When your doctor gives you a diagnosis of prostate cancer, he or she is also likely to tell you that you must have treatment immediately or you will die.
If you're being treated by a urologist, a surgery called radical prostatectomy will probably be recommended. Also known as open prostatectomy, or simply the radical, radical prostatectomy is a major surgery which calls for your belly to be cut open and your entire prostate cut out. The theory behind the radical prostatectomy is deceptively simple: pluck out the entire prostate, cancer and all, before the cancer has a chance to spread.
If you're not careful, your doctor will have you believing that the radical prostatectomy is as simple and effective as using your spoon to scoop a little piece of hair out of your soup. If only it were true!
The surgery works only if the cancer is totally confined to the prostate, and not a single cancer cell has spread beyond it. Despite advances in testing, doctors cannot guarantee that a few cells haven't escaped the prostate. Many thousands of prostates have been surgically removed without curing the patient, for tiny bits of the cancer had already escaped. The surgeries were for naught and for many came at great sacrifices in quality of life.
Most men who undergo a radical prostatectomy end up suffering from varying degrees of impotence and incontinence. That's not surprising, given that the nerves controlling erection run right along the outside of the prostate. Even with the newer, "nerve-sparing" approach to the surgery, these precious nerves are often damaged or destroyed. Although some men recover to some degree, half or more of all men whose prostates have been surgically removed will never regain the ability to get and maintain an erection. And of course, there's a chance that you will die from the surgery itself.
But even if the radical prostatectomy worked more often and more effectively, it would still be ill-advised and dangerous. Why shock the body by cutting it when you can regain health without going under the knife? And the prostate is the center of a man's sexual energy when it's gone, his total energy is bound to lag. Look at and listen to men who have had the surgery. Ask your doctor for names of men who have had the surgery or, better yet, find a support group such as PAACT (Patient Advocates for Advanced Cancer Treatments).
If, on the other hand, you happen to wind up in the hands of a radiologist, you'll get an entirely different recommendation. Since they've been trained to use radiation, these specialists urge their patients to undergo radiation therapy, also called radiotherapy or irradiation. The idea is to radiate cancerous cells to death, hoping to shrink and possibly eliminate the cancer. The radiation doesn't kill the cancer cells right away; instead, it "gets" them when they attempt to divide in two. If, however, the cancer has spread beyond the prostate, radiation therapy can only slow its growth. It will not cure you.
The standard approach has been to apply the radiation externally by "beaming" radiation right into your abdomen as you lie on a table. Radiologists will usually apply the radiation beam to an area larger than the actual cancer, just in case they've underestimated the size. If the cancer is localized in the prostate or the areas immediately adjacent, radiation treatment generally takes between six and eight weeks, five days a week. Common side effects of external beam radiation include incontinence, nausea, fatigue, diarrhea, radiation skin burns, and skin irritation. If the radiation damages the nerves that control erections (which run right by the prostate, touching the gland) you may wind up impotent. Of course, you can never be sure that the radiation "got" every single cancer cell in the body. If even one cell remains, the tumor can regrow, the cancer can spread, and all will have been for naught. And if the cancer does come back, you can't turn to radiation again, for too much radiation can actually cause cancer.
A newer approach to radiating prostate cancer, called internal seed radiation, uses tiny radioactive "seeds" surgically implanted in the prostate. Internal radiation refines the approach by getting the radiation right up against the cancer cells instead of passing it through the body and possibly harming other tissue along the way. The radiation seeds, which look like rice or bird seeds, are pushed through small needles right into your prostate. Fifty or more radiation seeds may be used on a typical patient.
Internal seeding has some advantages over external beam radiation. It's an outpatient procedure that takes only an hour to two. The seeds are placed right at or close to the cancer site, delivering their radiation "on target". Because the radiation is more focused than the external beam, there appears to be less risk of impotence and incontinence, and recovery takes only a day (or less). Andy Grove, CEO of Intel, elected to have seed radiation after researching the issues quite carefully. He wrote an outstanding article on the subject, called "Taking On Prostate Cancer" in the 5/13/96 issue of Fortune magazine must reading for anyone considering treatment of prostate cancer!
