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"David, why did you wait?" A profile of prostate cancer.

My 53-year-old cousin David phoned me last week. We aren't the closes of friends, but we're relatives. His father, Uncle Ernie, and mine were two of seven brothers. That's why I chilled as he told me in terse, tense phrases, "The PSA is 400, Ernie." David always uses my middle name when he wants my opinion, especially medical. I'm the only doctor in the family.

I was silent. I knew he was aware of the implications of this number, because I'd recently told him the risks he faced in not having a simple but little-known blood test: the PSA (Prostatic Specific Antigen). Three of our uncles died from cancer of the prostate, so David and I, as well as every male member in our generation of the family, are at high risk for developing the disease.

What I'd told David during our recent conversation--the conversation which spurred him to visit his doctor and take the test--was that any man high at risk past the age of 40 should have a PSA annually. Furthermore, any man past the age of 50--with or without a family history of cancer of the prostate--should have an annual PSA.

I had reached these conclusions only after a thorough review of the current academic urological literature, which acknowledges a certain ambivalence about the whole business of prostate cancer detection efforts. This ambivalence is based on the unproven effect of treatment of prostate cancer that is discovered early. Yet common sense would dicate taht a cure is more likely in a patient whose disease is confined rather than metastatic. Fortunately, the National Cancer Institute is currently assessing this question in a controlled study.

But meanwhile, "There's a simple $35 blood test for cancer of the prostate," I insisted to David. "I'ts been clinically available for at least three years, and yet few men even know about it."

The fact is, the PSA test marks a monumental breakthrough in preventive medicine: the advent of the most reliable (sensitive and specific) tumor marker and "tumor detector" in medical history. Sure, other cancer-antigen marker tests exist--such as CEA for colon, Alphafeta protein for testicular cancer, and HCG for choriocancer--but none of these can be used, as can the PSA, as an early-warning system of pending bad-news cancer.

The PSA should be to cancer of the prostate what the Pap smear is to cancer of the uterus and cervix, and what mammography is to breast cancer. Men should be trading their PSA numbers right along with their cholesterol scores--in the operating room, at the office, in the spa, playing golf, wherever men gather. And yet the word hasn't gotten out.

"I just didn't think it would happen to me," David said now, speaking quietly over the phone from his general practitioner's office. "I mean, my doc tells me the digital rectal exam was norma."

"I told you the DRE didn't mean. . ." I trailed off, trying not to scold. One of the most insidious features of cancer of the prostate is that it's so hard to detect by the old standard, the finger examination of the prostate. Studies have shown that the DRE will miss up to 50 percent of early-stage prostate cancers.

"Look," I said, searching for a way to ease his anxiety, "There's probably nothing to worry about. . ." I was thinking. It's Friday afternoon. I can't get him to a urologist before Monday. Then I thought of something. "David, was the rectal exam done just before the blood was drawn for the PSA?"

"Yes, Yes!" he said. He wanted to explain away that high PSA number as much as I did. He knew from our earlier talk that Benign Prosthetic Hypertrophy (BPH) is found in most men, and that an inflammation of the prostate is common. "Right, and you know the doc did the exam before the blood was drawn," he finished.

We both knew a high normal PSA (by the most commonly performed assay, the Yang technique) was just 4.0 ng/ml (the units aren't important). With a biologic half-life of two-and-a-half days, the PSA protein will as much as double (to 8 or even 10) after a rectal exam, and return to normal only after two weeks. BPH or an acute inflammation can cause the value to jump up to as high as 100.

"Maybe that's what cause the elevated numbers," I said, trying to sound reassuring. "I'll just see if a urologist friend of mine can fir you in, say. . ." I waited. "Monday," he interjected. "OK, Monday," I said, and we hung up the phone.

I thought about my cousin all weekend. He and I both knew a 400 probably meant that he not only had prostate cancer, but that he had it bad. Cancer is a progressive disease. Autopsy studies show that three out of every ten men over the age of 50 have a cancer or the prostate, and that number climbs to seven out of ten for men over 70. Since more than half of the tumors originate in the front half of the gland, making them inaccessible to the examining finger, and since the examiner's evaluation is subjective and inexact, calculated screening detection rates are sometimes as low as one to two pre 100. These are detection rates far below palpation of the breast for breast cancers or pelvic exams for cervical cancer.

Eleven percent of all cancer deaths in American men are caused by cancer of the prostate. This percentage is second only to thta of cancer of the lung. The American Cancer Society estimates that during 1990, 106,000 new cases of prostate cancer were found, and more than 30,000 men died of the disease. Prostate cancer is the most prevalent cancer in the aging male adult population, with black men suffering a threefold incidence over their white counterparts. And yet most men--even doctors--are unaware that an inexpensive blood test can diminish the risk of prostate cancer.

Recently, for example, I had lunch with several surgeons and internists. During a conversation, I learned that not a single one of them, all men over 50, knew about PSA.

Because I'm at risk for the disease, I have always taken a cautious route. I'm 44. I know the family history, so for several years I've had an annual ultrasound exam of my prostate, called a Transrectal Ultrasonic Examination of the Prostate (TRUSP). Using sound waves, the urologist can pass through the rectum a fiber optic probe the size of a thin straw. It's actually less uncomfortable than the classic digital rectal exam. The ultrasound image gives a remarkably clear picture of the tissue-density changes of the prostate, making office biopsy a simple, safe, and almost painless procedure. A TRUSP allows for 80 to 90 percent detection rates, and I relied on this test until two yeas ago, when I learned about PSA. Now, however, I just have the annual PSA before a digital rectal exam. If the PSA falls into a gray-zone range--4.1 to 10 ng/ml--then I'll have the TRUSP.

Over the weekend, I also thought about my Uncle Ernie, who died from so-called stage D prostate cancer. Prostate cancer was classically "staged" or classified at the time of its first clinical detection. A tumor confined strictly to the prostate and small in size is an "A." Once spread to the bone or distant organs, such as liver or lung, it is said to be metastatic. Right now, it's a stage D.

In the years since Uncle Ernie's death, there have been refinements, with sub-categories and additions of tissue "grading" to determine how "differentiated" the cells seem to be. Early detection is now possible. In fact, the whole staging system is currently in a state of redefinition because of the introduction of TRUSP and, especially, of PSA.

Yet 20 years ago, my uncle had plain old stage D prostate cancer that had already spread to his bones before they picked it up. He lingered the average two-and-a-half years a person of his age and stage usually lives, if you can call it living. He had the medically indicated castration, the radiation and the hormone therapy. But he still suffered the pain of multiple bone fractures, especially when his spine started collapsing. He developed the severe anemia leading to continuous bleedig. He suffered the metabolic comas of liver failure, and finally he welcomed the mercy of death.

Monday arrived. I spend the day in the operating room, and at one point the topic turned to my cousin's case. As we talked, I realized the 65-year-old surgeon across the table from me didn't know about PSA. I got on my soapbox, and by the end of the case he knew all he needed to know, and more. Consequently, he went to the lab for a PSA.

I called my cousin that night. He'd had the complete workup: history and physical, blood work, TRUSP with biopsies, a radionucleotide bone scan for metastases, and a Magnetic Resonance Image (MRI).

"Well, amigo," he said when he called, and then his voice trailed off. "Like father, like son." He tried to regain his composure. "Stage D."

I remained silent on the phone as my heart cried out, "David, why did you wait?"
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Author:Dittman, Ralph E.
Publication:Saturday Evening Post
Date:Nov 1, 1991
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