Ralph Davison wants people to start talking about prostate cancer. He understands that packaging the words "prostate" and "cancer" in one soundbite creates a phrase of uncommonly low conversational appeal, a compact cluster of social taboos, but his own recent battle with the disease convinced him to go public.

"Men don’t talk about prostate cancer," he says. "But being macho is not worth dying for."

That's the lede of this week's column. You can read the whole thing after the jump.

Talking about prostate cancer

by Edward Cone
News & Record
4-13-08

Ralph Davison wants people to start talking about prostate cancer. He understands that packaging the words "prostate" and "cancer" in one soundbite creates a phrase of uncommonly low conversational appeal, a compact cluster of social taboos, but his own recent battle with the disease convinced him to go public.

"Men don’t talk about prostate cancer," he says. "But being macho is not worth dying for."

This is the way it works in American culture: we try to ignore illnesses, even at the expense of our own health, until someone famous comes along and says it's OK to start the conversation. Research and funding for a disease exposed to this kind of sunlight increase with the new openness. Betty Ford did it for breast cancer more than 30 years ago, and now an educated, pink-ribbon-wearing public takes its mammograms in stride. More recently, Pedro Zamora helped the MTV generation understand what it means to live with AIDS.

Davison, the retired Head of Greensboro Day School, doesn't fancy himself a celebrity, although his deep involvement in this community and a long stints as a parenting expert on both WFMY and WGHP have given him a reasonably high local profile. He's a thoughtful, well-respected guy with a story to tell, and he'd like to encourage people to save their own lives.

It's easy to see why people avoid this particular topic. Anything affecting the prostate threatens a man's sexual potency, which rates an 11 on a 1-10 scale of fraught issues. (We'll advertise Viagra and other chemical pick-me-ups, because both big money and the promise of a good time are involved, but the reason a lot of men need that stuff remains unspoken.) The doctor's digital examination of the gland makes men uncomfortable in every sense of the word, and thus is spoken of mainly in second-rate standup acts ("You could have at least bought me a drink first"). And cancer, despite great advances in treatment and survival rates, carries with it intimations of mortality that a lot of folks find very difficult to handle.

But prostate cancer is too big a problem to ignore. Men have a one in six probability of getting it at some point in their lives. Many will develop it late enough that the cancer doesn't kill them, but for younger men and those with more aggressive strains, it's a big damn deal. An estimated 186,000 American men will get the disease this year, and more than 28,000 are expected to die from it – almost 10% of all male cancer deaths in this country.

Davison, healthy at 61, was diagnosed in December after a blood test, known as a PSA test, led his doctor to recommend a biopsy. He had been getting the PSA screening as part of his routine physical for years, and it is this simple procedure that he wants all men to make a habit. After researching various treatments, talking with other men who had beaten the cancer, and consulting with his physician, he opted for the most aggressive approach: surgical removal of the prostate. Then he took off with his wife, Jean, for a long-planned trip to Antarctica, which gave him something to do while waiting for the operation.

Until recently, prostate surgery was an enormously invasive procedure, and damage to the nerves controlling sexual and urinary function was common. But Davison had a very different experience. His doctor at the Moses Cone Cancer Center, Les Borden, sat at a console, operating a joystick and looking at a screen, as a robotic device made six small holes in Davison's mid-section. The robot is incredibly precise, and Davison emerged with the key nerves intact.

Throughout the course of his illness and treatment, Davison kept family and friends informed via a series of emails sent with the subject line "full disclosure." Eventually, the list would grow to about 100 people. Responses from this group helped him through the process – especially conversations with men who had undergone similar experiences. "There's no point in going though it alone," he says. "It does not need to be a lonely journey." His advice in a nutshell: "Check your PSA, and talk freely to others who have been there." Two months after his surgery, Davison is ready to resume his second career as a globe-trotting school consultant.

I am not a disinterested narrator of this story. Not only is Ralph a good friend, but my own father died at 54 from prostate cancer. This puts me and my son at somewhat greater risk for the disease. (My dad, himself an oncologist, did have regular checkups, but the screening technology was not as well-developed at that time, and as he said with clinical dispassion of his rapidly metastasizing cancer, "the second cell traveled.") I’ve been having my PSA checked, and enduring those intimate moments with my doctor’s index finger, for years.

You should, too.

© News & Record 2008

Comments

[Sue]

While I want everyone to have all the cancer screenings possible, it still strikes me as ironic that men have this "thing" about 'close to genital' area examinations and the human discomfort that goes with it. Women, I suppose, are so used to gynecology that it's joked when in labor, "everyone, including the hospital janitor, had his hand up my..."

