at the urinal waiting for the darned thing to finish.

Benign swelling can also cause pain in the lower back, pelvic area or upper thighs, blood or pus in the urine, as well as difficult or painful urination and ejaculation. And as these are also the symptoms of a bacterial infection or prostate cancer, any one of them signals it’s time for a visit to your doctor.

Because heredity is one of the surest indicators of the disease, he or she may ask if any of the men closely related to you — father, brother, uncle — have had prostate cancer.

To begin, the doctor, using a rubber glove coated in lubricant, performs a mildly uncomfortable digital rectal exam (DRE) to feel whether the prostate is swollen. Depending on the result, the doctor may suggest a PSA test. And here’s where things get tricky. A high reading may indicate prostate cancer or simply a benign enlargement of the prostate. In fact, two out of three men with high PSA readings will not have prostate cancer. On the other hand, a low PSA rating doesn’t rule out cancer entirely. Only a biopsy will tell for sure.

Even then, doctors and their patients face a conundrum. "It may be," says Dr. Peter Venner, a medical oncologist at Edmonton’s Cross Cancer Institute, "that a significant portion don’t need to be treated."

In Scandinavia, he says, the tendency has been for doctors to adopt a policy of "watchful waiting" — keeping an eye on the cancer, but not intervening unless absolutely necessary. And death rates, said Dr. Venner, are no different in that part of the world than in much more interventionist North America.

"What we do not have," he says, "is the ability to reliably determine which cancers pose so little threat that active treatment can be deferred indefinitely."

In the absence of certainty, doctors consider the probable life expectancy of the patient. "I certainly would not be relaxed about a man of 50 (with prostate cancer), who may have 25 years to live," said Dr.Venner. A man of 70 might be a different matter. Radical treatment — surgery or radiotherapy — is generally prescribed only where there is a reasonable expectation of at least 10 more years of life.

If caught early, the chances of a cure are good; if the cancer has spread beyond the prostate the emphasis shifts to keeping the patient comfortable.

• Hormone treatment
: This suppresses the production of testosterone and, as a result, shrinks the prostate. This technique is often used as a preliminary to surgery or radiation, but induces uncomfortable symptoms of "menopause", including hot flashes. Surgical castration is also sometimes suggested to halt testosterone production.