Chapter Excerpt

Introduction

Welcome. Maybe you’re reading this book because, along with more than 200,000 American men this year, you’ve been diagnosed with prostate cancer—and found yourself a member of what many call the reluctant brotherhood, a club you never wanted to join. Or maybe you’re in the reluctant sisterhood, and you’re reading this so you can help your husband, father, brother, son, or a close friend. Or maybe you’re not yet an official member of the club, but you’ve received the unwelcome invitation—a change in your prostate-specific antigen (PSA), maybe, or a prostate biopsy that turned out to be negative. In any case, we’re glad that you have found your way here, because we want you to know that the world of prostate cancer is full of hope. More men are being diagnosed earlier than ever before, and more men are being cured of this disease.

This is a big change from the early 1990s, when Pat Walsh and I first started writing about prostate cancer. Back then, the PSA test—instead of being a mainstream screening tool for most physicians—was largely unheard of and was used mainly to monitor prostate cancer that doctors had already diagnosed. Many men who found out they had prostate cancer died of it, and the treatments were so variable that for many men, the side effects were at least as frightening as the disease itself. The picture for men with advanced prostate cancer was bleak, and if cancer had spread outside the prostate or had returned after treatment, the philosophy seemed to be to wait until everything else failed before even attempting chemotherapy. That fatalistic worldview has changed, largely thanks to oncologists such as Mario Eisenberger and Michael Carducci, of Johns Hopkins, who have helped develop and test many new drugs, some of which work in entirely novel ways. Now, oncologists have means of predicting who’s at risk of a cancer recurrence—and instead of waiting for cancer to show up, they go after it as soon as possible, when it is most susceptible.

So much has changed. Thank God. Deaths from prostate cancer in the United States and other countries where there is an active approach toward screening and effective treatments for localized disease (curable disease, still confined to the prostate) are fewer every year. In fact, very soon now, it looks as if we may even be able to cheer that prostate cancer is moving down the ranks of fatal diseases. As this book is heading for the printer, the American Cancer Society estimates that prostate cancer may even fall behind colon cancer as the number-two cancer killer of men. Also, with this book, we celebrate something that doctors believed for many years. A landmark study from Scandinavia, discussed in chapter 7, proved that radical prostatectomy—for years the “gold standard” treatment for prostate cancer in America—saves lives. Are we out of the woods yet? Far from it; unfortunately, the burden of prostate cancer will not let up soon. As the huge baby boomer generation enters “the prostate years,” the number of new cases is predicted to double, and the number of men dying from the disease may triple (see chapter 3). This is why we are also working harder than ever to learn how to prevent this disease.

One thing you’ll learn from this book is that every single case of prostate cancer is different—as individual as snowflakes. The seriousness of a man’s cancer depends on so many things. Some of it’s the genetic deck of cards he was dealt—for instance, whether prostate cancer runs in his family, particularly if his father or brother developed it at an early age—and about half of it has to do with his environment. Environment here doesn’t really mean the air he breathes (unless he happened to spray Agent Orange in Vietnam, in which case it does; see chapter 3). It may have something to do with where in the world he lives—how much sunlight he’s exposed to, or the mineral content of the soil where his vegetables are grown, for example. But it has an awful lot to do with what he eats—whether, over the course of his lifetime, he’s eaten a lot of vegetables, or red meat, or fish, or olive oil, or tomato sauce, or drunk red wine or green tea, and probably even whether today, for lunch, he picked tuna salad or a meatball sub. We are learning that every minute choice a man makes can affect his susceptibility to prostate cancer, and conversely, his ability to fight it off.

It makes sense, then, that the treatment for every man is different, too. My coauthor, Patrick C. Walsh, is one of the most respected prostate disease specialists in the world. In fact, he developed the revolutionary, now-standard operation called the anatomic radical retropubic prostatectomy, in which the prostate is removed, but potency and continence are preserved. (This operation is also known as the Walsh nerve-sparing procedure.) Does he, then, recommend surgery for every man? Far from it. He has operated on thousands of men with prostate cancer. He has also not operated on thousands of men with prostate cancer. That’s why we say on the cover of this book “Give Yourself a Second Opinion”—not just from a surgeon, but from pathologists, radiation oncologists, and medical oncologists. Just as every man’s disease is different, so is every man’s ideal treatment. But first things first—do you indeed have cancer? And if you do, is it growing quickly or slowly? The right treatment starts with diagnosis, and there’s nobody better at looking at prostate cancer cells, and understanding them (see chapter 6), than Jonathan Epstein of Johns Hopkins, one of the world’s most gifted pathologists. Your second opinion from radiation oncology comes from two of the best in the business, Danny Y. Song and Theodore L. DeWeese—both in the Department of Radiation Oncology and Molecular Radiation Science at Johns Hopkins, and both people dedicating their careers to making external-beam radiation and brachytherapy better than ever (see chapters 9 and 10). The revolution in medical therapies for advanced cancer, with opinions from the renowned oncologists Mario Eisenberger and Michael Carducci, is discussed at length in chapter 12.