If they created a testicular a cancer screening that involved squeezing male testicles very tightly between two pieces of glass to x-ray them while you're staring at signs that declare, "We compress because we care," and "no, you're not getting any pain meds," and "just walk from this room to that room without any pants on - we'll give you a little pink towel," then men might have a clue as to what women's normal healthcare involves. (And btw, you must have that screening every year.)

I guess I'm having difficulty understanding why any man would shy away from a routine screening because he was embarrassed or even humiliated by being touched "that way" by a doctor and btw, would it matter if the doc were male or female? Most women my age are desensitized to male doctors having intimate access annually to all our 200 parts so it's a trifle perplexing to comprehend male angst. With an annual pap smear, mammogram, daily self-exam and more, it's logical that women just don't "get" this male discomfort. We wonder why it's taken men so long to get used to such screenings but it's assumed that women do this happily.

Go figure. But do get a PSA every year and all the embarrassing moments of medical care that screen for cancer of every possible type. And make sure EVERYONE has equal access and equal education as to why that's important.

[Ed Cone]

What an odd response. The column addresses some of the issues men face -- it goes a bit beyond attitudes about close-to-genital exams -- and points out that women with breast cancer were dealing with similar issues only a generation ago.

I've gotten a lot of good email on the column, and I hope it will make a difference for someone.

[Stormy]

Ed,

It looks like Sue just being Sue. Talk about killing a healthy discussion about prostate cancer. Sue just did it.

[Ed Cone]

It was a bucket of cold water, Stormy, but I hope people will shake it off and have that discussion anyway.

[Stormy]

Ed,

I previously related my story to you this morning about prostate cancer, but Sue's post has clearly shown why this discussion doesn't occur by men in a public forum. If a man said something similar to what Sue said about breast cancer, Katie bar the door. I'm outta here on the discussion. You can close this strand down.

[Fred Gregory]

Ed,

Thank you for this column.

I have a good friend (and I think I have told you this story ) who is one of 5 brothers and two sisters. Four of the brothers have already been detected with prostrate cancer , fortunately in time.

If there is a male hang-up about the digital rectal exam. I don't have it or never met anyone who did.
I am leaving this link not to get a chuckle but to point out lightheartedly that the procedure is invasive but essentially painless ( Yeah, I sent it to you earlier ) Fear not Dr. John Longfinger:

Tomato

** Full disclosure . I am aware of some doubters of the benefits of lycopene, but that really wasn't the point of the above video

[Jeffrey Sykes]

Ed: Good column on a very important issue.

[jimcaserta]

The local men's baseball league I play in rasied some money last year for the prostate cancer foundation. The national league we are affiliated with has adopted PCF as their charity of choice. It got some discussion, at least in our small group of managers and players.

[Conrad Henselder]

Looking for help and advise,
I aleays had low PSA numbers in the range of 1.4. On 21 March 08 I had a TURP. The bipsy showed cancer in the Prostate. The Doc informed me on 3 Apr 08 that the grade was 3+3 on the Gleason scale. I meet with him on 1 May. I am 66 years old in good health and looking for input on what to do.
Thank You
Conrad

[Ed Cone]

Conrad, I don't have the expertise to give medical advice, but I do see a lot of information online. Click here for a site that looks like a good place to start. I will ask Ralph Davison if he knows of other good resources, and email you with any useful tips. Best of luck to you.

[bc]

My dad had the shaped aperture radiation and he is 100%.
With this method, they limit collateral damage to a few millimeters. His was done in Pittsburgh Pa. The male hormone shut down drug Luprin wiped him out but apparently that buys time while you wait for the zap treatment. Really, it was very impressive.

[Christopher Johnson]

I was diagnosed with prostate cancer at the end of February last year when I was 51. I get regular blood counts for my doctor and in one of them, he noticed that my PSA count had suddenly jumped to 5.3. So my doctor sent me to a urologist who recommended a prostate biopsy(really not a painful procedure but one of the most disconcerting things I've even been through; let's just say that the finger up your you-know-what is not the worst thing that can happen in a doctor's office) which turned up cancer.

I had that robotic procedure in May although they didn't remove all the prostate. First week after it was pretty rough but not as rough as cancer can be; I've got a friend who's been through breast cancer, radiation and chemo, and she had it a lot worse than I did. After that, it hasn't been too bad. I'm still not 100%(they said it does take a lot of time) but I'm happy and my last two PSA counts were undetectable.

[Donna B.]

Thanks for the column. My husband sees a urologist a week from tomorrow because his annual exam came back with a high (can't remember the number right now) PSA.