Most men with cancer that is still confined to the prostate wind up undergoing either surgery or radiation. But if the cancer has spread, doctors will typically suggest hormone therapy. Hormone therapy is based on the idea that prostate cancer cells are especially hungry for testosterone, the male hormone. Take away this "food" and the cancer cells die. Most of the testosterone in a man's body is produced in the testicles, which is why doctors used to simply cut them off to "cure" prostate cancer. (The surgery to remove the testicles is called orchiectomy.)
But it's not enough to surgically remove a man's testicles, because the adrenal glands go into action to produce even more testosterone. So even after the testicles have been removed, a man suffering from prostate cancer must still take medicines to block the flow of testosterone from the adrenal glands. Another approach, which allows men to keep their testicles, is to use powerful drugs to block the flow of testosterone.
Whether a man keeps his testicles or not, hormone therapy deprives him of his usual testosterone. This slows the cancer somewhat, but has unpleasant side effects and undesirable psychological consequences. Men find themselves unable to get or keep erections, they lose muscle mass and gain breast tissue, and they suffer from fatigue hot flashes, reduced brain function, and other problems. Hormone therapy can be a helpful temporary measure to arrest or shrink the cancer.
Other Methods of Treatment
Although surgery, radiation, and hormone therapy are the medical system's favored approaches to treating prostate cancer, there are others. For example:
Cryosurgery is a relatively new procedure in which cancer cells, and the prostate they are in, are frozen to death. It is still considered to be an experimental procedure by many authorities. Although it's a "lesser" surgery than the radical prostatectomy, cryosurgery is still a major surgery that is a shock to the body. Impotence and incontinence are common. Other side effects include bleeding, infection, hypothermia, urethral-rectal fistula (which may lead to a colostomy), injury to the bladder or urethra, urgency and frequency of urination, and urinary retention. Cryosurgery is an effective alternative medical treatment that is far less invasive and just as effective as a radical prostatectomy.
Hyperthermia, the opposite of cryosurgery, is utilized separately and in conjunction with radiation. With hyperthermia, heat is applied to the prostate via microwaves coming from a cigar-box-like device placed between the man's legs or over his abdomen. No one knows quite how heat kills cancer. Some authorities argue that the heat damages the blood vessels leading to cancerous cells, without affecting normal cells, or that it kills the cancer cells weakened by radiation. Still others believe that heat interferes with the cancer cells' ability to make proteins or keep themselves "clean" but it is effective.
Chemotherapy uses powerful drugs to kill cancer cells. But the drugs don't specifically target cancer cells. Instead, they look for any rapidly growing cell. Cancer cells grow rapidly, but so do hair cells, cells lining the stomach, cells of the immune system, and cells in the bones. They, too, are killed by chemotherapy, causing a host of terrible side effects. Chemotherapy is not effective against prostate cancer per se; it's typically used only when the cancer has spread. And it's not a cure; it only helps relieve some advanced cancer symptoms.
Watchful waiting is recommended by some doctors (usually for older men) in the early stages of prostate cancer, before the tumor is big enough to "warrant" attack by surgery or radiation. Watchful waiting has the benefit of not assaulting the body, but it does nothing to stimulate the body's defenses. Many studies have found that watchful waiters match or slightly exceed the life spans of those who opt for surgery, and that the quality of their lives is far superior. (For more on this subject, read "Still Waiting, Watchfully" in the 5/13/96 issue of Fortune magazine.)
These interesting approaches may be useful adjuncts or substitutes for the traditional surgery, radiation, and hormone therapy, but they all miss the boat. None of them cleans the body of toxins and blockages, or strengthens the body's ability to heal itself and this process is the only way to successfully deal with prostate cancer.
WHAT SHOULD YOU DO?
