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A guy thing One in seven Canadian men will be diagnosed with prostate cancer during their lifetime. What you need to know.
BY JOEL SCHLESINGER When Norm Oman retired from teaching more than 18 years ago, the proverbial golden years lay ahead of him. His first order of business was to spend a little time taking it easy and helping out his son. "I spent the first few months helping out at my son's deli, Norm and Nate's," Oman recalls. "I was taking my time, kind of waiting and seeing how things would turn out." Then his life changed in a way that he'd never imagined. In 1991, Oman noticed a lump on his testicle. He was worried the mass might be cancerous, even though testicular cancer is often associated with younger men. Better safe than sorry, he thought, so he made an appointment to see the doctor, who referred him to a specialist. The urologist, who examined Oman, said the lump was nothing to be concerned about, but he also wanted to give him a blood test, the first in a series of exams and follow up visits over the next several weeks. Within two months, Oman was diagnosed with prostate cancer. The news came as a surprise to the Winnipeg man. Although the incidence of prostate cancer had been rising at a rate of about three per cent a year since 1970, it was still a little known disease at the time Oman was diagnosed. "I may have vaguely heard of it," Oman says. "You know, your old Uncle Louie. Something happened to him somewhere, but no, this was not something I thought about." But Oman soon discovered he was not alone. At the time of his diagnosis, prostate cancer had overtaken lung cancer as the most commonly diagnosed cancer among Canadian men. And by 2000, two highprofile cases of prostate cancer put it front and centre into the Canadian public's Today, one in seven men in Canada will be diagnosed with prostate cancer during their lifetime, according to CancerCare Manitoba. More men are diagnosed with the disease than any other form of cancer. And while the level of awareness has risen significantly over the last decade, many men are still in the dark about prostate cancer, and how it is diagnosed and treated. This uncertainty was underscored recently by the preliminary results of two studies - one American, one European - that seemed to raise questions about the effectiveness of screening for prostate cancer. A lack of encyclopedic knowledge among men about prostate cancer is not surprising. Like Oman, most men never think about their prostate health until later in life when their doctor often starts to look for signs of the disease. The prostate itself is a gland about the size of a plum or walnut, located in front of the rectum and below the bladder. Among other things, the prostate helps produce seminal fluid and regulates the flow of urine. While the causes of prostate cancer are unclear, this much is known: it is the third leading cause of death, behind lung and colorectal cancers, it is considered one of the more curable forms of the disease, and it doesn't always spread aggressively - a factor that complicates decisions about treatment options. "Therein lies the controversy and conundrum with prostate cancer," says Dr. Jeff Saranchuk, a urologist at the Dr. Ernest W. Ramsey Manitoba Prostate Centre at CancerCare Manitoba. "It's determining which patients are going to benefit from treatment" and which will do just as well without it. The roots of that controversy can be traced back to when Oman was being diagnosed in the early 1990s. At the time, doctors started screening men more frequently for prostate cancer, according to Dr. Dhali Dhaliwal, President of CancerCare Manitoba and Medical Director of Oncology for the Winnipeg Health Region. The most common test was the digital rectal exam. But physicians also started using something new: a prostate-specific antigen test - or PSA - which measures the level of a protein produced by a man's prostate gland. "There was a big wave of new cases discovered in the early 90s," says Dhaliwal, noting that the surge was partly due to the development of the PSA test. "That led to a lot more people talking." "Before digital rectal exam and PSA tests were being used, the most common way to diagnose it was for someone to come in with back pain, and it had spread," says Dr. Darrel Drachenberg, who is also a urologist and Director of Research at the Manitoba Prostate Centre. But by that time, it may have been too late to treat the disease. But while screening tests provided a tool for early detection, they also posed a problem because they weren't always accurate in determining the presence of cancer. A physician conducting a digital exam may discover someone with an enlarged prostate who may not have cancer, and vice versa. Likewise, a PSA can tell you what your antigen level is, but that is not necessarily proof of cancer, while a lower