Conscious Choice: The Unkindest Cut?

August 2005

The Unkindest Cut?

After five uncles with prostate cancer underwent a variety of treatments with drastic side effects, this Central Illinois doctor set out to find a kinder, gentler cure

By Darcel Rockett

Even though Dr. Bradley Hennenfent is tired while driving home across the Central Illinois farm fields following his research and speaking trip to Europe, he still has time to field phone calls about one of his life’s passions: finding a cure for prostate cancer.

Who could guess that this Midwestern farmer’s son would be upsetting the medical cart with his relentless mission to inform millions of men diagnosed with prostate cancer that they have more options than surgery, which can lead to impotence and incontinence.

He’s undaunted in this self-appointed controversial task and points out that he’s not “anti-treatment.” He just wants better treatment.

“What really set me off, each time an uncle came down with it, I couldn’t believe how bad the science was and how exaggerated the claims were,” said Hennenfent, who had several uncles diagnosed with the disease. “If you look at the spin urologists put on it you would think we had a cure … We don’t. We need to refocus and find a cure that works all the time.”

There’s a growing controversy surrounding diagnosis methods and treatments. Test scores can be confusing. This makes it difficult for a patient to decide what to do, and part of what motivated Hennenfent, to write Surviving Prostate Cancer Without Surgery (Roseville Books, 2005).

“I have been working on the book for 20 years, ever since my uncle, Stephen Arthur Mills, died of a heart attack after starting estrogen therapy for his prostate cancer in 1984,” said Hennenfent, a graduate of Northwestern University, the University of Illinois Medical School and its emergency medicine residency program.

As Hennenfent researched prostate cancer he said he grew increasingly “dismayed” at what he called “drastic operations” that men underwent without understanding the consequences. He went on to found the Internet newsgroups, sci.med.prostate.cancer; sci.med.prostate.bph and sci.med.prostate.prostatitis. Together with his father Mike, he co-founded the nonprofit Prostatitis Foundation, which he reported draws almost a million Internet visitors per year.

“There is a great deal of confusion about prostate cancer,” said Hennenfent. “Unfortunately the psychology of prostate cancer is such that despite the statistics, most men seem certain that they are going to die from prostate cancer.”

According to the American Cancer Society’s Cancer Facts & Figures 2005, prostate cancer is the most commonly diagnosed cancer among men in the United States and is the second leading cause of death in men behind lung cancer. The organization estimates that 232,090 new cases of prostate cancer will be diagnosed this year and 30,350 men will die from it — 1,230 men in Illinois.

Hennenfent points out that Stanford University School of Medicine urologist Thomas Stamey found that 80 percent of prostate cancer cases don’t progress quickly enough to kill before the person succumbs to old age or some other disease. In some cases, Hennenfent said it may be better to just watch and wait.

However, prostate cancer can be very deadly and treatment in many cases is absolutely necessary, said Dr. Walter Stadler, who is an associate professor and director of the genital urinary prostate program, at the University of Chicago Hospitals.

“It is actually both simple and complex,” Stadler said. “The number of people diagnosed with prostate cancer is very high. The number of people who die is much smaller. The issue is that all of us men, if we live long enough, will have evidence of prostate cancer in the prostate.

“The challenge is to identify the patients earlier in life that have prostate cancer that is going to become clinically significant … You do want to diagnosis and treat the 50-year-old man who is likely to die of prostate cancer before old age.”

Prostate Cancer Basics

The prostate is a walnut-sized gland just below the bladder. It produces a fluid that forms part of the semen. The gland helps regulate both bladder control and normal sexual functioning. Digital rectal exams (DRE), manually feeling the prostate wall through the rectum to check for lumps, and prostate specific antigen (PSA) tests, blood tests to check the protein level secreted by the prostate cells, are used to detect prostate cancer sans symptoms.

In the latter test, a normal prostate is supposed to produce a PSA reading between zero and four, said Hennenfent. Anything above that is considered abnormal, which may be a possible indication of a prostate with prostatitis (inflammation of the prostate), BPH (benign prostatic hyperplasia), a non-cancerous type of growth inside the prostate, or cancer.

