My bill, for two shirts, was $41.60. As I reached for my credit card, the cashier asked if I would like to round the tab up to $42.00. "The balance goes toward breast cancer research," she said.
"What about prostate cancer?" I asked.
"Men don't like to talk about that, so we stay away from it," she replied.
She was right, of course. But we've been wrong.
Guys, we need to start talking to each other (and our doctors) about prostate cancer. The research argues we need to begin earlier than most of us ever expected.
Who's at Risk
About 240,000 new cases of prostate cancer will be diagnosed in the United States by the end of 2012, according to the American Cancer Society — similar to the number of new breast-cancer cases. About 28,000 men will die from the disease.
Generally, it's an older man's condition: One in 15 men between 60 and 70 will get a diagnosis of prostate cancer; nearly two-thirds of all patients are 65 or older. Prostate cancer is the second-leading cause of cancer death in men, after lung cancer. But the disease advances slowly and the majority of men whose cases have been diagnosed will die from something else.
(MORE: Should We Stop Routine Prostate Cancer Testing?)
Although the preponderance of victims are older guys, about 1 in 38 men between 40 and 60 will receive a prostate cancer diagnosis — and the disease tends to be more aggressive in younger men. "Testosterone feeds the growth and proliferation of prostate cancer," explains Dan Zenka, senior vice president of the Prostate Cancer Foundation. "The initiation of prostate cancer begins when a man is in his 20s. When a man in his 40s presents with prostate cancer, it may indeed be a more aggressive form."
Testing for Early Detection
Detection of prostate cancer begins with prostate specific antigen, or PSA, screening. PSA is a protein produced by the cells of the prostate gland. Through a blood test, doctors measure the PSA level — in general, the higher it is, the more likely that cancer is present. However, no specific PSA level guarantees that a man either has the disease or is cancer-free. (Learn more about PSA testing from Next Avenue.)
Medicare and many insurance carriers cover an annual PSA test for all men 50 and older. Those at a higher risk due to a family history of prostate cancer are advised to begin testing at 40 or 45. African-American men are also at higher risk than other groups. For reasons that remain unclear, they develop prostate cancer at a rate of about 230 cases per 100,000 as opposed to 150 per 100,000 for white men.
"The PSA test, though not a cancer-specific tool, is the best first step in the diagnostic process," Zenka says. In many cases, men with a high PSA reading will undergo a biopsy to determine the presence or extent of cancer. Those results, combined with age, health and family history, help physicians plot the course the disease might take, as well as the most effective treatment.
The benefits of annual PSA screening have been questioned by some experts. Earlier this year, the U.S. Preventive Services Task Force concluded that doctors should stop using the test for men who were not in high-risk groups, in part because the occasionally fatal risks of biopsies and other potentially unnecessary procedures outweigh the benefits.
The task force estimated that annual PSA screenings saved only about one life for every 1,000 men tested over a 10-year period. Advocates of regular PSA checks dispute those conclusions. Before widespread screening began about a generation ago, Zenka says, about 60 percent of men with prostate cancer already had advanced, often untreatable, conditions at the time of diagnosis. Today, 60 percent of cases are caught in early, treatable stages.
We know that early detection is crucial for intervention and treatment, especially among younger men. Yet too many avoid testing, even if their family history puts them at high risk. When my prostate cancer was detected two years ago, I called one of my older brothers, who had his prostate removed a few years earlier. As we spoke, though, he never uttered the words prostate cancer. Instead, he called it "my problem," and referred to my case as "your problem." Another older brother, who had undergone radiation therapy to treat his prostate cancer, refuses to talk about the condition at all.
Men like me, in families with a history of the disease, are twice as likely to get a prostate cancer diagnosis as others. Those of us with two or more relatives who have had diagnoses are nearly four times as likely to develop the condition. There's no particular controversy about this point — even the task force did not dispute the wisdom of annual PSA screening for men in high-risk groups, starting at age 40.
So why aren't enough of us doing it?
A Dangerous Silence
Prostate cancer is often asymptomatic — men may not know they have it until the condition is advanced. I was one of the lucky ones who went to the doctor early after experiencing telltale symptoms, which may include trouble urinating, blood in the urine, pelvic discomfort or swelling in the legs. Had my cancer been asymptomatic, it's possible that my brothers’ reticence about their own conditions could have cost me my life. If prostate cancer is part of your family history and you're unaware of it, the consequences of that silence can be deadly.
For younger men, the disease is treatable, if caught early, as it was for me. If it's diagnosed too late, the only option may be palliative care. For example, lower back pain can be a symptom of prostate cancer. But it's a problem typically ignored by men, who assume it's a natural part of growing older. They resist seeking medical care and so they never get the early diagnosis, especially if their primary-care physician, like mine, does not routinely do PSA screening. When such a symptom is left unchecked for too long, a patient's cancer may not be detected until it's in an advanced stage, requiring more invasive treatment and possibly resulting in an early death.
We know that many men don't like to talk about their health or mortality. A recent study by Rutgers University researchers found that men with a strong belief in traditional notions of masculinity — in other words, macho men — are only half as likely to seek preventive health care, no matter their socioeconomic status. The prevalence of this mindset, the researchers concluded, "may be a partial explanation for the paradox of men’s lower life expectancy."
It certainly helps explain why too few men are looking out for their prostates. Treatment used to focus on radical prostatectomy or orchiectomy (testicle removal). In either case, virility was a casualty of the surgery. Advances in technique make prostate removal less invasive today, but many men still see the surgery as threatening. And while hormone treatments have largely replaced orchiectomy, the process, known as androgen deprivation, can include side effects like hot flashes, mood swings, breast growth, excess fat storage and even osteoporosis.
Given that unpleasantness, why would men want to talk about "our problem"?
(MORE: What You Need to Know About Prostate Problems)
Because it will save lives.
Raising awareness can also help raise the money crucially needed for prostate cancer research. We should emulate the women who have so successfully increased breast cancer awareness and support. We could promote research like recent breakthroughs in identifying various cancer genotypes that may enable doctors to better predict the course of an individual tumor and develop treatments unique to each patient. Despite the recent progress, there is still no way to fully predict or prevent the development of prostate cancer, and no medical intervention that completely guarantees a cure.
That's why men need to start discussing it with our brothers, sons, friends and, most of all, doctors.
The evidence shows that by talking about and screening for prostate cancer at age 40, more men at high risk will improve their chance to make it to age 50 and beyond — well worth a little discomfort.