San Diego Magazine / October 2004 / Facing the Fear

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Facing the Fear

SCRIPPS CLINIC UROLOGIST Dr. Leslie Klein wants to get one thing straight: Being diagnosed with prostate cancer is not—repeat, not—the automatic death sentence so many people seem to think it is.

“We have a lot of patients who as soon as they hear they’ve got prostate cancer write themselves an obituary,” says Klein, a former associate professor of urology at Harvard. “The fact of the matter is, the vast majority of people who have prostate cancer, when it’s discovered, especially in the older age groups, are never going to be bothered by it.”

It’s a classic example of the bark being worse than the bite. “It’s certainly a serious disease,” he says, “but the panic in the community far outweighs the actual risk. I just saw an 80-year-old man who 12 years ago had an elevated PSA [prostate-specific antigen, higher levels of which are often found in men with prostate cancer]. It went away, but ever since that time he’s been getting checked three or four times a year. The poor man—he’s emotionally distressed, and there’s no good reason for it.”

Dr. John Naitoh, a fellow San Diego urologist who, in 1998, published a lengthy paper on the diagnosis and treatment of prostate cancer for the American Academy of Family Physicians, agrees.

“You can back up even further and ask: Is it worthwhile to even be screened? Because right now we have very little data to suggest longevity and quality of life can be improved through early detection,” Naitoh says. “If you’re looking for a bang for your buck in healthcare, it makes much more sense to put resources into cholesterol, reduction of obesity, screening for and treatment of diabetes and hypertension.

“If you look at causes of death, prostate cancer is a relatively small blip on the radar. And having men undergo screening and treatment that has significant adverse effects on sexual and urinary function may cause more harm than good.”

Prostate cancer is a malignant tumor that begins in the prostate, a walnut-size gland of the male reproductive system between the bladder and the urethra, made up largely of muscular and glandular tissue. The prostate’s main function is to produce fluid for semen, which transports sperm.

According to the American Foundation for Urologic Disease, prostate cancer is the most common cancer in American men. About 10 percent of all men will develop the disease at some point in their lives, most after age 65. Although it is the secondleading cause of cancer deaths among men (skin cancer is the first), 85 percent of men with prostate cancer survive. Both the American Cancer Society and the American Urological Association recommend annual screenings for men once they hit 50. But the American Academy of Family Physicians and the U.S. Preventive Services Task Force oppose routine screenings, maintaining early detection has no proven benefits and the potential side effects of treatment may outweigh the benefits.

Here’s the rub: Aggressive tumors, which are very rare, can develop and spread in a matter of months, so by the time the next annual screening rolls around it might be too late. And in the case of slow-growing tumors confined to the prostate, patients may panic and rush into radical treatment, either surgery or radiation, that could cause more damage than if they did nothing.

“I make my living doing radical surgery, so I’m not opposed to it,” Klein says. “But what I am opposed to is putting people who don’t need such extensive treatment through the pain and agony and humiliation that results from it, all for a problem that may never actually hurt them.”

Naitoh agrees, citing in his paper data from autopsies that indicate 70 percent of 80-year-old men had prostate cancer when they died, and yet the malignancy is the cause of death in only 3 percent of all men. “Prostate cancer is often an incidental finding in elderly patients,” he writes. “The tumor grows so slowly that no symptoms appear; in essence, patients often die of other causes before the cancer causes serious problems.”

CONTROVERSY ALSO SURROUNDS the question of whether prostate cancer can be prevented. There are all sorts of ads for miracle pills that claim to prevent prostate cancer, but according to the Mayo Clinic Web site, that’s all a bunch of hooey. No formula, pill or product can guarantee you won’t get prostate disease, doctors at the prestigious clinic say.

Klein agrees. “It’s in the genes,” he says. “It’s most likely a genetic, predetermined disease, with some environmental variables.”

Those variables tend to be the same ones that could lower the risk for all types of cancer: eating more fruits and vegetables. According to the Mayo Clinic, “These foods not only provide vitamins, minerals and fiber, but also contribute to low-fat, low-calorie meals. . . . [And] according to one theory, fat increases the production of testosterone, which in turn stimulates the growth of prostate cancer cells.”

Some specific dietary recommendations from the Mayo Clinic:

* Tomatoes and tomato paste, which contain lycopene, an antioxidant that protects cells from the damaging effects of toxic molecules called free radicals.


* Soy products, such as soy milk, flour, nuts and tofu, which contain isoflavones, plant-based compounds that appear to stimulate the body’s binding proteins that keep testosterone in check.


* Garlic, with sulfur compounds that enhance immune function, which helps combat tumor growth.


* Green tea, which contains a natural substance that appears to inhibit enzyme activity necessary for cancer growth.

Naitoh also says some studies suggest that vitamin D and omega fatty acids could be beneficial. “There was a Swedish study comparing twins,” he says, “and it found the incidence of prostate cancer was two to three times lower if they ate fish two or three times a week.”

Treatment options vary, depending on the severity of the disease and the age of the patient. Watchful waiting is often the best approach for men with small, low-grade cancers that appear to be slow growing, particularly if they are elderly and have other medical problems.

“You check every three or four months, and then if there is a change you usually have to decide if you want to do a curative treatment or just something to slow it down,” Naitoh says. “We actually have some interesting data—we had men who were known to have prostate cancer but decided not to have treatment, and they were followed by a cancer registry. Those men did very well, compared to average men without cancer. In fact, they actually lived a couple of months longer, probably because of the constant medical attention.”

But for men with more aggressive cancers, “Watchful waiting is not an option,” Naitoh says.

The best chance for a long-term cure comes from a radical prostatectomy, in which the prostate is either totally or partially removed. Possible effects include long-term urinary incontinence and impotence, and the procedure is more appropriate for younger patients, due to various surgical risks. For older (70 and up) patients, radiotherapy is recommended, although again, risks include short-term bladder and bowel symptoms and long-term impotence.

Ultimately, however, it’s up to the patient. “If you have prostate cancer, sit down with a trusted physician and have a conversation about your options,” Klein says. “Preferably you’ll come in with your wife, and you’ll talk about the options and what the implications of your choice may be, because treating prostate cancer can have serious implications on your lifestyle— your ability to control your urination, enjoy your sex life, procreate.

“You also have to factor in competing diseases. If you’re a 53-year-old guy who’s had two heart attacks, you’re a completely different guy than a 53- year-old with no heart attacks or other serious illnesses.”

Most importantly, Klein adds, “You don’t let your physician choose. His job is to give you all the information and then let you choose.”