Urologists argue passionately for surgery, while radiologists sing the praises of radiation therapy. Other physicians may insist that hormone therapy is the only salvation. Each specialist urges you to opt for their approach, insisting that it's absolutely the best thing to do, and that you should do it right now.
If your doctor tells you they have you scheduled for surgery or radiation tomorrow, or if they want to remove your testicles, start grilling them. Ask them to describe the side effects of these treatments, and the likelihood of suffering associated with each. Verbally pin them to the wall; make them defend their approach and show you the statistics that prove theirs is the best approach. Ask the doctors if their approaches help the body heal itself. If they are honest, they'll admit the answer is no. Ask for comparative analyses with other possible treatments. Get second and third opinions. Learn all you can.
After you've discovered the limitations of standard Western medicine, look into ways of cleansing your body and removing the blockages that encourage disease. Think about and visualize strengthening your body's ability to heal itself. Doesn't that make the most sense? If you agree that the best approach is to make your body strong enough to naturally and completely dispense with the cancer, keep reading. Then spring into action!
Implement your own healing plan. It can work, and it can work quickly: in 90 days! Remember, healthy bodies successful ward off cancer every day! Regularly monitor your progress. You can always fall back on your medical treatment of choice if necessary. (My unused fall-back choice was seed radiation.)
Bone marrow transplants have been giving hope to people with stubborn cases of breast cancer for years, but the effectiveness of the procedure has never been clear. A new study has renewed the debate.
The Health Unit is a partnership with the Henry J. Kaiser Family Foundation.
SUSAN DENTZER: Nine of Joanne Ruddy's eleven children gathered in a hospital room last month to wish their mother a happy 55th birthday.
KIDS SINGING: Happy Birthday, Dear Mom, Happy Birthday to you.
SUSAN DENTZER: As she opened gifts and read cards from her two absent children, Joanne seemed eager to return home from Georgetown University Hospital after her latest bout of treatment for breast cancer.
JOANNE RUDDY: Thank you everybody -- a lot to look forward to when I get home.
SUSAN DENTZER: It's been almost a year since Joanne, a former school teacher, was diagnosed with inflammatory breast cancer. That is one of the most aggressive and least curable forms of the disease.
JOANNE RUDDY: "Dear Mom, everyone who still thinks you look terrific raise your hand"--
SUSAN DENTZER: Once the cancer was discovered, Joanne had chemotherapy to kill cancer cells that may have spread throughout her body. That was followed by a mastectomy and still more chemotherapy. Then, even as she celebrated her birthday, she was undergoing still another treatment -- doses of chemotherapy so powerful that they virtually destroyed her bone marrow, blood supply, and immune system. To keep Joanne from dying from the high-dose chemotherapy, special cells known as "stem cells" had been removed from her blood beforehand. They were mixed with a preservative and temporarily frozen. When the high-dose chemotherapy was complete, the cells were thawed. Then they were transfused back into Joanne Ruddy's body to help her bone marrow, blood supply and immune system regenerate.
HEALTH CARE WORKER: And then we're just going to do your vitals every fifteen minutes for one hour.
SUSAN DENTZER: Just days before Joanne Ruddy underwent the treatment last month, this same therapy made the news. Splashed across the front pages of the nation's leading newspapers were headlines like these. The stories reported on five major studies of breast cancer patients who had undergone similar high-dose chemotherapy and transfusions, known as "transplants". At first glance, most of the studies seemed to show little, if any, benefit from the procedure. Joanne Ruddy wasn't deterred.
JOANNE RUDDY: My doctor all along has told me that they don't have definitive answers, that they don't have enough information yet. I'm putting my trust in God that, you know, you have to take a chance.
DR. KENNETH MEEHAN: Hi! How's it going, okay?
JOANNE RUDDY: Yes --
SUSAN DENTZER: Joanne's physician, Dr. Kenneth Meehan, is a breast cancer transplant specialist at Georgetown.
