Joseph C. chose surgery. Lloyd W. chose radiation therapy. And Norman B. tried keeping his precancerous condition at bay with an experimental diet. All three men are currently doing well -- testimony to the fact that, when it comes to prostate cancer care, one size definitely does not fit all.

Prostate cancer is the most common cancer among American men today. About 220,000 cases are diagnosed each year, and the disease kills about 30,000 men annually. Older men are at greater risk to develop prostate cancer; so are men of any age with a family history of the disease. Race is a risk factor, too: for reasons yet unknown, African-American men have the highest rates of prostate cancer in the world.

In its early stages, prostate cancer causes no symptoms. Later, it can cause difficulty with urination or -- in even more advanced stages -- back pain, weight loss, and weakness, which indicate that the cancer has spread into bones and other organs. By then, it’s too late. “If a man waits until he’s starting to feel like something is wrong, it’s no longer possible to treat prostate cancer with local therapies or cure it,” says W. Robert Lee, MD, a Duke radiation oncologist.

For that reason, many health care organizations recommend that men get screened for prostate cancer beginning at age 50 and annually thereafter. Men at high risk are sometimes urged to start at age 40.

Testing for Prostate Cancer

The primary tool for early detection of prostate cancer is a simple blood test for a factor known as prostate-specific antigen (PSA), a protein made by prostate tissue. There is a measurably higher volume of PSA when prostate cancer is present. “By measuring for PSA in the blood of thousands and thousands of men, we’ve been able to establish its normal range -- about 4 nanograms per milliliter,” Lee says. “Once the PSA goes above that level, the chances that you have prostate cancer go up.”

According to Judd Moul, MD, chief of urology at Duke, a PSA test should always be accompanied by a digital rectal exam. “Not all prostate cancers produce PSA,” he says, “but they will usually produce some abnormality that can be detected by examination.”

Despite the PSA test’s clear value as an early diagnostic, however, controversy persists regarding how extensively it should be used. Though, as Moul says, “Prostate cancer is always ultimately lethal,” many types are extremely slow growing and may not cause any ill effects for 10 or 15 years. For older men with other health issues, the fact that they have prostate cancer may not affect their health status or outlook.

One commonly invoked prostate cancer guideline suggests testing and treating only those men whose life expectancy would otherwise exceed what they could expect with untreated prostate cancer. But that still leaves a certain amount of ambiguity -- and the need for case-by-case, carefully considered judgment calls. “For an 87-year-old with heart disease, a diagnosis of prostate cancer would be moot,” Moul says. “But a 45-year-old man with a family history of prostate cancer should clearly have regular tests and receive aggressive treatment if cancer is found.

“Men in their late 60s and 70s present a more ambiguous situation,” Moul adds. “While some experts suggest no further PSA screenings after 70, a 72-year-old may benefit from diagnosis and treatment if he’s fit and active and running marathons. It’s probably more about biological age than chronological age.”

Choosing Surgery

At 68, Joseph was within that 10-year gray area (the average life expectancy for American men today is about 74 years). But when his PSA count doubled from 4 to 8 and a biopsy confirmed prostate cancer, this dynamic, decisive businessman wasn’t about to take the diagnosis lying down. He had no problem selecting radical prostatectomy -- complete surgical removal of the prostate -- as his treatment of choice.

“I had an uncle who died of prostate cancer, and I just was going to take no chance of it spreading,” Joseph says. “I want to do everything I can to prolong my life. Frankly, if I had cancer of the finger, I’d probably take my hand off at the wrist if that would keep it from spreading.”

Radical prostatectomy can be debilitating -- lessening or loss of bladder control and sexual function are common after-effects. The nerves that control these functions wrap around the prostate like “plastic wrap around an apple,” as Moul puts it. “And if the cancer cells are tucked in among the nerves, you have to choose between preserving the nerves and removing as much of the cancer as possible. If you leave cancer cells behind, the operation really hasn’t done the patient any good.”

Joseph, though he has experienced some mild complications from surgery, is comfortable with his decision. “I have a positive outlook,” he says. “I feel that, if I can lick this, I’ll last long enough that something else will get me. I don’t think it will be prostate cancer. I sure hope not.”

Choosing Radiation Therapy

Lloyd, who had been having annual PSA tests for more than a decade at the urging of his wife, learned he had prostate cancer at the age of 74. “My doctor called my wife, my daughter, and me in to break the news, and gave us a complete list of all our options. One of them was to keep an eye on me but basically just leave it alone and do nothing -- what they call watchful waiting. But I didn’t feel comfortable going that route. I want to be here with my family as long as I can.” With a history of problems with his urethra, however, surgery was not an option. Talking it over with his family, Lloyd recalls, “Radiation just seemed like the best way to go.”

