The prostate cancer dilemma.

Deceptive, paradoxical, and misunderstood, prostate cancer is an astonishingly common medical oddity. It is the second-leading cause of cancer-related deaths for men (behind lung cancer), yet most men who acquire prostate cancer do not die from it. One out of 10 men has it in some form by age 50, with die incidence increasing steadily after that. More than 80 percent of cases involve men over 65, with a median age of 72. Black men have the highest incidence in the world.

Since medical experts have not yet identified either cause of prostate cancer, they consequently cannot prescribe procedures for prevention, so only limited progress toward prevention has been made.

In general, systematic exercise and a low-fat, high-fiber diet are recommended for most men; in particular, Harvard Medical School (Boston) researchers reported die results of a study in the February 16, 1994, Journal of the National Cancer Institute linking men eating red meat five or more times a week to a greater risk of developing prostate cancer compared to men who ate red meat once a week or less. (Another study linked the eating of red meat to the spread, not the initiation, of the disease.)

Walnut-sized prostate. The gland lies underneath the urinary bladder, surrounding the urethra, the tube through which urine passes.

Gland trouble comes in three forms: (1) prostatitis, an infection or inflammation of the prostate, which is extremely common and poses no long-term threat; (2) BPH (benign Prostatic hyperplasia), an enlargement of the inner portion of the prostate obstructing die flow of urine as it moves through the urethra, like a choking collar (by age 65 about three quarters of all men will experience a form of it); and (3) prostate cancer.

Detection as early as possible is desirable. Screening tests include DRE (digital rectal exam) and PSA (prostate-specific antigen), a presently popular but not always reliable blood test. An elevated PSA level helps separate the more aggressive prostate cancer from the less aggressive. "I strongly endorse the policy of pursuing early detection, including PSA and DRE, on an annual basis in men over age 50 (in Black men, over 40)," says Dr. Abraham T. K. Crockett of the American Urological Association, Baltimore, Maryland. Another test is transurethral ultrasound, which uses sound waves to form a readable image of the prostate.

Treatment for prostate problems varies. Open prostatectomy is removal of the entire prostate through an incision in the abdomen. For localized prostate cancer, radiation is another treatment that shows good results. According to some estimates, the surgery cure rate for confined prostate cancer is about 85 to 90 percent, and for radiation, 75 to 80 percent. A few studies show much greater failure rates for both treatments. For BPH, the standard surgery is called transurethral resection of the prostate (TURP), performed more than 335,000 times yearly by inserting a tiny looped wire through the urethra and trimming away the excess prostate tissue that has grown into the urethra, blocking the flow of urine. However, each treatment carries a risk of side effects ranging from incontinence to impotence. And in the case of surgery, there's the risk of cardiopulmonary troubles, urine blockage, and rectum or bowel injury.

Ironies abound. Determining the value of aggressive treatment - particularly prostate surgery - is difficult. Based on the facts known to date, the majority of men suffering from prostate cancer will die from something else. "If at age 69 you have cancer that would kill you, and you have treatment and then die at age 70 of heart disease, you didn't gain much," says Dr. Gerald W. Chodak, urologist at the University of Chicago Pritzker School of Medicine. Therefore, gains in life span are likely for younger, otherwise, healthier patients, men under 70 and even 60; yet these are the very men who are likely to live for years without symptoms.

Disagreement persists. After attempting diagnosis, counseling patients about the kind and extent of the management of their cancer is likewise difficult. The relative benefits of the different forms of treatment have not yet been proved to a consensus of medical experts. It seems reasonable, nevertheless, to conclude that for younger men, screening and aggressive treatment may be warranted (if the cancer is confined to the prostate), since prostate cancer is clearly a progressive disease (even if slowly progressive) and curative therapy is lacking for the disease in its advanced stages.

Although fraught with variables and disagreement, another choice is to do nothing, or more accurately, to wait (watchfully). For men over the age of 65 watchful waiting is as effective as active treatment, according to Dr. Craig Fleming of the Prostate Patient Outcomes Research Team (Oregon Health Sciences University). This means that men over age 60 or 65 with tiny, localized tumors should "do nothing" or simply monitor with PSA testing and digital rectal exams every six months, possibly followed by hormonal therapy.

But Dr. William J. Catalona of Washington University, St. Louis, Missouri, says, "Watchful waiting risks missing the opportunity for cure. Until we have solid evidence that this is as effective as active treatment in a representative patient population, watchful waiting should be considered experimental management in men with a life expectancy of 10 years or more."

Dr. Fleming counters with "The key question for the patient: `Is the potential for benefit worth die known risks of treatment?'" He adds that advocates have yet to produce any scientifically credible controlled studies showing radical prostatectomy to be effective.

The decision whether to watch and wait or undergo some form of aggressive treatment is wrapped up in weighing the individual variables of each case and the inevitable trade-offs.

Studies show more than a third of all men over age 50 already have at least microscopic malignant prostate tumors. About 13 percent will eventually develop diagnosable cancer, and only about three percent will eventually die from them. It is notable that this low death rate results more from the characteristically slow growth of most prostate cancers than from medical intervention.

"Growing old is invariably fatal," Dr. Whitmore says, while prostate cancer is only sometimes so."

"There isn't a right answer," says medical ethicist Arthur Caplan. "You can choose to have the surgery if what matters to you is a longer life and you don't care if you become impotent or have a harder time urinating. Or someone at age 70 might decide, `I'm not buying enough time [years of life] to put those functions at risk."'

Tom Jenkins writes from Englewood, Colorado.