“Men don’t want to talk about it, but it’s absolutely vital to get the two tests together, to find it sooner,” said Mary Sullivan, a registered ICU nurse and executive vice president of Olympian Labs, a nutritional supplement company in Scottsdale, Ariz. that offers supplements for prostate cancer.

If either a lump is felt or levels are high a physician may recommend a biopsy, during which a urologist inserts hollow needles into about half a dozen areas of the gland that feel or look suspicious to gather tissue. The samples are examined to identify the differences in cell and tissue and are given Gleason Scores and a stage. The higher the score, the higher the grade of tumor and more likely it is to grow quickly and spread. Scores between two and four are considered low grade, five through seven, intermediate and eight through 10, high grade. Staging refers to the extent of the cancer — how big it is, and whether it has escaped the prostate to other parts of the body. They are defined as T1, T2, T3 and T4.

T1 and T2 tumors are still localized to the prostate. T3 cancers have already escaped the prostate. And stage T4 means cancer has invaded areas below the prostate.

Treatment Options

One of the problems facing prostate cancer patients is the uncertainty surrounding the management of the disease, according to the National Cancer Institute, pointing out on its website that it is not known if surgery is better than radiation, or even no treatment in some cases.

Hennenfent said he believes some urologists are jumping to conclusions based on too few controlled studies on radical prostatectomies (the removal of the entire gland and nearby tissues).

Hennenfent argued aggressive treatment is often unnecessary and harmful.

“Surgeons tout surgery as the cure. This is clearly misleading,” Hennenfent said. “Prostate cancer is a disease that requires you to do your homework. Read and study! You stand to lose your sexual function, your urinary function and the ability to enjoy the remaining years of your life.”

And given the high levels of incidence with impotence and incontinence after this type of surgery, Hennenfent suggests looking at other options.

“I’m all for treatment,” he said. “I want them to develop a treatment that is highly successful and doesn’t have all those adverse side effects that surgery has … there are a few people that will benefit from surgery, but it’s a small group. But the problem is it’s hard to pick them out of the crowd.”

Hennenfent said that men should consider all their options before going to surgery, which should be the last option considered.

“Surgeons cut and want to cut it out, but cutting it out is not always the right choice,” Sullivan added. “If people knew about alternative therapies, they wouldn’t be so fast acting with their decision and left with bladder problems. One should back up and regroup to get all the information.”

Cryoablation is a process that freezes cancer with argon gas through probes that are inserted through the skin into the prostate.

Hormone blockade inhibits the enzyme that converts testosterone into DHT, a potent initiator of prostate growth and probably cancer growth, and low doses of estrogen can also be taken to suppress testosterone and slow down prostate cancer. Then, there’s various forms of radiation therapy. They involve the delivery of radiation directly to the prostate in an outpatient setting. During external beam radiation, photon beams shot into the prostate from different angles kill cancer cells by damaging their DNA. 3-D radiation therapy uses a computer in combination with CT scans of the prostate to direct the radiation beam.

Brachytherapy entails implanting radioactive seeds into the prostate via needle.

Watchful Waiting

Then there’s watchful waiting, or watching one’s prostate cancer until it causes symptoms, then treating those symptoms if they ever arise. Hennenfent said this approach spares the man with low grade, low stage and appropriate Gleason scores, the pain and possible side effects of surgery or radiation.

“Watchful waiting is a reasonable starting point for all men with small, low-grade prostate cancers until a controlled study proves otherwise,” Hennenfent said in his book. “In fact, there are those that believe it is the best option for such men. Why don’t more men choose watchful waiting? It seems to be difficult for many men to ‘wait’ when they have cancer, which is partly due to a lack of understanding about the disease and its treatments. It’s also hard for doctors to encourage watchful waiting for fear the cancer will spread and they will be sued.”