“Radiation has a long track record of being used as a treatment for prostate cancer,” says Lee. “It can be very effective in properly selected patients.” Lloyd received a new type of radiation therapy called brachytherapy, in which tiny seeds that release a radioactive substance are inserted into the prostate gland, combined with a more standard type of radiation therapy from an external source.

“Between his age, early diagnosis, and health issues, Lloyd was an excellent candidate for radiation therapy,” says Lee.

Lloyd agrees: “My life hasn’t been disrupted at all,” he says. “When you have something like this, it really makes you think about what’s important to you. This was the perfect choice for me.”

Another Strategy: Active Surveillance

Norman was 62 when his physician suggested he see a urologist to investigate his rising PSA count. A biopsy revealed non-cancerous lesions known as high-grade prostate intraepithelial neoplasia, or HGPIN. Because HGPIN is considered a forerunner of prostate cancer, the finding was ominous.

Still, the condition didn’t call for full-blown cancer treatment. So Norman’s Duke urologist, Cary Robertson, MD, suggested that he talk with Wendy Demark-Wahnefried, MD, a nutrition scientist studying the effects of a flax seed-supplemented diet on prostate cancer. (Demark-Wahnefried has since left Duke.) Flax seed is high in fiber and a rich source of both plant-based omega-3 fatty acids and of lignan, a family of compounds that influence hormone metabolism and seem to slow the growth of cancer cells.

After talking with Demark-Wahnefried, Norman agreed to try a very low-fat diet augmented by three heaping tablespoons of ground flax seed in his breakfast cereal each day. While not overly impressed with its culinary appeal, he says, “I ate it religiously.” Three months later, Norman’s PSA levels had dropped from 5.9 to 2.7. When he was re-biopsied seven months after beginning the diet, there was no PIN -- a finding that was later verified by prostate cancer pathologists at Johns Hopkins.

Norman stayed on the flax seed diet for five years. During that time his PSA began to climb again, but the HGPIN has never resurfaced. His doctors then advised him to resume his usual diet, and his PSA, while still high, has since stabilized. Through six subsequent biopsies, there has been no trace of HGPIN or prostate cancer. He even had a bone scan to make sure that undiagosed cancer hadn’t somehow slipped out of his prostate and penetrated his bones. “I’ve been told that some men just have high PSA counts, so I’m just living with this thing,” Norman says, adding that he was so impressed with Demark-Wahnefried’s work that he and his brother helped fund additional research on the topic.

Future Treatments

Several newer prostate cancer therapies are being tested or are on the horizon. At Duke, a dedicated prostate cancer research program brings together scientists and clinicians to understand prostate cancer better, develop new treatments, and expedite the journey from bench to bedside.

Improving treatment often means looking at what has worked well in the past. That means following up with men who have undergone surgery and or received other treatments for prostate cancer. For that reason, Leon Sun, MD, PhD, an associate research professor, put together a patient outcomes database that tracks PSA recurrence and other data in patients at Duke. Sun and his colleagues are currently using the information to compare the effectiveness of traditional retropubic radical prostatectomy and the newer robot-assisted laparoscopic prostatectomy.

Another urologist, Stephen Freedland, MD, is studying risk factors for prostate cancer using a separate database that he established. Drawing on information from several hospitals around the country, Freedland's team was one of the first ever to describe the increased risk of cancer recurrence after surgery among obese men.

"Our ongoing research clearly supports the idea that obese men fundamentally have a more aggressive form of prostate cancer," Freedland says. "We are now trying to understand why. We hope that understanding this will lead to newer and better preventions and treatments for this disease for all men."

With dedicated efforts like these under way at Duke and other leading medical centers, it’s only a matter of time before all men with prostate cancer have more treatment options. In the meantime, says Lee, the most important thing for men to do is to talk with their doctors about prostate cancer and the diagnostic and treatments most appropriate to them.

“I think it’s very important for men to be savvy consumers of medical care,” Lee says. “You never go to a car dealer and buy the first car you see at the sticker price, and you shouldn’t immediately accept the first prostate cancer treatment recommendation you get, either. If you ever test positive for prostate cancer, see both a surgeon and a radiation oncologist, then talk over what they say with your doctor and your family.

“And take your time -- you don’t have to rush into a decision. This is not a cancer that is going to go from small to terminal in a matter of weeks. Once you’ve gotten beyond the shock of the diagnosis, get the information you need to make the decisions that are right for you.”

There’s little doubt that, if a contest were ever held to determine the one disease men would least prefer to ever think about, prostate cancer would take first place. Still, despite that understandable reluctance, “Men are becoming much more health-conscious, and more aware of prostate cancer as a major health problem,” Lee says. “They’re taking the lead in requesting information and testing.”