I’ve been writing about prostate cancer for nearly fifteen years, and I came to the subject in the worst way you can imagine. In 1991, I watched my fifty-three-year-old father-in-law, Tom Worthington, die of it. His death was horrible. Within a year of his initial diagnosis, after fleeting success with hormonal therapy, his tumor spread like wildfire. He died in a nursing home, castrated, hooked up to a catheter, in agonizing pain, pitifully thin, his bones so riddled with cancer that his arm snapped in two when a nurse tried to move him. I thought of him a lot as we wrote chapter 12. Now, new drugs are actually targeting prostate cancer in the bones even before it gets there, snatching up the welcome mat from this site that advancing prostate cancer seems to love so much. I try not to play the “what if” game, wondering if one of these amazing new treatments could have made the difference for Tom, but sometimes I can’t help it.

Back to 1991 for a minute. It was in hopes of finding out how this could happen—how this “old man’s disease” that men were supposed to die with, not of, could kill a man in the prime of life—that I found Pat Walsh. So unattuned was I to the world of prostate cancer that I didn’t even know who he was, other than that he was the head of urology at Johns Hopkins Medical Institutions, where I happened to work as editor of the medical alumni magazine. (I must confess that, until all of this, I had never given much thought to the prostate at all and didn’t even know what it did or where it was located. I knew that men had one and women didn’t, but that was about it.) I had no idea that there was a cure for prostate cancer, that Walsh had invented it, and that his operation had been for years a gold standard for cancer control that maintained continence and potency. I didn’t know, then, three very important things: One, that he developed the operation after years of intense, meticulous study of the anatomy of the prostate and male urinary and reproductive systems—a bedrock knowledge of the fundamentals, as athletes say. Two, that he is a consummate perfectionist, always working to improve his technique and the operation itself. About six years ago, for example, he spent his free time one summer watching hundreds of hours of videotape—of his hands performing the radical prostatectomy in dozens of patients. Why? He wanted to see whether some slight modifications in his technique could improve his patients’ recovery of sexual function (it could; see chapter 8). Other surgeons have now started doing this; he was the first. And three, curing prostate cancer isn’t just a job for him, the basis of a successful career that has won him every possible honor and award in the field. It’s his life’s mission. At Hopkins, Pat Walsh put together a world-class team of oncologists, radiation oncologists, molecular biologists, pathologists, urologists, and geneticists, who have been tackling this disease from every angle for the last two decades. The fruits of their labor appear throughout this book. Walsh, along with his longtime research director, a brilliant man named Don Coffey, is the driving force that made much of it happen.

I also had no idea that he would, within a few years, be the reason that prostate cancer was diagnosed early in my own father. What are the odds that this gifted surgeon with whom I would start to write books, would one day take out my dad’s prostate and cure his cancer? That was seven years ago; Dad’s PSA remains undetectable. In writing this book, our fourth, I have found myself feeling a bit like Charles Dickens must have felt as he wrote A Christmas Carol—introspective and personally haunted by three visions of my subject—the past, present, and future.

Prostate Cancer Past: The past is still too recent for me. It started with Tom, of course, but he’s not the only man I’ve known whose life has been cut short by this disease. There was Sam, a successful banker, who was diagnosed ten years ago with prostate cancer at age fifty and opted for radiation because, newly divorced, he didn’t want to face the recovery from surgery by himself (at that time, it was a bit longer and more difficult than it is today). What nobody knew then (again, things are different now; see chapter 10) was that he had a very aggressive cancer. When I met him, it had already come back locally. He fought the disease valiantly with hormonal therapy and then chemotherapy, but he died about three years later. I always think of him when I see a red convertible, because he bought one right after his wife left him as a symbol of his new life. Another man was Lester, a U.S. Marine drill sergeant, tough as a boot and also a wonderful cartoonist, who drew many pictures for me and my children. Les, a black man in his early fifties, had family history and race going against him. He had undergone a radical prostatectomy before I met him, but, as with Sam and Tom, the cancer had spread silently before he ever sought treatment, and he died less than five years later. He and his wife had an unshakeable faith in God that helped them tremendously throughout their ordeal. Because of his race (black men are more susceptible to prostate cancer—see chapter 3) and family history, Les should have begun screening for prostate cancer when he was forty. Nobody realized this then; we know it now.

