It all Depends*


"Who feareth to suffer, suffereth already, because he feareth." Montaigne

Although I have not heard from the New England Journal of Medicine yet, I think I have stumbled upon a totally effective panacea for Arthritis, back pain, aching knees and middle-aged dyspepsia; especially if you are a man over fifty. It is called a positive biopsy of the prostate. When you get that phone call from the lab your afflictions will vanish faster than you can say "weapons of mass destruction".

Adenocarcinoma of the prostate is the most common cancer in men in the western world, excluding skin cancers. Three men in a hundred die from it. If your father or grandfather had it then you are an excellent candidate to get it yourself. If your brother had it you are probably gonna get it. As a matter of fact, if your wife had breast cancer you have a better chance of getting prostate cancer! African-American men get the shaft again because they are 40% more likely to get this disease than Caucasians. This year 180, 000 men will be diagnosed with it and 35, 000 will die from it. Or, to put it another way, 14% of all males born each year in the 21st Century will develop clinical Prostate Cancer. Statistical semantics aside, the fact is, shit happens with unpredictable democracy. Prostate Cancer is for men what breast cancer is for women; both attack sexual organs and both are hormone, diet and genetically-related.

Thanks to the courageous efforts of many women, breast cancer is now out of the prude-closet and every woman with an IQ of three digits is going for checks and doing the right thing. We men do not have any such advocacy. Bob Viagra Dole, Norman Schwartzkopf and Rudi Giulani haven’t done diddly-squat for Prostate Cancer compared with what Betty Ford alone did for Breast Cancer. Why don’t these so-called macho-paragons make a point of bringing prostate cancer out of the Cimmerian cave of male sexual fears? Is it because most men with prostate cancer end up with limp dicks (and sometimes diapers) that we are reluctant to advertise the risks and warnings of this patriarchal disease? Ironically, the one guy who has done a lot for Prostate Cancer research is Mike Junkbond Milken with his CaP-CURE foundation for which he has raised 100 million dollars.

Money is indeed, part of the problem. AIDS, Breast Cancer and Prostate Cancer each kill about 35, 000 people a year in the United States. AIDS gets nearly $1.5 billion in federal funding, Breast Cancer gets $315 million and Prostate Cancer is left with a parsimonious $56 million.

A few years ago the husband of an old friend of mine got Prostate Cancer and I confess, with no small chagrin, I gave it very little thought. I didn’t even know what the prostate was! I was sympathetic of course, but the significance, the meaning, the "horror of it all" as Kurtz would say in Heart of Darkness, did not sink in (the story of my life). I did not read a word about Prostate Disease nor did I take a single precautionary measure.

For whatever reason, perhaps a life-long ambivalent hypochondria, I went for a physical in Berkeley a year ago and, in fact, when the doctor gave me the "digital" exam, he felt that my prostate was slightly large. When the blood work came back my PSA was 5.2. (anything over 4 is considered abnormal, if not high) I have to admit that he did say, "Come back in six months." But Jesus Christ! An enlarged prostate and an elevated PSA with a guy in his late fifties? Hello!!! (Well, of course, it was MY fault that I was so complacent and did not investigate further on my own…as they say in Haiti, it is not a crime to be stupid, it just makes life more difficult).

Ironically, six months later at a rural clinic in southern Utah, I went for another physical required by the Peace Corps to which I was applying. At that time the self-conscious, Mormon nurse practitioner did not feel anything with a perfunctory DRE (digital rectal exam) but the PSA was, again 5.2 and he scheduled an appointment with a urologist who, as is his wont, daily has a digit up countless woolly orifices and he felt the prostate both large and with nodules. In early January he did an ultrasound biopsy and of course that was positive. So here we are. I feel great; I ride my bicycle a hundred miles a week and walk and exercise the rest of the week and do Yoga every morning. My father died working at ninety-two. My heart is strong, blood pressure perfect, sitting pulse of 55….and I have f…..g cancer… which has been growing in me for years!

Well, you gotta dance with them what brung ya.

It’s a guy thing. The prostate makes some of that "sticky" which carries our micro-progeny. Besides the great feeling we get when all those little spermies shoot out, what about the mechanics of it all? This little ping pong ball called the Prostate, located just below the bladder, deep in the protective cavity behind our pelvic bone, is very busy. The prostate is attached to the bladder. The urethra runs right through the middle of the prostate sort of like the main stream and our procreative fluids feed in like tributaries. Various muscle groups control the flow of urine and velocity of ejaculate. Along the sides of the prostate are the minute nerves administering to the rise and fall of our "John Thomas." Just above it are the seminal vesicles. Your prostate is a command center of liquid waste management and sexual activity.

