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OPTIONS FOR TREATMENT
By Dr. Shafiq Qaadri, MD
'Am I going to be okay?" asks a 61-year-old man. "You're sure my prostate cancer hasn't spread?"
It had not. This individual was fortunate, as his disease was diagnosed early. But 20,000 Canadian men who will learn this year that they have prostate cancer will ask their doctors the same question.
Cancer of the prostate is the most common cancer in men -- affecting one in eight individuals -- and killing 4,500 men this year, according to the National Cancer Institute of Canada.
Tragically, the number of men affected will increase, as the baby-boom generation ages. Yet doctors hope to address this trend with early detection of the disease, aggressive treatment and vigilant monitoring. But many challenges remain, and Canadians must learn more about prostate health.
Barriers to diagnosis
People are still misinformed about the prostate. Recently, a 52-year-old woman asked to be tested for prostate cancer. When reassured that she didn't even have a prostate, she replied, "How do you know if you don't test me?"
"What is a prostate?" ask many patients, who have only vague ideas about the gland. Part of the male reproductive system, the prostate is the size of a chestnut, and secretes a milky nutritional fluid for sperm, enhancing fertility. Prostate cells begin to change at about age 45, commonly resulting in cancer a decade or two later.
"He took more care of his car than he did of himself," says the widow of a 59-year-old prostate-cancer victim. As a species, men are notorious for avoiding checkups, often having to be dragged to the doctor by their spouse. "I wish he had gone for regular physicals."
The American Cancer Society agrees, and recommends an annual blood test for prostate cancer, the PSA -- Prostatic Specific Antigen -- for men aged 50 and older. "Regular PSA screening can help identify prostate cancer long before any symptoms become apparent," according to the Mayo Clinic.
Yet men continue to feel embarrassed, scared or threatened by any problem potentially involving their masculinity. Even suggesting that a man have a screening test can lead to shock, defiance or anger. "Doc, there's nothing wrong with my plumbing," says a 55-year-old man who declined the PSA screen.
But such a cavalier attitude can kill, and must be changed. For example, 30 per cent of prostate-cancer patients -- about 6,000 men annually -- have tumours that have spread beyond the prostate at the time of diagnosis. This has a massive impact on survival, the intensity of treatment required and the quality of the man's remaining life.
Doctors are also amazed at how many problems prostate patients endure -- symptoms that range from bothersome to painful to incapacitating to lethal.
"Doctor, I get up to pee five times a night," says Walter Perz, a 73-year-old man with a non-cancerous prostate enlargement. "I'm so tired in the morning."
Some men will alter their lifestyles, learn the location of all washrooms, avoid social situations, even wear diapers -- anything, except ask their doctor for help.
Other men quietly suffer more ominous symptoms, including painful urination, bloody urine, loss of bladder control or low back pain caused by invading cancer.
The art of diagnosis
To confirm the presence of prostate cancer, physicians do a full examination, which involves touching, imaging and microscopically sampling the prostate. Feeling the prostate: A digital rectal examination involves inserting a gloved, lubricated, medically trained finger into the rectum, probing for suspicious lumps or bumps. Taking pictures: An ultrasound probe is inserted in the rectum and can distinguish between infections, cysts, non-cancerous enlargement or cancerous tumours. Tissue testing: Small bites of the prostate -- biopsy samples -- are the most accurate way of determining the presence or absence of cancer.
"What's the verdict, doc?" asks a 63-year-old man who had tests taken two weeks ago. "Give it to me straight." He trembled as he was told that he had cancer.
Announcing the diagnosis of cancer is routine for physicians, so they often forget how this numbs patients.
"When people are told they have cancer, their minds often go into panic mode," says Dr. Laurence Klotz, a professor of urology at the University of Toronto, and author of Prostate Cancer: A Guide for Patients.
It's also essential to share the diagnosis with the spouse, involving them in all aspects of care, as prostate cancer is truly a disease of couples. "What happens to him happens to me too," says Wendy Francis, whose 62-year-old husband is recovering from advanced prostate cancer.
Getting the patient's family involved early actually reinforces therapy. "Patients who do better, both psychologically and medically, are the ones who have a good support system," says Dr. Mark Litwin, a public-health specialist at the University of California at Los Angeles.
Choosing your cure
When selecting treatment(s), patients are often confused by the array of therapies. According to Dr. Klotz, "[Prostate cancer] is characterized by patient choices at almost every step of the disease process." Opting for surgery, radiation, hormone pills or "watchful waiting," men must work with their physicians to make individualized choices.
Many questions must be considered, such as: Can the prostate cancer be cured? What is the best therapy for this patient? What are the risks and side effects of therapy? How will the patient know if the treatment is working? Will the patient be on therapy permanently? What is the expected survival-time?
For example, since most prostate cancers take 10 years to become life-threatening, a 75-year-old man might test his PSA levels every few months, hoping to catch a rise, a strategy known as "watchful waiting."
Surgery to remove the prostate offers the best chance for immediate cure, and is recommended for younger men who expect to live many years after treatment. Hormone tablets are given to patients whose cancers have spread beyond the prostate, or whose cancers have recurred.
Deciding on the best treatment plan is a challenge for doctors, patients and their families, particularly as opinions shift with each new research finding. And surviving the disease, its treatment and the various side effects, calls on the coping skills of all concerned.
Back to life
Impotence is the most dreaded side effect for men. Most of the counselling, pills, injections, devices and psychotherapy are devoted to sexual function. "Men feel they cannot possibly be true men if they cannot perform sexually," says Dr. Stephen Rous, professor of urology at Dartmouth Medical School, and author of The Prostate Book: Sound Advice on Symptoms and Treatment.
"I didn't know you could have an orgasm without an erection," says a man who became impotent after prostate-cancer surgery. Through counselling, patients expand their ideas of sex and intimacy, learning new ways to pleasure and be pleasured. This individual's wife was delighted, saying, "It was like courting all over again."
There are also erection-injections for the penis, which men self-administer. Men are afraid at first, but they later appreciate the one-hour performance time.
Recovery from prostate cancer is a challenging and ongoing process. With guidance, couples move from anguish to understanding to coping to flourishing. As one prostate-cancer survivor's wife said, "We value life more than ever before. . . . Treasure your moments together." Doctors aspire to eradicate prostate cancer, believing that no man should die of this disease.
Dr. Shafiq Qaadri is a Toronto family physician and Continuing Medical Education lecturer. www.doctorQ.ca
How often have you felt as if your bladder did not empty completely after urinating?
Have you had to urinate less than two hours after you finished?
Do you stop and start several times while urinating?
Is it difficult to delay urinating?
Is your urine stream weak?
Do you push or strain to begin urinating?
How many times do you get up at night to urinate?
-- Adapted from the International Prostate Symptom Score
A Prostate-smart diet
Soy, fibre, fruits, raisin bran, vegetables, cold-water fish
Fats, caffeine, alcohol, sugar
Supplement with herbals:
Vitamin E, selenium, saw palmetto, nettle extract
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