Wednesday, June 20, 2007
Chicago Tribune
by Judy Peres

Deciding what treatment to pursue -- if any -- once a man has been diagnosed with early prostate cancer is a highly individual process with no clear choices, doctors said Tuesday.

Because so much is unknown, "I tell patients they need to go with their gut feeling," said Dr. Otis Brawley, a cancer expert at Emory University in Atlanta.
Brawley also tells patients to take six months to interview specialists before making "one of the most important decisions in their life."

The staff of Cook County President Todd Stroger revealed Tuesday that he waited for 10 months after his diagnosis before he had surgery.

Several experts said waiting that long was unusual and perhaps not recommended for someone at high risk of dying of prostate cancer.

Brawley said a 10-month delay is "not that outrageous" if the patient has a low or moderate Gleason score, indicating that the cancer is not particularly aggressive. The Gleason score is a numerical method for evaluating the likely prognosis for a man with prostate cancer. It is based on microscopic examination of cancerous tissue.

But Rick Kittles, a geneticist at the University of Chicago, disagreed. "If you have three big risk factors, you should deal with this right away, no matter what the Gleason," said Kittles.

Stroger is African-American, he's relatively young at 44, and his father had prostate cancer. Those factors increase his risk of getting a life-threatening form of the disease.

Experts said it's possible Stroger at first opted for "watchful waiting" -- doing nothing but monitoring the progress of the disease -- and that something changed recently. Blood tests or a repeat biopsy might have indicated the tumor was growing, relatives might have pressured him to treat his disease more aggressively, or he might have grown uneasy knowing there was a cancer inside him.

"Sometimes a patient loses it and says he doesn't want to wait anymore," said Dr. Arieh Shalhav, chief of urology at the University of Chicago. At that point the patient gets to choose between removal of the prostate surgically, radiation of it (with external beams or implanted seeds) and, less commonly, freezing it.

Surgery is often the preferred treatment for younger men with localized prostate cancer. But "there's never been a study comparing [surgery, external-beam radiation and seeds] to be able to say for sure which is better," said Dr. Gerald Chodak, director of the Midwest Prostate and Urology Health Center. "The complication rates at three years are similar."

The most common complications of prostate cancer surgery are erectile dysfunction and incontinence.

Another major unknown in prostate cancer is whether healthy men should undergo regular screening tests for it. There is no solid evidence that screening saves lives, even though it detects the disease earlier, because many of the cancers found through blood tests and physical exams would never have caused problems.

"The downside of screening is you may be diagnosed with a non-life-threatening cancer and get treated and suffer complications you could have avoided," said Chodak.

But Kittles said there's "no controversy when you're dealing with African-Americans" because they have higher rates of aggressive prostate cancer.