The Diagnosis

This part of the story is rather straightforward. I had naturally thought about the best age at which to begin prostate cancer screening. Even today, screening for prostate cancer is controversial (Table I). In fact, neither the National Cancer Institute nor the American Cancer Society recommends prostate cancer screening. Dr. Otis Brawley, a prostate cancer specialist at the National Cancer Institute and a close personal friend, has written at length and with considerable insight on why prostate cancer screening may not be wise. 

In contrast, I have favored screening. My views on this were strengthened this past year by two events. First, prostate cancer death rates have clearly been falling since 1993. The timing of this decline fits perfectly with what you would expect if PSA-based screening were responsible. Second, Dr. Ferdnand Labrie published the first randomized controlled trial that evaluated the impact of screening on prostate cancer deaths. He reported a greater than 60% decline in deaths among screened as compared with unscreened patients. I should note that this study remains quite controversial, and for this reason it is important that these findings be duplicated by other investigators. Despite the controversy, these twin findings led me to advocate screening in this newsletter twice within the past year (September, 1998, and February, 1999). 

I was 55 when I was diagnosed with prostate cancer. When should screening start? Recommendations range from 45 to 55 years of age. Only about 2% of the men are diagnosed with this disease at age 55 or younger. Of that 2%, roughly half have a family history of prostate cancer. I had no family history of prostate cancer, and so I thought age 55 should be early enough. Rose did not agree with me: she had wanted me to start screening at age 50 and had become increasingly vocal about this issue as the years passed. 

I remember not feeling any anxiety or concern when I went for the digital rectal exam and PSA test. I had no symptoms, no family history, and a generally healthy life-style. I did not anticipate any problems. I had selected a urologist, Dr. Marguerite Lippert, in whom I have complete confidence. You can image my shock when she said, "You have a nodule." The prostate gland was on the small side and the nodule was rock hard š findings classic for cancer. We agreed on a biopsy, which was done immediately! I will always be thankful to Dr. Lippert for rearranging her schedule on such a short notice so that the biopsy could be done right away. Unlike many patients, I did not have a long wait to find out if I had prostate cancer.

Rose was at a physical therapy meeting in Seattle and flew home when she heard that I had had a biopsy. We spent a sleepless night. The next day, we were told the PSA was 20.4 nanograms per milliliter and the biopsy specimen contained a Gleason 7 (3+4) prostate cancer. 

The patients most likely to be cured of prostate cancer by radiation therapy or surgery have Gleason scores of 6 or lower and a PSA of 10 or less. I had a real problem: my cancer could well have spread outside the prostate gland. It might even have spread to lymph nodes or bone. I might have meta-static prostate cancer! I might die of prostate cancer! I knew that our lives would never be the same. 

Rose was very supportive and kind. I think it helped that through her work on the Prostate Forum she too has become an expert in prostate cancer. We both knew that while I had a problem, there was hope. We agreed that we would attack this cancer as aggressively as possible. 

At this point, I also began to confront the issue of when to go public with the diagnosis. I wanted to be able to seek the advice of physicians around the country who had expertise relevant to my problem. I had always been impressed that patients did better when they were part of a support group, and I did not want to deprive myself of that advantage. Also, I knew that it had been a mistake for me not to start screening at age 50. I wanted to be able to use my experience to convince others to begin prostate screening early. Finally, I could not imagine writing this newsletter while keeping my diagnosis secret: it seemed to me to violate a trust between you and me. 

It is said that the Doctor who treats himself has a fool for a patient. I have had to assemble a group of physicians to guide my care. While it is possible for me to get advice from professional colleagues around the country, on a day-by-day basis I needed physicians here in Charlottesville whose judgment I trust. Dr. Lippert, Dr. Dan Theodorescu, and Dr. Roger Cohen are physicians with whom I have shared the management of many patients and have come to trust their judgment. I chose them to help develop my treatment plan and coordinate my care.

References:

The first two references are on screening. The first is Dr. Labrie‰s recent controversial publication that reports a dramatic reduction in prostate cancer deaths associated with screening. The second is a well-reasoned discussion on why it is premature to recommend prostate cancer screening.

F. Labrie, et al. "Screening Decreases Prostate Cancer Death: First Analysis of the 1988 Quebec Prospective Randomized Con-trolled Trial" The Prostate 38:83-91, 1999.

O. Brawley. "Prostate Carcinoma Incidence and Patient Mortality" Cancer 80: 1857-1863, 1997.

The next two papers from Dr. Alan Partin and his colleagues provide tables useful in predicting whether the cancer has spread beyond the prostate gland. Dr. Steven Strum has made these tables available over the internet. You can access the tables at:

http://rattler.cameron.edu/prostate/strum/narayan.

A. W. Partin, et al. "Combination of PSA, clinical stage and Gleason Score to Predict Pathological Stage of localized Prostate Cancer š a multi institutional Update" Journal of the American Medical Society 277: 1445-1451, 1997.

This last paper is of considerable importance because it compares the ProstatScint scan with the Partin Tables and a number of other tables generated by other investigators. The ProstaScint scan compares favorably with all of these other techniques, but the best results come from combining the ProstaScint scan with the Partin Tables. 

T. J. Polascik, et al. "Comparison of Clinical Staging Algorithms and (111) Indiumcapromab pendetide immunoscintigraphy in the prediction of lymph node involvement in high risk prostate cancer patients" Cancer 85: 1586, 1999.