There is much truth to the adage that "all men get prostate cancer if they live long enough." The corollary to that is that more men die with Prostate Cancer than of it. A study of a thousand male autopsies showed: 25% of all men in their thirties have latent prostate cancer; 30% in their forties, 40% in their fifties and 50-60% of all men in their 60’s have latent prostate cancer! The point is, prostate cancer is an insidious little bastard, which develops and grows deep within our bodies at a painless, slow rate for many years. Once it metamorphoses from latent to clinical and escapes the confines of the gland itself (to the lymph nodes, bones or seminal vesicles), it spreads with an immutable, painful virulence.

There are some things you should, and can do, to try to preclude this unappetizing phenomenon. First and foremost is to eliminate all red meat, most fats and unnecessary sugar and dairy from your diet. "Studies estimate that 75% of all cases of Prostate Cancer could be prevented by changes in diet and lifestyle." Become a vegetarian. Vegetarianism, as we all know, is good, both for us and the environment. Eat lots of beans, fiber and fruits and vegetables….the more colorful the better. Hundreds of studies at places like Harvard, Memorial-Sloan Kettering, Stanford and Johns Hopkins, have demonstrated an unarguable link between prostate cancer and fat. We are not talking Marin Country mushroom-gatherers here. As early as 1982 the National Academy of Science concluded, "…the incidence of Prostate Cancer is correlated with other cancers associated with diet, e.g. Breast Cancer." Today, in 2002, the Surgeon General’s office claims that four of the ten leading causes of (all) deaths are related to diet.

"All I maintain is that on this earth there are pestilences and there are victims, and it’s up to us, so far as possible, not to join forces with the pestilences." Camus, The Plague

Now that I have given up coffee, meat, sweets, alcohol and fats I am appalled (and nauseated) at the plethora of gastrointestinal horrors lining the shelves of every supermarket in this country. My guess is that the average American dinner contains more pasty, fatty, sugary, carcinogenic, bovine assaults to our immune system than anywhere else in the world. Speaking of bovine, Utah, where I live, has the highest rate of prostate cancer in the country. So re-read Andy Weil and get a good book on healthy cooking such as the Moosewood Restaurant Low-Fat Favorites or Martha Rose Shulman’s Mediterranean Light.

If there is cancer in your family, particularly Prostate Cancer, begin at age forty, otherwise, wait till fifty….to do yourself and all of us, a huge favor and give yourself a birthday present annually of a DRE (digital rectal exam) with a UROLOGIST and a PSA blood test. Prostate cancer is relatively curable if it is caught early, and the ONLY way to catch it early is by the DRE and PSA (Prostate Specific Antigen…a relatively new test; developed in the late eighties…so, not all physicians fully appreciate its importance). Before PSA, seven out of ten prostate cancers detected had already spread beyond the point of cure. With PSA, seven of ten cancers detected can be cured! The coup de grace is the ultrasound biopsy. With a stainless steel phallus, that looks suspiciously like something Dr. Specter might have used on James Bond, inserted painlessly in your orifice posterieur, a doctor can see on the computer screen an image of your prostate and then snip away microscopic parts to be analyzed. Then you will know; and "knowledge is power," to quote my uncle Francis.

The one good thing about Prostate Cancer is that it creates an abnormality in our blood which is clearly detectable. When your PSA spikes you know something is wrong. It might just be Benign Prostatic Hyperplasia…or it might be cancer. And, nice as he or she might be, do not rely on your family doctor to know what he or she is feeling as you are bent over about to fart with a finger up your ass. Furthermore, do not be misled by anybody who says such tests are equivocal, scary and unreliable. Believe it or not, there are many that do. Imperfect as they are, the fact remains, these tests are the only ways of detecting prostate cancer early on! Whoever argues against the PSA and DRE is like Chamberlain at Munich in 1938. Does the image of an ostrich come to mind? You know damn well what is going on and that you should do something; but it will be expensive and painful….so you do nothing and hope that he won’t actually spread beyond the Sudetenland. The extra year we gave Hitler allowed him just enough time to execute his sinister plans for expansion. PSA is the clue for "mobilization."

"It is not surgery that kills people; it is delayed surgery." Dr. W.J. Mayo

Incidentally, there are some symptoms, which might portend cancer or, very likely, some other prostate disease. Nocturia is the official name for having to get out of bed and stumble to the bathroom several times a night. Likewise, if you find yourself having to pull over to the side of the autobahn with painful alacrity to water the grass you might begin to think about the cause of this embarrassing inconvenience. Difficulty getting the stream started, intermittent stream, burning, painful ejaculation, bloody urine or semen, or pain in the lower back are other symptoms. As I said, there are no early clues, so when you do begin to have significant symptoms you’re already hearing the roar of the rapids….and you don’t have a paddle.