A last resort.
DR. KENNETH MEEHAN: Most patients, in general, when they come to see me, they will do anything to try to live as long as they can without disease. Joanne, in particular, has a very large family, a number of children. She wanted to be very aggressive.
SUSAN DENTZER: That determination has hurtled Joanne into the midst of a raging medical controversy: How well -- and for which breast cancer patients -- do high-dose chemotherapy and transplants work? The debate constitutes a case study of the most difficult issues in medicine, where costly innovations offer new hope to the very sick -- however slim that hope may be. Dr. Lee Newcomer is medical director of United Health Group, one of the nation's largest health maintenance organizations. A cancer specialist, he has reviewed hundreds of cases of patients seeking high-dose chemotherapy and transplants.
DR. LEE NEWCOMER: I think the big issue is what's the right thing to do, and do we have some science and some evidence to tell a woman facing this decision what she really has to look forward to in terms of side effects, and in terms of outlook.
SUSAN DENTZER: A woman, that is, like Joanne Ruddy -- or like 49-year-old Sandra Rolef, who had a mastectomy for breast cancer several months ago. By that time, the disease had spread to 16 of her underarm lymph nodes, putting her at very high risk for a recurrence. Along with her husband, Rolef is now consulting oncologist, Dr. Robert Siegel of George Washington University. They are considering whether to go ahead with the high-dose chemotherapy and stem cell transplant.
DR. ROBERT SIEGEL: It's not a slam dunk one way or the other.
SANDRA ROLEF: So you're not ready to really make a final recommendation to me yet?
DR. ROBERT SIEGEL: I just think it's important not to jump to conclusions before you have to.
SUSAN DENTZER: Although Dr. Siegel is uncertain, other doctors Rolef consulted encouraged her to proceed.
"It's a kind of personal decision."
SANDRA ROLEF: One of the doctors said something to me that really is kind of sticking in the back of my mind, and she said, "You know, it's kind of a personal decision. And if you're the kind of person that wants to make sure that no stone is unturned, that you have done everything humanly possible to fight this disease and make sure that you're rid of it, then you should do it."
SUSAN DENTZER: The debate over the treatment's effectiveness has raged since the 1970s. Back then, high-dose chemotherapy and transplants were first used successfully to treat other forms of cancer, such as leukemia. Inevitably, doctors also began testing the approach in "advanced" cases of breast cancer in which the disease had spread to organs or bones. Such patients were given doses of chemotherapy drugs that were five to 30 times higher than those used in conventional treatment.
DR. LEE NEWCOMER: There was a lot of theory about the bigger the dose, the better the chance of getting rid of the cancer. By the middle 1980s this was a fairly common procedure.
SUSAN DENTZER: At the time, doctors used patients' own bone marrow for the transplants. They later switched to using blood stem cells when these proved just as effective. The treatment was costly -- as much as $200,000, or several times the price of more conventional breast cancer therapy. It was also very risky. Early on, as many as 1 out of 5 who got the treatment died from it, rather than from breast cancer. Besides the risks, there was also no hard scientific evidence that the treatment was effective. As a result, many health insurers balked at paying the costs. Breast cancer survivor Fran Visco is president of the National Breast Cancer Coalition, a group of 25 patient advocacy organizations.
FRAN VISCO: Physicians would say to women, a bone marrow transplant is the only thing that could possibly save your life. And you had situations where women sued insurance companies, requiring their company to cover a bone marrow transplant.
SUSAN DENTZER: The quest for treatment generated some of the highest-profile lawsuits brought against health insurers over the past decade. One involved this California woman, who sued her HMO, got the treatment, and subsequently died. In her case, as in others, courts ordered insurers to pay the costs.
FRAN VISCO: Well, insurance companies threw in the towel and started paying for bone marrow transplants broadly because of some of the verdicts.
But does it work?