He's recovered from colon cancer (successful surgery there) and I'm glad to hear that there's a good surgical procedure for prostate cancer if it turns out he has it.

Pay no attention to Sue. Not all women take those exams as nonchantly as she apparently does. Besides, this is not a battle of the sexes.

[openwheel11]

Yeah, Sue sure threw some cold water on what should be a very important discussion. It's not about the exam, its about the concequences. Men have a natural tendency towards denial; if I don't look for it, it won't be there.
I was diagnosed with prostate cancer at age 46. Fortunately, and through pure luck, I had been getting PSA and digital exams since I was 42. I had been living with the threat of cancer for 4 years due to slightly elevated PSA levels even though my first biopsy was inconclusive. That is by far the worst part, the nagging thoughts in the back of your head. I was also lucky in having a very supportive brother in law who had gone through it as well; it is critical to have someone to talk to who "has been there".
I am very lucky, the robotic surgery went well, I was back at work in 4 days, my PSA levels are zero, and I have had minimal side effects. Medicine has come a long way, but it is key to get that blood test.

[bornhotraisedcold]

Prostate cancer was diagnosed three years ago when I was 67 and treated within a year; treatment included chemo to reduce the prostate, radiation implants, followed in two months by 6-weeks of X-Ray radiation therapy. All in all, it was relatively harmless but did require re-learning how to control urination and during the radiation therapy, I had to stay within 5-minutes of any lavatory. My most recent PSA is 0.3, which my urologist said was in the very acceptable range and that my PSA will never go to zero.

My only question is whether removing the prostate wouldn't have been a better approach. The question of a man's libido can be resolved, especially now with prescription medicines available and possible surgerical procedures, and over the age of 65 libido questions can be rationalized somewhat, perhaps.

My urologist was not too informative about why radiation was preferred to surgery and I'm still not convinced that my treatment was the best approach. However, one lingering concern is that medicine apparently cannot clearly determine when a PSA value indicates a cancerous prostate versus a mere growth. A cousin had his prostate removed 10-years prior to my procedure and his PSA is now zero.

The lesson seems to be that a man need to have PSAs periodically and needs to consult with his doctor. There was a most recent local case of a well-known personally who died from prostate cancer, apparently because he avoided the issue altogether. It is unnecessary for that to occur in most cases.

[Dennis]

As many men die of prostrate cancer as women do from breast cancer a year. You would not know that from the coverage it gets.
Sue demonstrates that no matter what the subject or its seriousness to a segment of the population it always becomes about women. If only they could stop thinking of themselves just long enough to realize that maybe they might give as much care to men's issues as they expect men to do for theirs.
Prostrate cancer is a serious issue for men and those who care about them.

[Ed Cone]

As I researched the column I read about the alleged politicization of cancer along gender lines. I don't really see that as the defining problem here, although I understand the frustration over a perceived lack of attention to prostate cancer.

I think the reason breast cancer gets more mindshare and funding is (as I wrote in the column) because it's had an effective, long-term awareness campaign, which can be traced back to Betty Ford.

Attitudes toward disease are shaped by culture. Heart disease was long understood as a male problem, for example, but our understanding of its broader impact has begun to change.

The issue is not some kind of gender war, but one of strategy. How do we get people to focus on prostate cancer? Part of the answer may be copying a page from the playbook that's worked so well for other illnesses, including breast cancer. That's what Ralph Davison and I are trying to accomplish with the column.

[Charlie]

Way to shine a light, Ed. Shortly after meeting him for the first time, I lost my future father-in-law to prostate cancer that had been controlled for several years and then came roaring back. Nasty stuff, but even in his case being diligent about getting exams and checking in with his doc bought him several years.

An interesting, and related topic, is the mystery that is prostate infections. There was a great article about it in Best Life magazine a year or so ago. In an age where science can identify where in the world a certain strain of disease originated from down to a couple miles, in some cases, prostate infections have remained a great mystery, and their link to cancer down the road is still vastly understudied.

Again, way to put important stuff out in the fresh air.

[leishman]

I am a physician and can speak to the screening issue. The U.S.Preventive Services Task Force, which weighs all the data before recommending for/against a screening/preventive service, remains agnostic as to the benefit/risk ratio. "The USPSTF found good evidence that PSA screening can detect early-stage prostate cancer but mixed and inconclusive evidence that early detection improves health outcomes. Screening is associated with important harms, including frequent false-positive results and unnecessary anxiety, biopsies, and potential complications of treatment of some cancers that may never have affected a patient's health. The USPSTF concludes that evidence is insufficient to determine whether the benefits outweigh the harms for a screened population." Yes, research is needed to (a) create a more effective screening instrument and (b) better distinguish, prior to medical intervention, which person's cancer is very slow growing and not a risk, versus which person's cancer would warrant treatment. In the meantime, we--patients and physicians--are flying in the dark.