All of you have given up smoking thanks to years of study and incontrovertible evidence apropos the link between heart disease, lung cancer and the asshole on his horse. Almost the same amount of scientific evidence now exists to show a direct link between fat intake and prostate disease. Back in the sixties we joked and said, about food labels, "If you can’t pronounce the word, don’t eat it." What I am telling you now is that if the label says there is more than three grams of fat don’t eat it. That is to say, try to keep your total fat intake to less than forty grams a day. Meat fat is the worst, butter is bad (switch to using almost exclusively olive oil…sparingly) dairy fat is not good, vegetable fat is not particularly good either (although better than animal fat). Hydrogenated oils are BAD. Practically the only "good" fats are from fish (omega 3 fatty acids) and olive oil.

I used to love coffee, Pringles, steak, bacon and eggs, roast pork, hotdogs, cake and ice cream. Within twenty-four hours of getting my biopsy results I threw away at least a hundred dollars worth of that stuff, switched to green tea, tofu, tomatoes, rice, beans, broccoli and good old H20, and within days felt noticeably improved. And, despite the unhappy knowledge that I had cancer, I was sleeping better – I think due to the elimination of coffee. The good news is that simply by switching to a palatably agreeable (vegetarian) Mediterranean diet (lots of tomatoes and extra virgin olive oil!) you will be eating mostly good food. You don’t smoke, you wear a seatbelt, you get your oil changed regularly, you don’t flip off strangers….so stop eating anything which looks like it might appeal to a junior high school student.

You can ignore this hysterical-sounding admonition about diet, fat and exercise. I did too until a few months ago. But, please, please do not ignore what I have said about the testing. This is a very treatable cancer if it is caught early, and you are lucky, as I was, and find a good man with a knife. Under the best of circumstances, it is a very complicated surgery deep down in the abdomen. When the prostate is removed, the urethra has to be sewn back on to the bladder. Caught early (before metastasis) the erectile nerves, which are attached to both sides of the prostate, CAN be saved. An excellent surgeon can also sew up the bladder in such a way that you won’t have to wear diapers for the rest of your life. But it all depends on catching it early!

To reiterate…every man over forty should take this very seriously. (Frank Zappa died at fifty-two). Learn a little bit about your prostate and prostate disease (included is a bibliography). Then, from now on, schedule an annual PSA blood test and a DRE with a urologist. The whole deal won’t cost more than a ticket to the opera. Don’t be a victim of fear or ignorance. The point is to know, and catch this sonofabitch early while it can still be cured….and doesn’t leave us (terminally) prostrate.

BIBLIOGRAPHY

1. Arnot, Robert, M.D. The Prostate Cancer Protection Plan. Little Brown, New York, 2000. This exceptional book is a follow-up of Dr.Arnot’s work dealing with breast cancer prevention. For the serious cancer ultimate fighter this is a must-read. The good news is that a diet for prostate cancer is a good diet for breast cancer, colon cancer and heart disease. ****
   
2. Berberich, Ralph, M.D. Hit Below the Belt. Berkeley, 2001. This is a very unique look at PC from the perspective of a doctor who opts for the Chernobyl plan. Actually, Dr. Berberich figures out his own therapy…chemical castration via hormones, external beam radiation and then a back-up dose of radioactive seed implants (brachytherapy). ****
   Bostwick, Maclennon and Larson. Prostate Cancer. American Cancer Society. 1996. Basic, brief overview of PC with various treatment options. *
   
3. Gotlieb, Bert. The Men’s Club. Oxnard, CA. 1999. A personal account of surgery by a wise-ass, name-dropping New York ad agency scriptwriter. Interesting look at how foolish people can be. ***
   
4. Inlander and Norwood. Understanding Prostate Disease. New York, 1999. Good, basic introduction to all sorts of prostate diseases. *
   
5. Jesling, Nadine. Prostate Cancer. Boulder, 1999. Ms. Jesling organized a weekend retreat for about ten men who had had a variety of experiences with their Prostate cancers…treatments discussed vary from standard surgery, external beam, brachytherapy to cryotherapy (new, high-tech, as yet unproven way of freezing the cancer cells). This is the good, bad and worst side of things. ***
   
6. Jaffe, Dennis. Healing From Within. New York, 1982. Given the huge amount of evidence linking PC with diet, stress and exercise, this famous old book certainly has relevance for the Prostate Cancer extreme fighter. ***
   
7. Kantoff, Philip, M.D. Prostate Cancer: A Family Consultation. Houghton Miflin, New York, 1996. A good introduction to the disease, good diagrams, case histories, alternative treatments…slightly old now. **
   