antigen level is not a guarantee that cancer does not exist. Only after a biopsy - the removal of tissue samples from the prostate - can doctors know definitively whether cancer is present. Compounding the problem is the fact that most men at some point in their lives will develop prostate cancer, though in many cases it may be relatively harmless. The chances of a man having the disease in some form roughly relate to his age. If you are 30, for instance, you theoretically have a 30 per cent chance that if doctors did a prostate biopsy, they'd find very early signs of disease. For the most part, however, prostate cancer is an older man's disease. Most men aren't screened until age 50, although men in higher risk groups - those of African-Canadian heritage or someone whose brother or father was diagnosed under the age of 60 - are offered screening after age 40. Still, it is a disease that will at some point affect the lives of a large number of men. "The chance of an 80-year-old man having prostate cancer is about 80 to 90 per cent," Saranchuk says. But about half of men diagnosed with prostate cancer have an indolent form. It's slow-growing and doesn't easily spread to other parts of the body. "It often can go unchecked for years and do nothing to the patient," Saranchuk says. As a result, some experts have long questioned the effectiveness of screening because it can lead to invasive procedures when leaving the cancer alone would have resulted in the same outcome. That view appeared to pick up momentum in the wake of the early results from the U.S. and European studies reported recently in the New England Journal of Medicine. Saranchuk says the studies suggest PSA testing saves few, if any lives, while exposing men to invasive treatments that can result in incontinence and impotence. "Good evidence showing there was a benefit to PSA screenings has always been lacking," says Saranchuk. "Now we are starting to see that there may actually be harms associated with it, in that it can lead to overdiagnosis and unnecessary treatment." Does that mean men should avoid being tested? Not necessarily, says Saranchuk. "What it does mean is that when you go down that road (to testing), you need to have a thorough understanding of the issues and have a good conversation with your doctor about what the test results mean." Drachenberg agrees, adding that he personally believes all men over 50 should continue to be tested. "Although many men with prostate cancer will die of causes other than prostate cancer; some men will have aggressive disease, and it is these men that early diagnosis and treatment will help," he says. It's also important to put the studies in context, says Drachenberg. "The reason the screening studies showed no significant benefits to screening is because there are many more men with non-aggressive cancer than aggressive cancer, and this diluted the results since these low-risk types of cancer never really need to be found and treated." Nonetheless, Drachenberg says the testing dilemma is a real one. "Men need to be educated about the risks and deficiencies of screening and the data that does not really support screening with PSA," he says. "(But) it is very difficult to stop screening since it is now entrenched in the medical community and ever moreso demanded by patients. Therefore, as long as one is thoughtful about who to treat and when to treat, hopefully we can end the needless treatment of many men (majority) and focus on those men who do require therapy." The key to appropriate treatment, of course, is determining whether the cancer is aggressive. Once that is done, other factors, including the age and health of the patient, can determine the treatment. Many patients, for example, are offered the choice of having no treatment at all, if, after a biopsy, doctors can determine the cancer is not aggressive and is unlikely to spread. Doctors are increasingly advising patients with a low-grade form of the disease to choose the watchful waiting route because the alternatives - an array of treatments ranging from a radical prostatectomy to radiotherapy - can cause lasting side-effects, such as urinary incontinence and impotence. There are several ways to actively treat prostate cancer: Radical prostatectomy This involves surgical remove of the prostate. The downside is that it also causes stress incontinence - leakage when coughing, sneezing or heavy lifting. A significant side effect of this surgery, and one that causes men a lot of bother and frustration, is problems achieving and maintaining an erection. Men faced with other health problems and over the age of 70 are not good candidates for surgery, which potentially involves substantial blood loss and a prolonged hospital stay. Radiotherapy This treatment uses a focused beam of radiation to destroy cancer cells. It is offered to men of advanced age with aggressive cancers. This