Living Well at First Sight

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Early detection is the key to treating genital-pelvic cancers

By CHRISTOPHER JOHNSTON

Upon being diagnosed with prostate cancer, KevinBraunschweiger was less concerned about losing his life thanabout losing his love life.

"At a fairly young age, 45, I had some specialconsiderations," recalls the Mentor resident. "My wife is fiveyears younger than me, and although I was done having kids, Iwasn't done having fun."

Men being men, fears of being less than virile unfortunatelyoften take precedence. Despite the high cure rate for prostateand testicular cancers that are detected early, most men withgenital-pelvic cancers are more concerned about the possibilityof impotence and incontinence that may occur as a result ofsurgery to remove the tumor. Then, there's always the potentialembarrassment because of the tumor's physical location and theprimal, psychological gravitas a man invests in his manhood. .

Braunschweiger admits the former was his initial concern inAugust 1998, when his urologist prescribed surgery after

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diagnosing the disease during an examination. "You have toconsider all the options, not just cutting the prostate out, becauseyour life may be miserable after you cut it out," he says. "Someolder people might not care if they have to carry a bladder bagaround, but it's different for a younger person who has to gointo people's homes or go to an office every day and is interestedin maintaining a good romantic relationship."

The embarrassment factor, though, never really entered hismind. "I'd probably still have an issue with testicular cancer, justbecause it's a sensitive area," Braunschweiger says, adding with alaugh: "But since I've never seen or touched my prostate, itwasn't that interesting to me."

Considered young for the average prostate cancer patient,Braunschweiger was actually very fortunate to have it diagnosedwhen he did, because the most insidious aspect of prostate canceris that it usually shows no symptoms in its early stages, when it ismost treatable. He had complained of a dull pain in his. lowerback similar to the discomfort he had felt in 1992, when he had akidney stone removed.

Although ranked by the National Cancer Institute as thesecond most frequently diagnosed non-skin cancer in Americanmen, prostate cancer stands a distant second to lung cancer as a

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cause of death. Lung cancer killed 94,400 of the 98,300 menstruck with the disease in 1997, vs. the estimated 41,800 deathsfrom the 209,900 new cases of prostate cancer detected,according to NCI statistics.

About 80 percent of men develop prostate cancer by the timethey reach their 80s, though only 2 to 3 percent die from thedisease. Still, the American Cancer Society recommends that,starting at age 50, every man should have an annual check-upthat includes a digital rectal examination and prostate-specificantigen (PSA) blood test, a powerful diagnostic tool developed inthe late '80s to detect cancer activity in the prostate gland.

That recommended starting age drops to 45 for Caucasianmales with a family history of prostate cancer and for AfricanAmerican males who, for reasons yet undetermined, have ahigher incidence of prostate cancer than Caucasians. For AfricanAmerican men with a family history of prostate cancer, theannual check-up should start even earlier, says Dr. JosephDankoff, member of the Department of Urology and assistantprofessor of clinical urology at the Northeast Ohio College ofMedicine in Akron.

"We don't know if it's caused by a genetic predisposition orenvironmental conditions, but extensive research is beingconducted to determine the racial differences at researchfacilitiesworldwide," Dr. Dankoff says.

FAMOUS FOR PERFORMING exhaustive research into purchases,Braunschweiger, a financial planner for the Aid Association forLutherans, did some checking and found Dr. Rodney J. Ellis,director of brachytherapy, Department of RadiationOncology at University Hospitals of Cleveland. Ellis ispioneering brachytherapy - the implantation of radioactiveseeds or pellets into the diseased prostate - whicheliminates the risk of functional problems caused bydamage to the nerves during surgery. The procedurehas been used in the U.S. since the early 1980s.

"Generally, a prostatectomy is the numberone recommendation that most of theurologists will make," Ellis says. "But nowthe data for radiotherapy looks as good asit does for surgery."

Advances in computer technologylet surgeons pinpoint the cancer'slocation; doctors can more accuratelyinsert the radioactive seed implants orfocus the external radiotherapy beam closer tothe center of the tumor and provide a higher dose of radiationwhere it is most needed to eradicate the tumor. Depending onthe volume of the tumor, the implants typically average around100 tiny seeds of either an iodine or a palladium isotope.

