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With the progress in detection and treatment has come a wave of publicity about this very private kind of cancer, which was once rarely talked about. Many prominent men, from ABC News chief Roone Arledge to musician Frank Zappa, have revealed that they have the disease. Others, like Kansas Senator Robert Dole, who underwent an operation for early prostate cancer last December, are actively encouraging men 50 and older or with a family history of the illness to get tested and become familiar with the warning signs: frequent or difficult urination, blood in the urine, painful ejaculation or continuous lower-back pain.
A major element of the controversy over early detection is the test for PSA, a protein that is produced by the prostate and is believed to play a role in preventing semen from coagulating. High levels of PSA in the blood indicate an enlarged prostate, which is common in older men and is only sometimes the result of cancer. Research studies show that 20% to 25% of men with a PSA level between four-billionths and ten-billionths of a gram per milliliter of blood harbor a cancer in their prostate.
Unfortunately, even a low PSA level is no guarantee of good health. "A third of the men I operate on have PSAs less than 2.8," says Walsh. "So the idea that if your PSA is low, you don't have cancer, is wrong. But if you have a negative rectal examination and a low PSA, you probably don't have prostate cancer."
Everyone agrees that PSA tests should be given in tandem with rectal exams. But what if the tests seem to contradict each other? It is not unusual to have a PSA level in excess of four-billionths of a gram per milliliter and a rectal exam that reveals nothing. In that case, the next step might include further observation, an ultrasound exam or even a biopsy, a procedure in which bits of tissue are removed from the prostate and examined under a microscope. Should men with high PSA levels undergo expensive, anxiety-producing biopsies year after year to make sure they do not have cancer? Not necessarily. More important than the absolute level of PSA may be the change in levels over time. A dramatic rise is more likely to indicate the presence of cancer. A steady high level may suggest nothing more than an enlarged prostate.
Although doctors have found the PSA test helpful in spotting small prostate cancers, there is no guarantee that early detection is beneficial. The test may be turning up the less troublesome tumors and not ferreting out the killer cancers. Researchers are working on ways to improve the blood test. And the National Cancer Institute is launching a $97 million study to investigate whether early diagnosis translates into longer lives. But the results will not be available for another 16 years.
Until then, physicians and their patients will have to use their own judgment. Because prostate cancer runs in some families, men with affected relatives may want to take fewer chances with a high PSA level. For others, the best approach may simply be to wait and see. Rather than treat the diagnosis as an immediate call to action, or ignore the problem altogether, they will need to follow the situation closely with frequent examinations.