SUSAN DENTZER: But there was still little hard evidence that the treatment worked -- the kind of information only gained from rigorous clinical trials. That's in part because assembling such studies was difficult. In a well-done clinical trial of this type, patients are randomly assigned to receive either the experimental treatment being tested or the standard, effective therapy. But many patients resisted entering trials, since they were convinced that the experimental treatment was their only hope.
DR. KENNETH MEEHAN: Patients nowadays are very intelligent. They do not want to be randomized to the chemotherapy line, despite my emphasis saying, 'We're not sure if this works at this point in certain situations. I would recommend this trial.' They would go elsewhere.
SUSAN DENTZER: Out of the estimated 12,000 women who underwent the treatment, only 1,000 participated in clinical trials.
FRAN VISCO: The real tragedy in this story is that if women had enrolled in the bone marrow transplant trials, if their physicians had encouraged them to do so, we would have had the answer years ago, and it would have saved lives.
SUSAN DENTZER: Gradually, though, major trials were assembled and began to accumulate results. One conducted from 1990 to 1997 tracked women with advanced cancer that had spread to organs or bones. After three years, the study showed no difference in survival rates between patients who got the new therapy and those who got the standard treatment. When this and other major studies made news last month, Sandra Rolef says --
SANDRA ROLEF: It had my telephone ringing -- lots of friends and family hysterical over it because of what the studies say. 'Why are you doing this, and, you know, why don't you just take your stem cells and freeze them and think about it?'.
SUSAN DENTZER: But the studies have not cleared up the controversy and they may actually have deepened it. On one side, Fran Visco's group argued that the procedure was fruitless.
FRAN VISCO: High-dose chemotherapy with bone marrow transplants for breast cancer is not an effective therapy.
Clearing up the controversy.
SUSAN DENTZER: But other cancer specialists argue that the results of the studies were far more ambiguous. Dr. John Durant is executive vice president of the American Society of Clinical Oncologists, known as ASCO.
DR. JOHN DURANT: It's way premature to say this strategy doesn't work. I think the strategy will continue to be of interest as a means of improving survival.
SUSAN DENTZER: To bolster their case that the jury on transplants isn't yet in, Durant and other specialists point to the complexities of the studies. One important factor is just how sick were the patients in the clinical trials. For example, the studies suggested the new therapy did not improve survival of patients with advanced cancer that had spread to organs or bones. On the other hand, the treatment looked more promising for patients like Sandra Rolef, whose cancer had only spread to 10 or more underarm lymph nodes. In one study conducted in South Africa, these high-risk patients who underwent the experimental therapy were far more likely to survive. Some of the clinical trials will now continue, and in addition, doctors say new studies are needed. For example, they want to know how effective the treatment is for other forms of breast cancer, such as the inflammatory cancer that afflicts Joanne Ruddy. They also want to understand the effects of treatment innovations that have taken place since the first studies began. For example, new procedures have cut the transplant death rate to as low as 1 in 20 patients. And powerful new chemotherapy drugs such as Taxol may also have yielded better results.
DR. KENNETH MEEHAN: I think that in the long run there will be a small advantage to transplant. It's not going to be 50, 60, 70 percent. It may be 10 percent, maybe a little bit higher.
SUSAN DENTZER: But Durant says it will be a while before those results are in.
SUSAN DENTZER: On a scale of one to ten, one being we know almost nothing about all of this, ten being that we know everything, where are we?
DR. JOHN DURANT: Oh, we're at two or three probably.
SUSAN DENTZER: The uncertainty raises the stakes for patients like Sandra Rolef.
SANDRA ROLEF: I don't want to look back in a year, or two years, or five years and say I should have, when they have more data, and maybe the data is going to end up saying that it does help. And how could I live with myself?
SUSAN DENTZER: After all, for Rolef, Ruddy and their families, the goal is living to celebrate more birthdays.
KIDS: All right! clapping
SUSAN DENTZER: The transplant studies will be a major topic of discussion next week. That's when cancer experts meet in Atlanta for ASCO's annual conference.