The Unlucky Odds of Prostate Treatment

A survey of internet chat rooms where men discuss life after prostate cancer treatment is a surprising glimpse into the rarely discussed world of eviscerated masculinity. Men describe rituals of devices, pills and injections they undertake before attempting sex. Some have given up trying. They discuss embarrassing dribbles, diapers and bed pads.

They also describe pain—from sex and defecation—and grief, as they express feelings of loss, impact on relationships, regret and anger. “Rage is justified when doctors lie or withhold the real truth, the in-depth of what really happens to you,” says one man who had his prostate surgically removed three years ago.

Prostate cancer is the male equivalent of breast cancer—except not many people hear about the Blue Ribbon Campaign.

Yet, a lot of people must know someone who’s had prostate cancer. Every year, more than 46,000 men are diagnosed with the disease in Britain alone and more than 11,000 die of it. The American Cancer Society estimates that more than 161,000 new cases will be identified this year in the US and about 27,000 men will subsequently die, making it the second biggest cancer killer among men, behind skin cancers.

Weighing only an ounce and frequently compared in size to a walnut, the gland nestles under the bladder. It may be small and obscure, but the prostate is an important contributor to male sexuality. It’s most busy during intercourse, when sperm are sent from the testicles to the seminal vesicles, mixed with fluid and then sent to the prostate, which releases its own enzymes, citrate, magnesium, calcium and zinc, bathing the sperm in a milky alkaline fluid to protect them from the acidity of their destination.

As a man ages, the gland may swell, so restricting the urethra like a clamp on a hose—which can send him on repeat visits to the men’s room or racing to find a toilet.

Various conditions—benign and infectious—can produce these symptoms, but they may also be caused by cancer. But, as prostate cancer grows very slowly, there may be no symptoms at all. A man may die of other causes never knowing it was even there. And this is the heart of the controversy about screening and treating prostate cancer: how many lives does it really save? And how many men are harmed for each one saved?

PSA predicament

In the early 1980s, prostate cancer screening was done by digital rectal exam to feel the gland for lumps and bumps, and men with symptoms underwent further testing. But, from 1987 onwards, doctors began to rely on a diagnostic blood test.

The gland makes ‘prostate-specific antigen’ (PSA) which, the theory goes, generally stays put in the prostate—unless there’s cancer, in which case, PSA oozes out into the bloodstream. The higher the PSA score, the greater the chances that cancer is hiding in the prostate.

Except that it’s not specific to the prostate after all. PSA is found in women’s breast milk and other bodily fluids. Pregnant women’s blood levels of PSA are high, and it’s even found in amniotic fluid.1

In men, PSA test results don’t necessarily mean cancer growth either. It may be raised because of gland enlargement or infection, or just from riding a bicycle.2

Doctors chose a reading of 4 ng/mL millileter, rather arbitrarily, as the dividing line between a ‘normal’ and ‘abnormal’ read PSA levels. Yet, prostate tissue biopsies compared with PSA blood results reveal that men with levels under 4 ng/mL could have the cancer, while those with scores over 4 ng/mL could be cancer-free.

One study that followed 2,950 men for seven years found that 15 per cent of them, who never had an abnormal PSA test or rectal exam, had prostate cancer,3 According to one small study only one man in four with a high PSA reading (4-10 ng/mL) actually had cancer on biopsy.4

Biopsy blues

For decades, many urologists believed that prostate biopsy was painless, but up to 96 per cent of patients disagree. In a 2001 study, one in five men said they would refuse to undergo the procedure again without anaesthesia.5 In the past decade doctors say it’s been much improved, pain-wise, now that they do use anaesthesia routinely.

Normally, biopsy consists of having a dozen 18 gauge needles, about a millimetre thick each, sample from the gland. So many samples are taken to try to increase the odds of finding a cancer-ridden cell if cancer is present—in a kind of cancer lotto. It’s like plucking 12 marbles out of a thousand to find a red one.

Different stages of cancer may exist in different samples in the same man, and these findings are added together in a sort of cancer sum called the Gleason score, which is supposed to give an idea of the overall picture of what the tumour will behave like.

It’s close to a flip of the coin for accuracy, however. A study of around 1,000 biopsies compared with pathology reports of prostates later removed by surgery found a match just 58 per cent of the time.6 And here is still much debate about the accuracy of Gleason scores and how they impact men’s treatment choices.7

Newer template-guided biopsy techniques are now available that take more samples—40 to 60 on average—and are more accurate but require both general anaesthesia and the use of alpha-blockers to relax the prostate and a temporary catheter.

These biopsies are also not free of side-effects. Blood in the urine and semen afterwards is common, and the reported risk of infection is 3.5 per cent and rising, with two times the risk of needing hospitalization, according to a recent US study.8 Biopsy patients are usually put on antibiotics to prevent this.

To treat or not to treat

Even so, men might take their chances and choose to undergo biopsy if there is any true chance of catching cancer early based on a PSA test. The trouble is, there is no evidence that finding and treating prostate cancer early actually saves lives, as it’s usually so slow-growing and benign. Almost all men in their 90s have microscopic evidence of tumour—which clearly has not affected their longevity—and may be considered ‘incidental’.

And an aggressive, fast-growing cancer, even if caught early by PSA, is not likely to be stopped by conventional treatments.

In 2009, a huge US study delivered a nuclear assault on the PSA test—or so it seemed. In a report of nearly 77,000 men after seven years of follow-up, there was no significant difference between screened and unscreened men in terms of deaths.9

On the other hand, a major study of 182,000 men (in seven European countries showed a 20 per cent reduction in death rates, but at the cost of over-diagnosis and over-treatment, which “are vastly more common than in screening for breast, colorectal, or cervical cancer”.10

Yet another 2009 study found that, between 1986 and 2005, more than a million additional men were diagnosed with prostate cancer and needlessly treated by surgery or radiation11—and most likely lost their sexual function or bladder control as a result.

Put another way by Dr. Peter B. Bach, a physician and epidemiologist at Memorial Sloan-Kettering Cancer Center, men who undergo biopsy and treatment have about a one in 50 chance of being spared cancer that would otherwise have killed them within 10 years. And a 49 in 50 chance of being treated unnecessarily for a cancer that was never a threat.12

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