After interviewing Herbie Mann, I spoke with Dr. Paul F. Schellhammer, M. D., Program Director of the Virginia Prostate Center at Eastern Virginia Medical School, about prostate cancer. He emphasized the importance of an annual digital rectal exam (DRE) and prostate specific antigen bloodtest (PSA) for all men as part of their regular health care regimen. For most men, this should start by the age of fifty, but for those with risk factors---African Americans or those with family histories of prostate cancer---these exams should begin by the age of forty or forty five.
Dr. Schellhammer offered other life-saving advice:
Jim Newsom/Port Folio Weekly: What is the prostate, and why is it important?
Paul Schellhammer: It's a gland that is very important as a reproductive organ in our reproductive years. It's not important to us once those years are past as a functioning organ, but it becomes important as a liability because it is the seat of cancer in virtually every man if he lives long enough to be a centurion. So, we say that 80% of men who are eighty have some form of prostate cancer. Fortunately, their life expectancy is such that it won't be a problem in their life.
The reason cancer's such a hazard now, as opposed to a hundred years ago, is because men and women live to be seventy as opposed to forty-five or fifty. We encounter different risks as we age. We conquer certain diseases but then are exposed to others.
JN: What happens in prostate cancer?
PS: Either through some genetic or environmental alteration, cells take on the ability to divide and gain a degree of immortality which is contradictory to all organs and cells, because cells die and they're replaced. We are undergoing constant reconstitution. With prostate cancer and other cancers, the cells do not die, they do not have an orderly arrangement of exiting, so they reproduce and begin to take over space where the prostate is located in the pelvis. They can cause urinary obstruction, can cause pain in the pelvis and then have to find other areas to live. So, they go to other organs, most frequently to bone.
The irony is that, much like the uterus in women, it's a reproductive organ of great importance but once reproductive years are over, there's absolutely no need or use for it and it becomes a liability. The issue that might come up is why not rid your body of it straightaway once you've had your family? The problem is the prostate is wedged into a very compact area that involves the bladder, the rectum, sexual function, and the efforts to remove it would cause a lot of side effects that no one would agree to as a preventative measure.
The PSA is a test that is specific for prostate, but not for prostate cancer. So any man that has a prostate---any man---will have a PSA level. Abnormalities of the prostate such as enlargement, which occurs in a great number of men, will cause a PSA elevation. The dilemma is which elevations are due to cancer, and which are due to non-cancer. When a man has a PSA elevation it's hard to make that distinction, so we proceed to getting tissue from the prostate by biopsy to clarify whether it's a group of malignant cells or an overgrowth of benign cells that's causing the PSA elevation.
JN: Are there any particular risk factors?
PS: Every male should keep in mind that he is at risk for prostate cancer. If he is African-American, his risk is increased two-to-three fold. No one really knows why, but that's the case. If there's a family history, his risk is increased. That risk is increased in proportion to the number of individuals [with cancer] in the family. If he has a first-degree relative---brother or father---that doubles his risk. If he has two first-degree relatives, it increases his risk up to five-fold. So those issues---race and family history---should be imprinted on the male as he moves into his fortieth to forty fifth year to get a PSA level and get a DRE so he knows where his baseline is. It'll be very helpful in his future followup.
JN: Does diet have any impact?
PS: Probably does. There is evidence that our western diet, which is very high in animal fat as opposed to vegetable protein, might predispose, among other things, to this disease. The disease is pretty rare in Asia where rice, beans and soy are the staple as opposed to red meat and gravy.
JN: Herbie Mann was in remission for a couple of years, but now his PSA is elevated to 70. What does that mean?
PS: 0 to 4 is considered normal in general, but if you had a 3.5 at age fifty, that would be, in my opinion, abnormal. Normalcy is dependent on the age of the individual. What's normal for a sixty five or seventy year old wouldn't be normal for a forty five or fifty year old.
Mr. Mann unfortunately has prostate cancer cells that are producing this PSA, and they are numerous enough that the blood level is as high as it is. Seventy is high, but certainly there are many blood levels that are markedly higher than that. It doesn't mean that there's no avenue for treatment that can delay progression of the disease for many years. That does not equate to a death knell, it equates to the need to readdress the issue with other treatment efforts.
JN: What types of treatments exist?
PS: The dilemma with prostate cancer is that there are several ways of approaching it: Surgically, with radiation therapy either by external beam or by implanting radioactive seeds. There are a number of effective treatments that all rely on the cancer being confined to the prostate, not having spread, and it becomes an individual decision as to which one of the treatments the patient and his significant others feel is right and good for him. There's no wrong decision.
JN: What is the effect of these treatments on sex drive?
PS: The truth is that all the treatments have some impact on sexual function, on urinary function, on bowel function. You have this gland that's wedged in the pelvis next to all these other organs, and it's hard to kill one dead as a doornail and spare the others without any injury.
JN: What do you see on the horizon?
PS: There are a lot of very innovative strategies that will appear in the next five years which will be very successful. Medicine is undergoing what's called a "molecular revolution." We're trying to find out what actually causes the malignant process, what goes awry, and to address the specific abnormalities with drugs as opposed to just identifying what's gone awry and killing it completely with a destructive mechanism.
So, instead of search and destroy, which has been our method up to now, it's target and control. Targeting and controlling is a lot more sophisticated, it's a smart bomb concept as opposed to blowing up the whole airport in an effort to make sure all the planes are grounded. You'd have the ability to seek out the particular abnormalities and address them. The advantage is that you're treating the abnormality and not interfering with the surrounding cells that are normal. There'll be drugs to do that. Those are in the works.
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