The Big C

There’s an old adage that goes, “Never talk about your health… unless it’s good… unless you’re talking to your doctor.”

I try to live by that adage. After all, who wants to listen to someone’s list of health complaints? I was in the hospital this past October for three days, including two days in intensive care. When they let me out, I drove home and picked up living my life where I had left off. I didn’t go running about complaining.

But I’m going to make an exception. There’s something on my mind, and I’m going to write about it. You don’t have to read it, of course. You can skip down to an earlier post in this blog, or you can move on to the next person’s blog. But here goes.

This week I have a prostate biopsy scheduled. Prostate cancer is second only to lung cancer as a cause of cancer death in men. About 1 in 32 American men will die of prostate cancer. About 1 in 6 men will be diagnosed with prostate cancer at some point in their lives, and of that group about 1 in 5 men will die of the disease.

Prostate cancer begins in the prostate and often grows so slowly that a man living with it will die of another cause before the prostate cancer kills him. But not always. Sometimes prostate cancer is aggressive and spreads to other organs and to the pelvis and spine and legs. It can become disabling and agonizing. It’s something to avoid.

Doctors have a difficult time predicting how a prostate cancer will advance in a patient. Will it be slow-growing and safe to ignore? Will it be aggressive? Will it start out slow-growing and become aggressive? The answer is half science, half guess.

How do doctors know if a man has prostate cancer? One test is the PSA, which measures the amount of prostate specific antigen (PSA) contained in the man’s blood. The higher the PSA, the greater the chance of a tumor. But the problem with the PSA test is that it is notoriously unreliable. A man can have a normal PSA and still have prostate cancer. A man can have an elevated PSA and not have cancer. There are other possible reasons for an elevated PSA. One is inflammation (prostatits). I’ve had that. Another is benign prostatic hyperplasia (BPH) which is an enlarged prostate. I have that. BPH becomes more likely as a man ages. An estimated 50% of men will have BPH by age 50.

As far as PSA goes, there’s no magic number that indicates cancer. It’s probabilities. Doctors usually consider the cutoff point as 4.0 ng/ml. If a man’s PSA is below 4 and the digital rectal exam (DRE) shows no indication of cancer, and there are no symptoms, the doctor will say, “See you next year.” If the PSA is above 4, the doctor may want to do more tests. Because of prostatitis, my PSA has been above 4 for the last 6 years. In December 2010, it was 5.6. My urologist knows all these things, so he was pretty laid back about the number. But a month ago, December 2011, my PSA test result was 10.9. It had doubled in 12 months. My urologist held up the test result and said, “This test is screaming for a biopsy.” He said that his experience indicates I have a 40% chance of having cancer. The odds are in my favor, 60/40. It doesn’t make me feel comfortable.

Now comes the “fun” part. Allow me to explain how they perform the biopsy. The prostate is located below the bladder and in front of the rectum. The doctor will locate my prostate by inserting an ultrasound probe into my rectum and then take tissue samples by shooting hollow, steel needles through my rectum and through my prostate. He’ll take 12 tissue samples in 12 locations. Some doctors use 18 needles (though my doctor says in his experience 18 needles are no better than 12).

The doctor ran through a list of possible complications … pain, bleeding, infection requiring a course of antibiotics, and so on. He ran through the list so fast it was like listening to one of those TV commercials where at the end they voice-over a list of disclaimers so fast you’d swear the words are sped up by a computer that condenses them into the kind of continuous, rapid-fire stream of verbiage you hear from an auctioneer. But what difference does it make? I’ve pondered getting the biopsy. A biopsy could be the first step on a road to surgery or radiation or hormone treatments or chemotherapy or any of the other possibilities that come with a diagnosis of prostate cancer and that can leave a man incontinent as well as impotent: a panoply of treatments that may do absolutely nothing good for me and may be – indeed, are likely to be – completely unnecessary and very harmful. In fact, a recent study that followed 76,000 men for 13 years concluded that routine PSA screening has no affect on mortality rates.

On the other hand, if I do have prostate cancer and it’s becoming aggressive, I think that’s a good thing to know. It might kill me, but with treatment I might die in 10 years or 15 years instead of 2 years. Maybe by then I will have died of a stroke in my sleep instead of suffering from cancer that metastasized to my bones. I know a lot of people will say, “To hell with it, I’ll take my chances. If it kills me, it kills me. I’m not going to worry about it.” That’s fine, but you must know that’s never how it goes. You don’t go from being fine to being dead, as though you were hit by a bullet. It starts with little symptoms, like difficult or frequent urination. As the cancer progresses you have other symptoms, like pain in your lower back, hips, and upper thighs. At some point you go to the doctor, and that is when you find out you have cancer. You ignored it and now it’s too late for a cure. All the doctor can do is try to ameliorate the symptoms.

So. PSA, to test or not to test? Biopsy, get it done or roll the dice and hope for the best? Doctors who deal with individuals will tell you one thing, while scientists who study populations will tell you something different.

Ultimately, it comes down to this: it’s my life. Population studies are fine, but I’m an individual. And so I have to decide. At some point a few years ago I decided to get the PSA. And what’s the point of getting the PSA if I’m not going to get a biopsy when the PSA is screaming that I need one?