Prostate cancer is the second leading cause of death among American men, behind lung cancer. The prostate gland, which manufactures seminal fluid, usually causes no problems until midlife when a tumor can enlarge the gland and interfere with urination. Each year, 40,000 men will die from prostate cancer and more than 200,000 will be diagnosed with it.
Many new cases are coming to light solely because of the PSA test. The test -- which measures the level of an enzyme known as prostate-specific antigen, a substance usually elevated in men with prostate cancer -- has sparked a national debate among doctors, some of whom say it shouldn't be done at all.
It seems logical that early detection for a disease that can kill is a good thing. But no one has yet demonstrated -- beyond a shadow of a doubt -- that the PSA test saves men's lives.
Prostate tumors are unlike most tumors, due to a wide variation in how they behave, says Dr. Philip Kantoff, an oncologist and director of the Prostate Cancer Clinic at Boston's Dana-Farber Cancer Institute. Some prostate tumors spread rapidly to bones and other organs. Others remain dormant for decades. Dr. Kantoff estimates that 8 million men in the United States have prostate cancer right now. Most will remain blissfully unaware of it throughout their entire lives.
"More men die with prostate cancer than from it," says Dr. Kantoff. Prostate cancer is present in 30 percent of men over age 50, and it becomes even more common with each passing decade. But many tumors are "clinically insignificant," he says. The difficulty lies in distinguishing these from potentially lethal ones. There's no way to predict, with total accuracy, which tumors will turn deadly.
In the past, prostate cancer was discovered when a doctor felt a suspicious lump or when it caused pain or trouble with urination. By then, the cancer had often already spread. Today, the disease is almost always found much earlier, and the PSA test is widely hailed as the reason.
But here's the reason for the controversy: The test generates a high number of false positives, often creating unnecessary anxiety. Even if cancer is found, it may not be the deadly kind. Conversely, a PSA reading can be normal even in the presence of cancer.
"The key is if PSA testing will decrease mortality rates," says Dr. Peter R. Carroll, a urologic oncologist at the University of California, San Francisco Medical Center. "I think it will, but the question will be, 'At what price?' "
But Dr. Otis W. Brawley, an oncologist at the National Cancer Institute, is convinced the PSA test is dangerous. He's so certain that he's betting his life on it. Dr. Brawley is a prime candidate for prostate cancer. He's 39 and African-American (this cancer often strikes black men early), and two uncles had the disease. Yet he won't even consider taking the test.
"I practice what I preach," Dr. Brawley says. "I believe that when we finally get the studies done, we will find prostate cancer screening will ruin lives, not save them. I really believe that."
PSA screening, he concedes, can pick up tumors before they cause any symptoms. But, he says, early diagnosis doesn't necessarily add years to a patient's life. Instead, he says, the PSA test exposes men to the very real threat of needless treatment. Prostate cancer often grows so slowly that a man will die of something else first.
"Yes, they have cancer, but it was never going to kill them," says Dr. Brawley. "That's the big problem."
Cancer eventually returns in one quarter of patients who have a prostatectomy, negating the benefits of undergoing a major operation. No one, he says, has proven that any patients were actually cured through medical intervention. Their tumors might not have spread anyway, with or without treatment, says Dr. Brawley.
He cites findings published in the Journal of the American Medical Association. Two groups of Swedish patients with early, nonaggressive prostate cancer were followed over 15 years. One group was treated; the other wasn't. The outcome: Absolutely no difference in the death rate.
But Dr. Patrick C. Walsh, chief urologist at Johns Hopkins Hospital and one of the country's most noted authorities, condemns this study. He coauthored the journal's accompanying editorial, which said Swedish men die from prostate cancer at an alarming rate.
Sweden, a country in which screening generally isn't available, has the fourth-highest, age-adjusted death toll in the world. Dr. Walsh argues that many patients with advanced cancer might have been cured if treated earlier.
Dr. Walsh says, however, that the PSA test should be done in conjunction with a digital rectal exam. When used together, the two tests usually find the cancer while it's still confined to the prostate.
"I think every healthy man over age 50 who doesn't want to die of prostate cancer should be tested," says Dr. Walsh. "If they're African-American or have multiple family members with prostate cancer, that age is lowered to between 40 and 50. If they don't care, that's OK. But I think men need to know there's a test out there picking up the disease."
So if you're a middle-aged man, what should you do? If you're a woman, should you encourage the men in your life to be screened?
Although the average age at the time of diagnosis is 72, prostate cancer does occur in the prime of life. And, when it strikes early, it often moves swiftly. But even a slow-growing tumor can pose problems for a man in his 40s, 50s, or early 60s.
The National Cancer Institute isn't a fan of early screening, saying there's insufficient evidence that it helps reduce deaths. The American Cancer Society says doctors should offer the test to men over age 50 and provide them with information "regarding potential risks and benefits of intervention." Men at high risk for prostate cancer may consider testing in their mid-40s.
Dr. Kantoff doesn't think anyone will have the answer any impact to the mortality rate becomes apparent. Since prostate cancer typically grows slowly, it takes at least a decade to notice a difference in the death toll. Widespread screening has only been available since 1992.
However, Dr. Kantoff believes the data will fall squarely on the side of screening. "I'm laboring under the assumption it will," he says. "Right now, the PSA test is the best thing we have."
He says only elderly men whose doctors predict will live 10 or more years should consider screening. And, he says, it should be done only if they understand what can happen as a result of taking the test. About 20 percent of men over age 50 who undergo a digital rectal exam and PSA test get an abnormal finding. Often, an ultrasound and biopsy follow. Then, between 2 to 6 percent of these patients are diagnosed with cancer, and must then make difficult decisions.
"It is possible that PSA screening may save lives," says Dr. Kantoff. "But it's also probable it will alter the quality of your life."
Yet, one fact remains. A growing group of men, including Bob Watson, are certain they wouldn't be healthy today if it weren't for the PSA test.
Few conditions create as much controversy as prostate cancer, so it's no surprise doctors have different theories on how best to treat it. Patients who shop around can easily find a doctor willing to try something new or experimental. But some treatments are so new, it's impossible to judge long-term effectiveness, says Dr. Patrick C. Walsh, chief urologist at Johns Hopkins Hospital. Here are the most widely accepted ones:
Surgery. Radical prostatectomy is still considered the standard cure. Overall, about 70 percent of patients are free of cancer 10 years later. The prognosis is even more favorable for men with cancer that appears confined to the prostate. However, this isn't an easy cure.
Recovery takes four to six weeks. Impotence is a common side effect, although sexual function is sometimes preserved with newer surgical techniques. A small group of patients experience ongoing problems with bladder control.
A new study paints a more positive picture of life after surgery. It found 90 percent of patients were happy with their decision. It also found that men who chose surgery had only a slightly higher incidence of impotence and incontinence than prostate cancer patients who had a different kind of treatment.
"For men in their 40s and 50s, surgery is the best form of treatment because it has the best track record so far in terms of curing the cancer," says Dr. Walsh.
Radiation. External beam radiation is often recommended for men over 70, or for patients with cancer that has spread. Many experts argue that it doesn't have the same potential to cure as surgery, but it can control most localized cancers for long periods.
Watchful waiting. Managing the prostate with semiannual checkups is an option for older patients, as well as for men with tiny, nonaggressive cancers. Some men with advanced tumors may choose to just attack symptoms and not the underlying disease.
Watchful waiting may allow men to avoid the side effects of some treatments, but they should be aware that there's no way to predict -- with total certainty -- which cancers will spread.