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.
The concept of watchful waiting, in which a physician closely monitors
an untreated prostate-cancer patient for spiking PSA levels or other
signs that the malignancy threatens to spread, never appealed to
Bowman. At 54, he was in his prime, in good shape, and with many good
years ahead of him—years, reckoned Bowman, that could allow his cancer
to spread insidiously into other organs, his liver perhaps. Or maybe
the cancer would beeline for his colon before heading north to his
lungs.
Many physicians would argue that Bowman’s concern was for naught. In
the great majority of cases, prostate cancer is so slow growing that
Thomas Stamey, MD, the Stanford University urologist who pioneered PSA
screening, has been reported as saying that up to 90 percent of the
prostatectomies performed during the last decade were unnecessary.
Indeed, only one in four men with latent prostate cancer will ever show
symptoms, even if left untreated, and there is a less than 20 percent
chance that men ages 50 to 54 with early-stage prostate cancer will die
from it. Moreover, no long-term studies have proved definitively that
treating prostate cancer increases longevity. Mountains of data, by
contrast, attest to treatment’s bleak side effects, the most prominent
being the likelihood of erectile dysfunction and urinary incontinence.
What bothered Bowman, however, was that despite intense ongoing
research, there’s no reliable way to predict the nature of a prostate
tumor—whether it’s among the aggressive 25 percent that kills, or the
more benign 75 percent that rarely produces symptoms. “I can understand
the statistical argument, but from a personal survival standpoint, the
whole idea of ‘watchful waiting’ seems absurd,” says Bowman. “Wait for
what? For the tumors to magically dry up and go away, like warts? Or
for the cancer to invade my spine and liver, and then decide it’s time
to treat it?”
As recently as a decade ago, scalpel prostatectomy, which was pioneered
in the 1940s, was the standard treatment for prostate cancer, and
excising the malignancy—nerve bundles and all—was the surgeon’s
primary, and often sole, concern. In their defense, surgeons had little
choice in the matter. Most men seeking treatment back then had reached
stage II of the disease, and since their cancer had already spread,
saving their lives almost always entailed removing the gland. Today,
however, with PSA screening standard for men older than 50 and early
diagnoses increasingly common, the effort to save those delicate nerve
bundles—through techniques such as nerve-sparing radical prostatectomy,
robotic surgery, and now HIFU—has blossomed into a multibillion-dollar
industry. In short, men with prostate cancer finally have a say
regarding the preservation of their sex gland.
“One guy might say, ‘This cancer freaks me out. Cut it out with a knife
and damn the consequences,’ ” says Dr. Barkin. “A second man might want
every precaution taken to preserve the nerves and erections by being
less aggressive, but if the moment comes, err on the side of killing
the cancer. A third man might say he’d rather die than live with
erectile dysfunction. And men do die for that reason. You’d be
surprised how many.”
The sheer number of available prostate-cancer treatments—there are six
mainstream options—initially bewildered Bowman, and, like many newly
diagnosed men, he spent weeks studying the voluminous and contentious
literature on the subject. “I worked day and night,” he recalls, “but I
never seemed to get tired. I felt like I was in a war, fighting for my
life. And just like war, there was the fog: too much information.” He
obsessively surfed Web sites, interviewed a range of urologists, and
discovered that, invariably, each one recommended his own pet procedure.
This was due partly to the confidence each physician had in his craft,
but it would be naive to assume that none of them had an eye on
financial gain. National spending for prostate-cancer treatment, after
all, is about $8 billion annually. And the more patients a physician
treats, the bigger his piece of the prostate-cancer pie. What was once
an unglamorous medical specialty has, in the last 20 years, developed
into one of the most lucrative.
While none of the six standard treatment options are guaranteed to cure
prostate cancer, all are effective. A study in the New England Journal
of Medicine, for example, showed that prostate-cancer patients who
underwent surgery were 44 percent less likely to die from the disease
than men treated by watchful waiting. But life expectancy wasn’t
Bowman’s chief concern. “I just didn’t want to lose my potency, and no
conventional treatment could offer the successful statistical outcome I
wanted in that regard,” says Bowman. “In fact, having prostate cancer
brought home the degree to which sexuality permeates everything I think
and do. Your sex is who you are, to a certain extent. And I never quite
realized that until I was in danger of losing it.”
While none of the six standard treatment options are guaranteed to cure
prostate cancer, all are effective. A study in the New England Journal
of Medicine, for example, showed that prostate-cancer patients who
underwent surgery were 44 percent less likely to die from the disease
than men treated by watchful waiting. But life expectancy wasn’t
Bowman’s chief concern. “I just didn’t want to lose my potency, and no
conventional treatment could offer the successful statistical outcome I
wanted in that regard,” says Bowman. “In fact, having prostate cancer
brought home the degree to which sexuality permeates everything I think
and do. Your sex is who you are, to a certain extent. And I never quite
realized that until I was in danger of losing it.” 
