Once upon a time, Robinson Crusoe had a prostate biopsy just before setting sail from England to the New World. In his rush, he missed an appointment with his Harley Street urologist to go over biopsy results. The worried urologist filled a couple hundred sealed bottles with the message “Robinson Crusoe has prostate cancer” and cast them out to sea.
On cannibal watch one morning, Friday found one of the bottles that had washed ashore. He couldn’t read the message, but it looked important so he ran with the note to Crusoe, who read the one sentence message aloud. Silence followed.
“Robinson Crusoe has prostate cancer,” squawked Poll the Parrot breaking the silence.
Maybe the cancer was the reason he was getting up a couple of times every night to urinate. The parrot’s constant reminders of “Robinson Crusoe has prostate cancer” fueled his anxiety level. Years passed and nothing happened. Crusoe was still waking up and tripping over cats and goats a couple times a night. Polly finally shut up after 10 years or so. Crusoe began to wonder if the message had been a hoax.
For many men today a “positive prostate biopsy” isn’t a hoax, but it’s a scary message often best left in an unopened bottle. The shipwrecked Crusoe had less to worry about 200 years ago than say a 70-year-old man today with a positive prostate biopsy who lives in Metairie Club Gardens. Robinson Crusoe didn’t have to fret about options often associated with more complications than the cancer itself – repeat biopsies, surgery and radiation treatments.
Screening for any disease only makes sense when early detection and treatment leads to a better outcome measured by quality of life and quantity of life – preferably both. Most men with cancer cells in their prostate end up dying of unrelated causes. In my 30 plus years of practice, dozens of my patients have been diagnosed with prostate cancer. Yet, I can recall only three who developed advanced prostate cancer, and two of those had had prior surgeries removing their entire prostates.
No doubt urologists and oncologists see more patients with serious prostate cancers. Dr. Oliver Sartor at Tulane Medical Center is one of those specialists. He has published more than 150 articles and viewpoints related to prostate cancer. He is the only medical oncologist in Louisiana I know whose entire practice is devoted to treatment of prostate cancer.
“Men with low risk prostate cancers rarely benefit from treatment. Surveillance rather than surgery or radiation therapy has become the best option for most men diagnosed with prostate cancer today,” says Sartor. “This is especially true for those who had prostate biopsies just because of an elevated PSA (prostate-specific antigen). Surveillance programs are beginning to curb adverse effects from unneeded treatments.”
Serial PSA determinations, specialized imaging studies, and even repeat prostate biopsies define the backbone of aggressive surveillance, a strategy recommended by Sartor only for younger men likely to benefit down the line from more definitive treatment.
“Older men need more gentle surveillance. Chronological age is just a surrogate of life expectancy. But 50-year-olds and 75-year-olds are just different patients,” says Sartor, who just follows the PSA in some patients and tells others to recheck in a year unless some problem develops.
Back to Crusoe and his nocturnal awakenings on the Island of Despair: Men over the half-century mark often find themselves getting up two or three times a night to urinate. If this is your problem, you have an edge over Crusoe. Today there are effective drugs to help control urine storage and voiding problems.
Several prescription drugs relax the smooth muscle fibers to allow more complete bladder emptying. These drugs can also cause blood pressure drops and fainting that can be a problem, especially for persons with normally low blood pressures. I know from experience. A few years ago I slumped over in my chair at Galatoire’s Restaurant a couple of days after I started taking one of these drugs. I woke up with a city EMS team at the table asking me my name. I answered Melvin Rodrigue. They left me and my startled guests with “a goodbye Dr. Lutz” and a twinkle in their eye. I knew that twinkle. I have used that twinkle. It is the sort of twinkle medical personnel use to communicate to each other that maybe something related to alcohol was at play.
The FDA approved Proscar in 1992. Six months of daily Proscar can shrink an enlarged prostate by 20 percent, and that 20 percent can make a real difference in decreasing urinary outflow problems. Proscar also decreases the risk of prostate cancer. In a just updated cancer preventive study started 18 years ago, Proscar reduced the risk of the low-grade cancers that just need watching by 43 percent. The persons who took Proscar were a tad more likely to develop higher-grade and more problematic tumors over the 18-year period than the folks who took the placebo, but the survival rates were the same for both groups.
But there’s no free lunch. Proscar has its own set of potential adverse effects including decreased ejaculatory volume, impotence, and erectile dysfunction. It wouldn’t be a drug a former governor in his 80s looking to impregnate a young wife would want to take.
The Story of Sam Craig
“My PSA was high so I saw a urologist. I forget the actual value. I know it was over five but less than 10, so I had a prostate biopsy,” says a local man about town, who asked me to call him Sam Craig. “I returned the next week for the results and left the office with a diagnosis of prostate cancer. He told me that surgical removal of my prostate would cure the cancer for sure, but then he went over the complications. I considered myself a very active 75-year-old, so the prospect of impotency bothered me, if you know what I mean.”
He continues, “The urologist sent me to a radiation oncologist. She really gave me a hard sell on injecting my prostate with radioactive seeds. She downplayed any side effects, but I saw a friend in her waiting room who told me his story. Not only was he now impotent, he had to wear Depends. I called my brother who lives out of town. He suggested that I get another opinion and that’s when I heard about an option other than surgery or radiation – simply see what happens if I do nothing.”
“That was three years ago,” Craig says. “I am now a healthy 78-year-old and still going strong in that department – you know what I mean. I get up a couple of times a night to urinate. But most old men my age do that. Otherwise, nothing is bothering me in that department, and I’m not bothering it.”
Hopefully fewer men will face Craig’s dilemma. Routine PSA testing for men over a certain age has now gone the way of 78 records and eight-track tape decks. The United States Preventative Services Task Force is on record against routine PSA screening for men, stating that potential harms outweigh the benefits.