[bornhotraisedcold]

commenter leishman: Doctor, I didn't realize the questions regarding PSA until a recent insurance medical exam MD and I chatted about PSAs and their value. Don't recall even seeing that question discussed in the media, which is a problem.

Seems that raising the question about finding a better indicator should be a goal and that doesn't appear to be forthcoming. Couldn't the USPSTF do more, or encourage more efforts, to develop or verify a better screening tool? Or perhaps the medical profession have an effort to do more! Perhaps we need a woman to start this since we guys have done little to promote that effort.

[Bruce from DC]

Good column. As a guy (59) who just had his cancerous prostate removed two months ago, a few data points. Unlike lots of cancers, including breast cancer (my wife was diagnosed 11 years ago), prostate cancer is almost always slow growing. But that doesn't mean its not fatal. The simple facts told to me are these: if the disease is organ-confined at surgery (no invasion of seminal vesicles or penetration of the prostate capsule and no signs of cancer in adjacent lymph nodes), then doctors talk about a "cure." (i.e. you can forget about it). However, if those conditions don't exist (which is the case with me), they talk about "management," which, in blunt terms, is trying to prolong your life so that you die of something else first. Most of prostate cancer is driven by testosterone, so the initial therapy after either surgery or radiation is to give the patient a drug that suppresses testosterone production for a year or two. Then we wait and monitor the PSA. If it starts rising, then the "hormone therapy" is resumed for a while. Eventually, the cancer stops responding to the hormone therapy and becomes "hormone refractory." At that point, there seem to be few options. Taxol, a chemotherapy drug has some, but limited effectiveness. What kills the patient is the cancer metastasizing in either the bones or the liver. However, this process takes time . . . it appears to be somewhere between 5 and 10 years, maybe longer depending upon the patient. The leading edge of research seems to be focusing on vaccine-like treatments that stimulate the immune system to attack the cancer cells. 1980s "junk bond king" Michael Millken was diagnosed with a very serious case of prostate cancer in 1993, when he was 49. My guess is that, at that age and at that time, he was symptomatic; and his disease was not discovered by a PSA test. Nevertheless 15 years later, he's still very much alive. He's also put a ton of his own money into prostate cancer research and really pushed the medical community to attack this disease.

As a person with a serious case of the disease (I was "symptomatic" and the disease was not diagnosed as a result of PSA tests) and as the husband of a Stage 2 breast cancer patient, I find all of this discussion about who gets attention and who doesn't to be - at the very least - beside the point. The fact is that these diseases kill a lot of men and women every year and they ought to be taken seriously.

As far as men being squeamish about the digital exam, based on my conversations with several prostate surgeons, the problem for men isn't the exam, the problem is their knowledge that loss of the prostate means a loss, to some degree or other, of sexual function. Let's remember that the prostate is a sex organ; it produces the seminal fluid that carries the sperm that is pumped out in an orgasm. So, even if a man can get an erection post-operatively, the "orgasm" that he has is quite different than before. As a result, regrettably, some men take the ostrich approach about the whole thing and just "don't want to know" because of the possible implications of that knowledge.

[leishman]

The USPSTF is kind of like Consumer Reports--it just reviews, without particular bias, the existing studies and draws conclusions, but without being responsible for creating the things (e.g., tests or treatments) it reviews. Federal research funding, which is the actual source of most research, is prioritized on at least a partially political basis (AIDS, breast cancer). Prostate cancer is more common in African-Americans--maybe that might be a political hook.

[BHRC]

Doctor "leishman" I'm going to raise this issue with Senator N. Coleman and Rep. John Kline and with others that may come to mind. The information you provided is valuable. If you wish to contact me, take a look at my typepad profile.

[BHRC]

Shucks, Doctor, my email is wrightdn@charter.net. BHRC stands for bornhotraisedcold

[Chuck Gallagher]

As a prostate cancer survivor, I am writing a book on the subject to help men and their families deal with the issues that arise - not only the physical issues but those emotional issues that are present when dealing with this disease and the likely side effects (even if only temporary). My new blog is a prelude to the book. Likewise, I am actively conducting (confidential) interviews of men and their partners related to their prostate cancer experience. For more information contact me at chuck@chuckgallagher.com.