Health & Fitness

More and more men are facing a medical conundrum: Either risk losing your sex life forever, or travel abroad for a $20,000 procedure that the FDA hasn’t approved yet.

Jack Barkin, MD, picks up a scalpel and cuts a quarter-inch incision below the navel of patient Mike Bowman, a 54-year-old medical-equipment salesman from North Carolina. Bowman lies with a spinal anesthetic in a semiconscious sprawl, his legs spread in a stirrup chair similar to those used by obstetricians. Through the incision Dr. Barkin guides a suprapubic catheter into Bowman’s bladder, which will remain in place for a few days after this morning’s procedure until the swelling in the prostate area has subsided. Before this, Dr. Barkin ran a Foley catheter up Bowman’s penis to flush water through the prostate region and to fill the bladder. “For better visibility,” explains Dr. Barkin. “Water is good and air is bad for conducting ultrasound.”
Then Dr. Barkin slides a lubri­cated probe, which is connected to a Sonablate 500 acoustic ablation device, eight inches up Bowman’s rectum. Turning away from his patient—he will not touch Bowman again during the ensuing two-hour procedure—he clicks the mouse of the Sonablate’s computer, firing up the R2-D2–size machine. Deep inside Bowman, the probe shoots out three beams of high-intensity focused ultrasound (HIFU), an energy source similar to what doctors use to dissolve kidney stones. The beams triangulate Bowman’s cancerous prostate, which appears as a fan-shaped gray mass on the computer’s monitor. “This doesn’t look so bad,” says Dr. Barkin. “The cancer is small enough that we can treat it in two sections instead of three.”

Indeed, Bowman’s prostate is in such relatively good shape (meaning that its tumors are well-defined, threatening neither to invade surrounding tissue nor metastasize to distant parts of his body) that if it were 20 years ago, he may not have known he had prostate cancer until it was too late. It wasn’t until 1985 that the FDA approved PSA screening, a test that measures levels of prostate-specific antigen in the blood; an elevated score—from 4 to 10 ng/mL—suggests the presence of cancer. In the absence of early symptoms and timely diagnosis, he may very well have become one of the nearly 30,000 American men who die annually from the disease, the most common cancer among males.

Today, however, patients like Bowman—fit, affluent, sexually active men in their forties, fifties, and sixties with early-stage prostate cancer—are Dr. Barkin’s prime customers. They’re living the short-straw end of the statistics that show that, in North America, men are 35 percent more likely to develop prostate cancer than women are to develop breast cancer, and that by 2015, the number of newly diagnosed prostate-cancer cases will jump to 300,000 a year—a 50 percent increase from today. These medical early adopters have considered every treatment option covered by insurance in the United States—scalpel surgery, radiation, cryotherapy, and brachytherapy—and have chosen instead to pay $20,000 out of pocket to come here, the Can-Am HIFU clinic in Toronto, where Dr. Barkin uses ultrasound to heat their prostate tumors to 212°F, destroying them in less than three seconds. “Basically,” says Dr. Barkin, rather matter-of-factly, “we’re cooking the prostate.”

The speed of the procedure, however, isn’t what will draw an estimated 700 American men across the border to Canada or to clinics in Central America to pay for a treatment that has yet to gain FDA approval. Rather, it’s HIFU’s astonishingly low rate of erectile dysfunction. “I do every kind of prostatectomy, from scalpel to robotics,” says Dr. Barkin, “and the rate of erectile dysfunction with all other treatments, no matter how skilled the surgeon, is around 50 percent. With HIFU, it’s less than 10 percent. Plus, you can’t beat the recovery time.”

At Dr. Barkin’s clinic, which he runs as a sideline to his standard urology practice at Toronto’s Humber River Regional Hospital, men are treated as outpatients on Saturday. On Sunday, most feel well enough to go sightseeing.

The operating room is small, brightly lit, and oddly cheerful, seeming more like a dentist’s office than a place of life-or-death stakes. Content that the procedure is proceeding smoothly, Dr. Barkin, an inveterate teacher, launches into a quick lecture on the walnut-shaped gland that is the prostate. The first spurt of an ejaculation comes from the prostate, he explains, whose evolutionary function is to secrete enzymes that protect sperm from acids in the vagina. All male mammals possess a prostate. In humans, it sits at the crossroads of several crucial organs: the rectum, anus, bladder, urethra, and seminal vesicles. Two razor-thin bundles of nerves run vertically along both sides of the prostate and are largely responsible for stimulating and preserving erections. “Here you can see them plain as day,” says Dr. Barkin, pointing out two faint dark lines on the monitor. I fix my eyes on the glowing computer screen, which shows sonic beams systematically zapping Bowman’s tumors into benign scar tissue, which possesses an eerie resemblance to cooked popcorn.

Bowman’s long journey to this fifth-floor cancer clinic—marked only by a hastily word-processed sign next to the elevator—began three months earlier, in July, on the day that his prostate biopsy returned positive. “My first thought was, I’m going to die,” recalls Bowman. “My second was, Why me?” After the initial shock and subsequent pulse of anger, Bowman confronted his first fateful choice: Treat or not treat? Take out the gland that delivers a man so much pleasure during the first half of his life, and so much anxiety later, or proceed with watchful waiting?