treatment can also damage nerves responsible for erectile function and cause erectile dysfunction or ED. Radiotherapy is also used to treat men under the age of 70, but it is not commonly offered to men in their 50s or younger because exposure to radiation may itself cause cancer several years later. Unlike the prostatectomy, radiation therapy does not cause incontinence, but patients can experience rectal bleeding and diarrhea following treatments, which involve hospital visits every six weeks. Brachytherapy This is another form of radiotherapy, but does not require as much of a time commitment. The urologist implants tiny radioactive seeds in the prostate. While the patient can go home the same day, erectile dysfunction can occur. Some doctors may also advise the patient he shouldn't have children sit on his lap for about one year because of concerns about radiation - though other doctors would say that's being overly cautious. Hormone deprivation therapy The causes of prostate cancer may not be well understood, but doctors understand one thing: Testosterone fuels prostate cancer growth. Androgen deprivation therapy involves medication that cuts off the supply of testosterone and often completely stops the cancer from growing for an extended period of time. Hormone deprivation therapy is often only used for advanced cases of prostate cancer and often in conjunction with radiotherapy. Cryotherapy CancerCare Manitoba Foundation last month announced it is funding a vital piece of equipment to allow a novel way of treating prostate cancer patients using cryotherapy. This procedure freezes prostate tissue to treat early stage cancer in patients who may not be suitable for radiotherapy. Oman's case illustrates the challenges in determining how to treat a patient. He has been taking androgen deprivation therapy ever since being diagnosed in the 90s. When he was diagnosed, the cancer had already spread beyond his prostate. "The horse was out of the barn," he says. "Surgery as a treatment wouldn't have been that helpful." The prognosis was he would live five to six years. But more than 15 years later, he looks healthy, more like a man in his early 60s than late 70s. The only hint that he has prostate cancer might be a badge pin on his lapel asking, "What's your PSA?" While Oman's case is by no means unique, many other men are diagnosed before the disease is able to spread. It's a situation that leaves them with more options for treatment. The course of treatment can often come down to their personal preference - choosing the best course of action to suit their lives, and the side-effects they are willing to risk. Brian Sprott clearly remembers the moment the urologist told him he had cancer in 2006. But he remembers little of what the doctor told him shortly afterwards. "When you go to a urologist and he says you have cancer, you can hardly remember what he's saying after that," says Sprott, a retired carpenter in his early 60s. Sprott's PSA test results showed he had a slightly elevated PSA of five nanograms per millilitre of blood. Still, the doctor considered the reading to be reason enough to refer him to a urologist. After a biopsy, which the urologist had recommended, three of the eight samples taken from Sprott's prostate tested positive for cancer. The Gleason Score measures the aggressive nature of the cancer cells on a scale of two to 10. Sprott's Gleason was six, a very common score, often indicating the cancer was unlikely or slow to spread. Still, he chose to have the gland removed. "I thought that removal would eradicate the whole thing and that I would not get it later on, but we never know . . . do we?" He didn't rush into the decision. He knew about the sideeffects, yet he did what he thought would let him rest easy at night. "It comes down to a personal decision. That's kind of strange because if you have a broken bone, there's only one way to fix it, but this type of cancer, there are various treatments for it." Sprott didn't make it alone. Prostate cancer is often a two-person disease, and Sprott's wife, June, was there to talk through the issues. All of the major medical treatments available cause ED. Both the patient's and his partner's lifestyles can be affected. "When you have your prostate removed, you generally have erection problems unless you take a medication with a PDE5 inhibitor (Viagra, Cialis, Levitra)," Sprott says, adding even those may not be effective. The prostate is not easily removed without harming the bundles of nerves that control erections. "It's a trade-off. Do you want to have treatment and prolong life, or do you want to have sex until you die of cancer?" he says. "It wasn't as much of an issue for me as for some men." Vince Fontaine is an example of a younger man with prostate cancer who also opted for surgery. A guitarist with Eagle and Hawk, a Winnipeg-based alternative rock band, Fontaine was first