Maybe he lost his nerve, maybe he lost his lead, maybe it was the split with his wife. We've all got a favorite explanation for New York Mayor Rudolph Giuliani's abrupt withdrawal from the U.S. Senate race. But the reason Giuliani himself has given--his health--cannot be easily dismissed.
Recently diagnosed with prostate cancer, the mayor now faces an agonizing, almost certainly life-changing, calculation about treatment. And he's hardly the only one.
Every year, some 180,000 men learn they have the disease, and about 32,000 men die of it, usually after the age of 70. The diagnosis itself hits most men like a kick to the groin--and that's exactly where the disease strikes. The apricot-sized prostate gland is located right behind the genitals, where it makes the fluid that nourishes sperm cells. And treating (i.e., attacking) a cancer in the prostate seems nothing short of emasculation.
It doesn't help much to learn that most prostate tumors are very slow growing or that most men die with prostate cancer and not of it. In about 3% of all men, the cancer causes a painful, often lingering death, making it the No. 2 cancer killer among men, after lung cancer.
And here's the cruel punch line: Doctors can't tell for sure which prostate cancers are killers. They simply don't have enough scientifically valid research studies to guide their predictions as they do, for example, with breast cancer.
Doctors diagnose prostate cancer by measuring blood levels of a protein called prostate-specific antigen, or PSA. Doctors consider PSA readings below 4 to be normal, between 4 and 10 to be slightly elevated, and above 10 to be highly elevated and solid evidence of cancer. Urologists then examine biopsies taken from the prostate and rate them on a 10-point scale, called the Gleason scale, according to how deformed the cells look. From these two scores, doctors make an educated guess about how the cancer will behave. But it's a guess all the same.
"We've gotten very good at telling men whether they have the cancer," says Dr. Paul Nutting, a Denver family physician who has served on a national panel to evaluate prostate cancer treatment and now edits the Journal of Family Practice. "But we still don't know how to answer the big question: What do you do once you've got it? That is ultimately up to the patient--the man himself--to decide. A good doctor will lay out all the options."
Those options are not at all pleasant. You can have the gland cut out, a major operation called radical prostatectomy, which leaves about 6% of men incontinent and at least 30% impotent. In 85% to 90% of cases, doctors say, the surgery removes all traces of cancer. But in the other 10% to 15% of patients, the cancer recurs, and it's not clear how much the surgery helped, if at all.
Another way to attack the cancer is by zapping the prostate with radiation, either from an external beam, or from radioactive seeds that are implanted in the gland. Both treatments can cause urinary problems, and sometimes impotence. Like surgery, radiation therapy may leave some cancer.
A third option is to live with the cancer, hoping it doesn't spread and managing it with drug therapies, some of which are still experimental.
The most popular choice is surgery. About one in three men decide--often quickly--to have their prostates cut out.
"Once you learn you've got cancer, it's very hard to do nothing," says Claus Roehrborn, a urologist at the University of Texas Southwestern Medical School in Dallas. "You want it out, and you may not want to listen to all the other alternatives."
The ideal candidate for surgery, most doctors now agree, is a healthy man in his 50s or early 60s whose cancer is confined to the prostate and looks aggressive under the microscope. Men like Michael Tortosa, for example, a San Diego therapist who was diagnosed with a prostate tumor three years ago, at age 45.
"I decided to have the surgery pretty quickly," Tortosa says. "I'm healthy, I run half-marathons, I expect to live a lot more years, and I just couldn't bear the thought that this cancer would be growing inside me."
Men nearing 70, or in poor health, are usually poor surgery candidates, urologists say. They run high complication risks while under the knife, and that's why a good doctor will urge radiation treatment as an alternative. About 30% of patients try some form of radiation therapy, and most are men with significant detectable cancer whose life expectancy is not much longer than 10 years.
"Radiation is not quite as good as surgery at eliminating the cancer," says Paul Lange, chairman of the department of urology at the University of Washington in Seattle. "But it's easier on the patient and better at preserving potency."