8. Kantoff, Philip, M.D, Carroll, Peter, M.D, and D’Amico, Anthony, M.D. Prostate Cancer: Principles and Practice. Lippincott, New York, 2002. This 700 page encyclopedic tome is THE medical school textbook for prostate cancer. It’s a bit pricey at $150 but definitely worth a look at your local medical library. ****
   
9. Korda, Michael. Man to Man. New York, 1999. This must-read is a gripping first-hand account of PC and surgery written by a quintessential New Yorker (high drama, low pain tolerance). He should have sub-titled the book "Murphy’s Law and Prostate Cancer." Highly recommended. *****
   
10. Marks, Sheldon. Prostate and Cancer. Lister Books, 1999. This is an outstanding description of the disease, possible treatments and what to expect…by a renowned urologist; definitely one of the better books out there. Highly recommended. *****
    
11. Martin, William. My Prostate and Me. Cadel and Davies, New York, 1994. Although an "old" book, this is an excellent, professorial, good-humored description of the onset, various treatment options and emotional roller-coaster of it all. Good "Afterword" by Dr. Peter Scardino. Highly recommended. ****
    
12. Neider, Charles. Adam’s Burden. New York, 2001. Neider, a former Antarctica explorer, gets prostate cancer when he is 79, has radiation treatments and writes a male-chauvinist hero’s story about it all. It does provide an accurate description of external beam radiation and some good interviews. ***
    
13. Newton, Audrey. Living With Prostate Cancer. Toronto, 1996. This is the heartbreaking story of a ten-year struggle with metastasized cancer. The guy learned too late. This is the price of "watchful waiting."
    
14. Osterling and Moyad. The ABC’s of Prostate Cancer. Ann Arbor, 1997. Slightly out-dated, but good introduction to the horrors and hopes of PC. Includes some good science, diagrams and many brief accounts of famous people. **
    
15. Stoff, Jesse. The Prostate Miracle. New York, 2000. This is a pretty thorough look at alternative "cures" or palliatives for PC. The point is, once we have cancer, do we just continue to eat the same shit and assume our doctor will cure us or do we finally change to a truly healthy diet and supplements? ***
    
16. Taguchi, Yosh. The Prostate. Firefly Books, Buffalo, 2001. Although produced by a small house, this is an excellent description of non-cancerous prostate problems, the usual statistics, and a fairly detailed description of a radical prostatectomy. ***
    
17. Wallner, Kent, M.D. Prostate Cancer: A Non-surgical Perspective. Canaan, New York, 1996. This one-hour read is a good place to start familiarizing oneself with a radiation approach to treatment. *
    
18. Walsh, Patrick. Guide to Surviving Prostate Cancer. New York, 2001. This is THE book. Dr. Partick Walsh is the Czar of Prostate Cancer. If one could read only one book, this would be it. Sophisticated but readable science, good diagrams, well-rounded approach. Most highly recommended. *****
    
19. Washington, Gene. An Epitaph and an Elegy for a Prostate. Xlibris Corporation, 566 E. 600 North, Logan, UT 84321. Basically, this English Professor’s account is the ugly side of surgery… if you don’t do your homework and you don’t go to the best hospital. He opts for surgery in Utah. Duh? Remember the last time you landed at Salt Lake International Airport and the stewardess said, "Please fasten your seatbelts and set your watch back ten years?" Utah doctors still believe in "wide excisions." Translated, that means you’ll never get another "woodie" and you’ll spend the rest of your life in diapers. ****
    
20. Weil, Andrew. Spontaneous Healing. New York, 1995. Who hasn’t read this? But read it again. **

This bibliography is, by no means, exhaustive. These are just the books I happened to find in a couple dozen book stores from Salt Lake City to San Francisco. Needless to say, professional journals such as: The Journal of the American Medical Association, New England Journal of Medicine, The Journal of Urology and Urology, are excellent sources of contemporary research. For a guy in his mid-fifties who has just joined "The Club," I would recommend, first of all, visiting The Web. Type "prostate cancer" into any search engine and you will easily discover the sites of the American Cancer Society, Pub Med, CaP-CURE and the hospital pages of Stanford, Sloan-Kettering and Johns Hopkins etc.

I suggest reading, in the following order: Korda, Marks, Berberich, Walsh, Neider, Martin and Washington. Five stars is most highly recommended, one, least. Thorough research is pro-active and empowering. For my money surgery is the best option if the cancer is caught early. And for the best surgery you only have a few choices, namely: New York, Baltimore, Rochester, Houston, San Francisco and Palo Alto. You may love your doctor in Boise or Terre Haute but don’t let him cut your prostate out!

*Depends: brand name for adult, male diapers