diagnosed in 2000 at the age of 39 and says the news was devastating. "Let's just say that prostate and prostate cancer was not in my vocabulary," Fontaine says, explaining the shock of the diagnosis. At first, I was hopeful, very hopeful, that I would have prostatitis (an inflammation of the prostate)," Fontaine says in an interview. Fontaine recorded an 11 on his PSA test, and a biopsy revealed that his cancer was contained, but moderately aggressive. Fontaine says he didn't panic when he was diagnosed and thought carefully about his options, consulting three specialists before deciding on surgical removal of his prostate. "The conclusion (after consulting with the specialists) was that surgery was the best option," he says. His advice to men who are diagnosed with prostate cancer? "I would tell them to calm down and dig deep," he says. Don't panic, consider your options. You are not going to die today." Fortunately for Fontaine, life has returned to normal. But the surgery and the cancer has had an effect on him. "Any surgery is going to leave scars," he says, referring to the literal and figurative effects of an operation. Men facing a similar situation must prepare for the challenges ahead, he says. Dr. Anne Katz is a sexuality counsellor at the Prostate Centre and is writing a book about sexual health and chronic disease. She offers pre- and post-treatment guidance to men diagnosed with cancer at the facility. If a patient so chooses, he and his partner can meet with Katz several times to discuss at length the treatments and their potential impact on his physical, emotional and sexual health. At the top of the list for many patients is the potential loss of erectile function. Initially, she says, many patients may not be concerned about their ability to get erections when their lives are seemingly at stake. "But once the man goes through whatever treatment he has, he is essentially the same person he was before, and sex is an important part of many couples' lives," she says. "Erections are certainly part of a man's sex life, but they are much more than that. They are representative of masculinity and of how men see and perceive of themselves." Of course, for many men of advanced age, the ability to have erections is less of a concern, she adds. Many men, age 70 and older, may not even have that much choice in treatment. "We tend not to operate on men over 70 because the risks of the surgery are much greater than the risk of dying of the cancer," says Katz, adding that doctors often recommend the radiotherapy route. On rare occasions, the hormone deprivation therapy may be the only course of action after the cancer has spread. While the treatment may leave the nerves that control erectile function intact, it still causes ED and a whole host of other side-effects, including the reduction of a hormone called testosterone. "Testosterone is an essential part of your life," Dr. Katz says. "You probably don't realize it, but it gives you your male shape, hair distribution, sex drive, energy and, without it, men feel terrible." Oman has received injections of luteinizing hormone-releasing hormone (LHRH) analogs every three months since he was diagnosed with cancer. Before LHRH therapy was available, surgical castration was the only effective treatment to reduce a man's testosterone production. Oman has experienced weight gain and other undesirable side-effects, such as breast development, over the many years he has received treatment. "These are not fun things," he says. "But the treatment saves your life. That's worth the trade-off." While his cancer has been slow-growing, Oman has been anything but indolent in raising prostate cancer awareness. In 1992, the Prostate Centre didn't exist. Resources and support for prostate cancer sufferers and survivors were non-existent. The dearth of information prompted Oman to start up the Manitoba Prostate Cancer Support Group, one of the first in Canada. "Getting involved with the support group gives you a feeling of being active," he says, adding that the group meets every third Thursday of every month at Seven Oaks Hospital. Members often welcome newly diagnosed men looking for answers. Two Yet the biggest risk factor of all - at least for sufferers of advanced disease - may lie somewhere in the male psyche. "There is still a component of embarrassment or shyness about talking about anything to do with the nether regions," Dhaliwal says, adding that men have a tendency to ignore their health until they feel very ill. The Manitoba Prostate Cancer Support group is working to change that attitude, but much like the disease itself, Oman says the reason many men remain ignorant of their health is a bit of a mystery. "I don't know. I guess we're busy punching each other in the shoulder, and making rude noises." Joel Schlesinger is a Winnipeg writer.
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