"By sparing all of the other tissue from getting a high dose ofradiation, we can deliver the treatment more safely because it'sless toxic, and we can give a higher dose so that our cure ratesimprove," explains Dr. Ellis.

Those advances factored into Braunschweiger's decision to gowith the seed implants. "We looked at the statistics ofimplantations that were done 10 years ago, which weren't eventhe state-of-the-art procedures," he says. "So if what was done

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10 years ago was approximately equal to surgery in effectiveness,why not do the radiation seed therapy?"

While the surgery yields a higher risk of impotence orincontinence than the radiation, Ellis says, the advantage is that ifthere is a local failure afterward, patients can still receive theradiation therapy. With radiation treatment, however, if there is alocal failure within the prostate - which, Ellis argues, is lesscommon than with surgery - it is difficult to then performsurgery without damaging the bladder or the rectum. Moreover,new surgical grafting techniques have been developed to sparethe nerves that were most often damaged during aprostatectomy.

SIMILAR FEARSAND psychological issues also apply in the case oftesticular cancer, or testes tumor. Unfortunately, although onlyabout 7,000 American men are diagnosed with this form ofcancer each year, it can prove extremely deadly for those who donot respond immediately upon detection.

Michael Gusley, 44, of Parma, is fortunate to be recoveringfrom testicular cancer. Last year, he noticed that his righttesticle had become enlarged, but he put off seeing a doctor

'" because he wasn't experiencing pain, and his temporary\.'\ job did not provide any medical coverage.

. This past April, when he began feeling a sharp painin his right side, Gusley went to the emergency roomat Parma Community General Hospital, where aCAT scan revealed a cancerous mass in his abdomen.Surgeons also removed the enlarged testicle. Gusleyis currently undergoing chemotherapy to eliminatethe abdominal tumor.

"I knew it was cancer, but I put it off, whichwas a bad thing to do," Gusley acknowledges. "Inow tell people who realize they have an enlargedtesticle to get it treated as soon as possible, so thecancer doesn't spread asit did with me."

Testes tumor strikes men between their late teensand early 40s. (While older men can get a tumor in the

testicle, it is usually a lymphoma, which is treateddifferently and does not always require removal.)

Physicians tell too many tales of young patients tooembarrassed by their condition to report it - long past the

early stages of the cancer, which is defined as before itprogresses beyond the testes - even to the point where the fast-growing tumor, which doubles approximately every month ortwo, had reached the size ofa softball.

The irony is that testes tumor is highly treatable in its earlystages, especially due to advances in chemotherapy over the pastfew decades. To enhance early detection of testes tumor, theAmerican Cancer Society recommends monthly self-exams,starting in the early teen years.

"Testes tumor represents a very small percentage of allmalignancies, and it's highly responsive to chemotherapy," saysDr. Michael Oefelein, assistantprofessor, urology, Case WesternReserve University School of Medicine and University Hospitalsof Cleveland.

Again, the recently developed nerve-sparing technique canmitigate impotence and incontinence caused during the removal

NorthernOhioLive : August 2000

of lymph nodes around the retroperitoneum or the aorta andinferior vena cava in the upper torso, which are the first placestesticular cancer spreads to after leaving the testes. Damage tothese nerves can cause impotence by impairing the reflexcontraction that normally occurs during ejaculation, which closesthe bladder neck and forces the semen to discharge through theurethra rather than into the bladder.

Treatment of a new high-dose chemotherapy, followedby a bone marrow transplant to replace damaged blood cellproducers in the marrow, is available for patients withadvanced-stage tumors.

Perhaps most important, for both prostate and testicularcancer, increased awareness is the key to ensuring earlierdetection that can significantly raise cure rates. Today, physiciansapplaud the impact of major celebrities going public about theircancers - golfer Arnold Palmer and New York Mayor RudolphGiuliani for prostate cancer, and skater Scott Hamilton andcomedian Tom Green for testicular cancer - as the mostpowerful form of awareness-raising publicity.

Ultimately, Dankoff says, early detection is essential for savinga patient's life. "You can invent all the new chemotherapy andother treatments you like, but without early detection, once thecancer has metastasized, the newfangled stuff isjust like spitting inthe wind," he says.

Christopher Johnston Ulgesfnend and foe alike to undergo a yearly check-up.

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