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A man's tough choice

Not even doctors agree on the 'best' treatment for prostate cancer.

November 08, 2004|Timothy Gower | Special to The Times

The biopsy was positive. Don Cozza felt a wave of disappointment rush over him. He had been certain the test would show that he didn't have prostate cancer after all.

Cozza listened as his urologist described two options that were suitable for his cancer, which had not spread beyond the prostate and was likely to respond well to treatment: surgery or radiation. When Cozza, 54, told his wife that his doctor was leaning toward surgery, she urged him to seek a second opinion from a radiation oncologist. "He gave me a more encouraging view of side effects as far as radiation goes," says Cozza, of Port Hueneme.

Both doctors made compelling arguments for the type of therapy they perform, leaving Cozza confused in the face of a daunting decision: What is the best way to treat prostate cancer?

Doctors in the United States will diagnose about 230,000 men with the disease this year. About 8 in 10 of those men, like Cozza, will have their disease detected in the early, highly treatable stage. Although early-stage prostate cancer is rarely fatal, choosing from the various ways to treat the disease often heightens a man's anxiety.

"Patients feel like they're in a free fall," says Dr. Mark Kawachi, director of the prostate cancer center at City of Hope Hospital in Duarte. "There are so many options, so many treatments."

Doctors say that a paucity of research comparing the effectiveness of various treatment options is one reason for the confusion. Another problem, some doctors say, is the relative lack of cooperation among the various specialists who treat prostate cancer.

That list of options seems to grow each week. Kawachi, for example, is pioneering the use of minimally invasive robotic technology to remove prostates. And UCLA researchers are refining a relatively new technique called cryotherapy, which freezes prostate cancer cells. Others are studying whether ultrasound can be used to treat prostate tumors.

And the most commonly recommended treatments for prostate cancer each have variations men must ponder. The treatment known as radical prostatectomy, in which a urologist surgically removes the cancerous prostate, is the most common procedure. However, some doctors offer so-called nerve-sparing surgery, which reportedly reduces the risk of erectile dysfunction and other side effects of surgery. Radiation oncologists, meanwhile, zap tumors with brachytherapy (radioactive seeds implanted in the prostate) and external beam radiation (X-rays delivered from outside the body). A patient who opts for radiation treatment must also decide whether to seek out a clinic that performs "conformal" radiation, which allows for higher doses, or proton beam therapy, which bombards the prostate with atoms.

And chemotherapy and hormone therapy, which are not usually recommended for men with early-stage cancer, are used for those with more advanced forms of the disease.

Because prostate cancer is often slow growing, a minority of men choose not to be treated at all (so-called watchful waiting) unless blood tests suggest that the tumor is becoming more aggressive. However, here's what really confounds men who opt for therapy: Early-stage prostate cancer is unusual, compared with other forms of cancer, because no one knows the best way to treat it. "When you see a patient with kidney or bladder cancer, you tell them, 'This is what you need,' " says Dr. Arie Belldegrun, chief of urologic oncology at UCLA's Jonsson Cancer Center. "With a prostate cancer patient, it's very hard to know what to tell him."

The problem arises from a lack of hard data. Traditionally, urologists and radiation oncologists have not collaborated on studies to determine which therapy is best suited for given patients, based on the nature of their tumors or their age, for example.

Women with breast cancer face fewer treatment decisions because there has simply been more research, says Kawachi. He believes the available knowledge to assist men in making decisions about treating prostate cancer is about 10 years behind research on breast cancer treatments. "At this point with breast cancer, [treatment options] seem relatively clean and straightforward," says Kawachi. "Prostate cancer is only now entering that realm."

Despite the lack of evidence showing the superiority of one approach over another, physicians who treat prostate cancer often tilt in favor of the techniques they perform. A 2000 survey published in the Journal of the American Medical Assn. found that 93% of urologists would advise a man with early prostate cancer to have surgery, while 72% of radiation oncologists would say that radiation is just as effective.

"It can be bewildering for patients," says the study's lead author, Dr. Michael J. Barry of Massachusetts General Hospital in Boston. "I think they are being presented with all the options by physicians. But the emphasis on the options may be different, depending on who they see."

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