And finally, close to home once again, my husband’s maternal grandfather died of complications from radiation therapy for—you guessed it—prostate cancer, at age eighty-five. He had a number of health problems, including heart disease, had no symptoms of prostate cancer, and probably didn’t even need to be treated. (We discuss this strategy, called expectant management, in chapter 7.) Another man who probably didn’t need to be treated was my own grandfather, who died at age eighty-four of a heart attack, which I believe was caused by the heavy-handed regimen of hormonal therapy (five times the dose Walsh recommends in chapter 12) his uninformed family physician prescribed for prostate cancer. He had no symptoms of the disease and probably could have enjoyed his remaining years without even needing treatment; instead, the personality and physical changes caused by these hormones made his last months miserable.

Prostate Cancer Present: As in A Christmas Carol, this is the most joyful mode. I rejoice that for my father, prostate cancer was truly just a blip on the radar screen of his life and that he is around to love, and be loved by, his wife, two kids, and six grandchildren. It was the best example I know of an ideal scenario—prostate cancer detected early, treated, and cured. I am so happy for the many men I’ve met and kept up with over the years who have been treated for prostate cancer and who are doing fine now. I am as proud of Pat Walsh’s ever-improving surgical procedure and stellar results as I would be if they were the result of my own painstaking study, years of experience, self-discipline, rigorous standards, and mission. He once told me something that got him through medical school, something one of his toughest professors used to tell all of his students: “You are not here to make friends. You are here to find the truth.” And that’s who he is. He doesn’t mince words, doesn’t gloss over anything, and doesn’t pretend that all treatments are equal. But if he tells you something, you can trust him.

Prostate Cancer Future: And then there’s tomorrow, which has a shadow lurking overhead. Despite the overwhelming amount of good news in this book, this edition of the book has been troubling for me personally because of a bombshell in PSA screening, which we talk about in chapter 5. Scientists have learned that having a low PSA level is no guarantee that a man doesn’t have prostate cancer and that it isn’t serious. In fact, 15 percent of men with PSA levels lower than 4 ng/ml have prostate cancer, and 15 percent of these men have aggressive disease. If some of these men were to wait until their PSA level reached the now-outdated magic number of 4, it might be difficult to cure their cancer. Scientists such as H. Ballentine Carter, a pioneer in making sense of PSA, now realize how crucial a factor a man’s age plays in his PSA level. A man in his forties, for instance, who has a PSA level of higher than 0.6 that’s consistently rising faster than 0.2 to 0.4 ng/ml per year may well have cancer and should have a biopsy.

Well, guess what? My husband, Mark, whose family history (on both sides) of prostate cancer first catapulted me into this reluctant sisterhood, had a PSA level of 0.7 ng/ml (that’s certainly higher than 0.6) two years ago. We felt great about that low number at the time. We’re not that complacent anymore. His PSA today is still 0.7. But we’re watching it like a hawk now. (We were appalled that five years had gone by since his last physical. How did that happen?) He’s forty-five years old. He doesn’t smoke, takes selenium when he remembers, and enjoys a glass of red wine several nights a week. But he’s a doctor, and like many of his colleagues, is excellent at caring for others and not very good at taking care of himself. He’s a father of three active kids ranging in age from thirteen to three. We barely have time to cook dinner many nights, much less to figure out how to incorporate prostate-healthy foods into our diet. Have we blown it? Is it too late for us to lower his risk or perhaps delay or even prevent prostate cancer from forming in his body? We’re praying that it’s not. My husband and I each have a younger brother. What about them? We have two sons. What about them?

I’m telling you all of this to show that when I welcome you into this reluctant brotherhood and sisterhood, I mean it. I’m in it, too—which means that we’re in it together. It’s not an easy place to be, but again—believe me on this—it’s infinitely better than it has ever been.

—Janet Farrar Worthington

Copyright © 2001, 2007 by Patrick C. Walsh and Janet Farrar Worthington