Adding “Active Non-Invasive Therapy” to the watchful waiting mix — aggressively researching the disease, joining support groups, taking the pressure off of the prostate by sitting on a ring cushion in daily activities, and sticking to a low-fat diet and exercise program — turns the watchful waiting into an even more viable option, he added.

The National Cancer Institute reports that a number of studies have found that, for at least 10 or even 15 years, the life expectancy of men treated with watchful waiting, is not substantially different from the life expectancy of men treated with surgery or radiation, or for the population at large.

Areas of Controversy

The medical and academic fields don’t necessarily line up when it comes to talking about concepts in prostate cancer, which has led to numerous levels of controversy.

For instance, there is no set age when it comes to getting tested for the disease. Some suggest annual tests starting in the late 40s to early 50s, while some doctors recommend African-American males get tested at age 40, since statistic show they’re more prone to die from it. However, even men in their 30s have been getting screened.

There’s also not one set idea as to the cause of the ailment, some think it’s genetic and spurred by hormonal, dietary or environmental conditions. While still other camps are looking at the possibility that drugs might keep latent cancers from developing into active ones. High fiber and soy diets are also being looked at for prevention.

But perhaps the biggest issue surrounding prostate cancer is the accuracy of the tests that are used to detect the disease. The National Cancer Institute states neither of the screening tests for prostate cancers is perfect, either one can miss a cancer or produce a false positive after something like a prostate massage.

“Gleason scoring is not 100 percent accurate, as it depends on where one samples the prostate for biopsy,” said Dr. Durado Brooks, director of prostate and colorectal cancer programs at the American Cancer Society’s Cancer Control Science Area in Atlanta. “Some parts of the tumor may look different than another part. After Gleason scoring 25 percent of men are in the low, non-aggressive range, 25 percent are in the aggressive range and 40-50 percent of men are in the gray zone, which is the most difficult area to make a clear decision of cancer.”

“And the PSA is helpful as an overall evaluation, but still leaves a lot to be desired. These tests don’t let us differentiate between a slow-growing cancer or not. We need better screening and diagnostics to see what’s an indolent and what’s an aggressive tumor,” Brooks said.

In a study published in the May 28 Journal of the American Medical Association, Dr. James Eastham, a surgeon in the department of urology at Memorial Sloan-Kettering Cancer Center in New York City, stated: a single, elevated PSA level does not automatically warrant a prostate biopsy. Even if the repeat tests show an elevated level, prostate cancer will only be discovered in about one quarter of men who undergo biopsy, which is often painful and requires local anesthesia.

“The question is at what PSA level do you start sticking people with needles?” said Stadler from the University of Chicago Hospitals. “The first question is do they need treatment? Then [do they need] radiation or surgery? As far as I am concerned the two are equivalent. The challenge is in diagnosing the correct people.”

Stamey, a professor of urology and lead author of a 2004 study in the October issue of the Journal of Urology, goes so far as to say that PSA test indicates nothing more than the size of the prostate gland.

“The PSA era is over in the United States,” Stamey said in the study. “Our study raises a very serious question of whether a man should even use the PSA test anymore. Our job now is to stop removing every man’s prostate who has prostate cancer. Some men need prostate treatment, but certainly not all of them.”

Dr. Louis Potters, associate director of radiation oncology and medical director of the New York Prostate Institute at South Nassau in Long Island said understanding the dynamics of the results from the tests over time is more qualitative than the absolute value of one test.

“Based on the increase in detection and the presence of low-risk disease, people don’t need to rush into a treatment decision,” Potters concluded. “There are more available treatment options and while there’s no single definite treatment without side effects, it comes down to the avenue of least regret in terms of your decision.”

Darcel Rockett frequently writes about health, and lived in the Chicago area. She recently moved to London. Portions of this story were also reported and written by Conscious Choice staff.

Get More Info:
www.SurvivingProstateCancerWithoutSurgery.org or prostatitis.org; or write Roseville Books 140 N. Main St. P.O. Box 375, Roseville, IL 61478; or call 206-350-1242.

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