The Prostate Cancer Dilemma

The country is embarking on a huge screening program for prostate cancer which is likely to cost billions and may lead to many unnecessary operations, especially for elderly patients. But what may be bad at the national-policy level could be a lifesaver at the individual level for men in their fifties and early sixties.

A Better Surgical Outcome (Less Impotence)

FROM a surgeon's point of view, the big change in the prostate world began when one of Patrick Walsh's patients experienced no long-term impotence or incontinence after the operation Walsh had performed on him. Walsh was flabbergasted. He had removed the man's prostate, and doctors had known for decades that radical prostatectomy always had these side effects. It was a desperate operation for men in desperate circumstances, because it left most men impotent, incontinent, or both. "I congratulated him, of course," Walsh told me when I visited him recently. "But what I was thinking was, This man cannot be unique. If he could be spared these things, others could."

Then as now Walsh directed the James Buchanan Brady Urological Institute, at Johns Hopkins. Slight, usually softspoken, and possessed of slim, delicate hands, Walsh graduated from the Case Western Reserve University School of Medicine in 1964 and trained as a surgeon for seven years in Boston and Los Angeles before coming to Johns Hopkins. His specialty was urology, the treatment of the reproductive organs in men and the urinary tract in men and women (though most urological patients are men). Urologists work on kidneys, bladders, testicles, and other parts of the body, but they are most often called upon to assist in the treatment of prostate disease. Radical prostatectomy, often the only available treatment for prostate cancer, was a thoroughly unsatisfactory operation. "You were working blind," Walsh told me. "If you thought about it, it would scare you out of your wits." The incision caused so much bleeding from so many sources that the cavity filled faster than suction tubes could drain it. In addition to endangering patients, the blood "prevented you from seeing what on earth you were doing in there." Surgeons had to cut out the prostate by feel.

Johns Hopkins has long been a center of urological research. Hugh Hampton Young, one of the first important American urologists, pioneered radical prostatectomy there at the turn of the century, and was probably the first doctor to call for routine prostate screening. Walsh went to Johns Hopkins with the intention of building on the school's tradition. A central problem, he was convinced, was that the anatomy of the prostate region was poorly understood. Walsh worked out the location of the veins and figured out how to pinch them off during surgery. That accomplished, surgeons began to see what they were cutting apart. It was as if a whole new world had been revealed.

Halfway through the prostate, the urethra is joined by a second tunnel, the seminal duct, through which semen passes on its journey to the outside world. Small side tunnels carry the chemical products of the prostate to the urethra and the seminal duct. The whole structure is wrapped in what is called a capsule. One end of the capsule is ringed by the urethral sphincter, which surgeons had always sliced through - the principal cause of postoperative incontinence. Reducing the flow of blood let Walsh see well enough to cut out the prostate without damaging the sphincter.

The operation still resulted in impotence, but Walsh didn't think he could do much about that. Then he remembered the patient who had an entirely normal sex life after a prostatectomy. Walsh had been taught in medical school that the nerves controlling erection ran, like the urethra, through the prostate, and thus that impotence was an inevitable byproduct of removing it. The patient's experience sent Walsh back to his textbooks, which said little more than that the nerves were "small [and] difficult to follow." The medical profession had merely assumed that the nerves ran through the prostate.

Walsh looked for himself. The prostate was little studied, because it is surrounded by the kind of fatty tissue that does not survive embalming, and most anatomy research is performed on cadavers. In 1981 Walsh went to a medical convention in the Netherlands, where he met Pieter Donker, a retired urologist from Leiden. Donker had discovered that the ideal subjects for prostate dissection are stillborn infants, because their nerves are relatively large and the surrounding fatty tissue is thin. The two men spent an afternoon at the table. Walsh observed, to his excitement, that the nerve bundles were outside the prostate capsule, held in place by a thin, almost translucent sheet called the pelvic fascia. Scalpels had been blindly cutting through them. Lifting away the fascia like a blanket from a bed would give surgeons a clear path to the prostate. Walsh's first attempt at doing this, in April of 1982, was successful: the patient, a fiftytwoyearold man, was sexually active within a year.

Good surgeons operate often, to keep their touch. Using what has been called the nervesparing technique, Walsh performed more than 600 radical prostatectomies from 1982 to 1988. (Walsh has not assembled complete data on the longterm outcomes of the surgery he has performed since then.) Some 92 percent of his patients achieved complete urinary control; 68 percent of those who were potent preoperatively remained so, with the figure higher for younger men. (A hundred percent success is not to be expected; by the time of surgery, some cancers have spread to the sphincter or the nerves.) By the middle of this year Walsh had performed more than 1,300 radical prostatectomies; just two patients died, and about 70 percent seemed to be cured of cancer, Walsh says. Similar results have been reported by other pioneering urological surgeons, such as William Catalona, of the Washington University School of Medicine, in St. Louis, and Thomas Stamey, of Stanford.

Walsh was pleased, of course. And he was pleased that the arrival of the nervesparing technique roughly coincided with the arrival of the PSA test. The test, in his view, increased not only the likelihood of an accurate diagnosis but also the likelihood of diagnosis at all. Men as a group tend to avoid seeing their doctors, and even those who have annual checkups tend to refuse rectal exams. "Women have always had doctors poking at them," Walsh says. "It's unpleasant, but they recognize they have to do it. A middleaged man isn't used to it, and often won't do it." PSA testing suddenly made the job easier -- the doctor simply penciled in another X on the paperwork for the patient's blood tests. Walsh cautions, however, that one PSA reading is not enough to make a diagnosis. As many as a third of men with prostate cancer have low PSA readings, he says; a rectal examination is thus essential. Conversely, high PSA readings might not indicate cancer, and the test is often repeated over a period of months.

With the advent of moreeffective diagnosis and treatment, Walsh says, men finally began to talk about prostate cancer. They compared PSA levels over lunch. Celebrity victims emerged: Michael Milken, symbol of Wall Street; Frank Zappa, nosethumbing rock star. Jesse Helms on the right, Alan Cranston on the left. Robert Dole, whose cancer was discovered by a PSA test, endorsed a prostate advocacy group called Us Too. The King of Belgium discovered he had prostate cancer; Walsh operated on him. Billboards appeared in the United States, on which actors and sports personalities encouraged men over forty to see a doctor about prostate cancer. ScheringPlough, a drug company, distributed flyers about prostate trouble at doctors' offices and hospitals across the country. ("If you learn only one fact from this brochure," read a boldface paragraph, "let it be this: early detection of prostate cancer saves lives.") And Walsh himself, surgical mask at his throat like a cowboy bandanna, was featured in The New York Times in a fullpage advertisement placed by Johns Hopkins to extol its medical work.

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Charles C. Mann, an Atlantic contributing editor, has been writing for the magazine since 1984. His recent books include 1491, based on his March 2002 cover story, and 1493.

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