Sen. Bob Dole, the Kansas Republican, can tell you exactly how much of a telltale protein his prostate was producing last August. And he can tell you how his blood-test readings suddenly rose over a five-month period -- leading to a biopsy that revealed cancer and to his decision last December to have the tumor removed.
These days, he's talking comfortably -- as are several other men in the public eye -- about a disease that until recently few men wanted to discuss.
"I'm a legislator. I'm always looking for a compromise," he quipped during a relaxed interview last week. "I'm always asking, what can we do that doesn't hurt? But I was finally convinced that surgery was the way to go."
The issue of prostate has taken an increasingly high profile for a few reasons. Recently, the blood test that flagged Senator Dole's cancer has both gained in popularity and drawn the fire of scientists who say it could cause doctors to over-diagnose cancer and prescribe unneccessary treatments.
And the willingness of men in public life to discuss this very common disease -- or at least to disclose the fact they had it -- seems to have arrived with the swiftness of a Kansas tornado.
In the last year, the public has learned about prostate cancer from an assortment of men, many of whom would never have been mentioned in the same breath. Besides Senator Dole, they include tennis star Bobby Riggs and Maryland Attorney General J. Joseph Curran Jr.
News accounts have told of several other public figures who have been treated for the disease:
Rock star Frank Zappa, Time-Warner chairman Steven Ross, the late producer Joseph Papp, Senators Jesse Helms and Alan Cranston, Supreme Court Justice John Paul Stevens and ABC (( news president Roone Arledge, who is recovering from prostate surgery at Johns Hopkins Hospital.
About a week ago, Mr. Curran composed a letter to state lawmakers, revealing how early diagnosis and surgery arrested his cancer before it could spread to surrounding tissues and threaten his life.
In a letter utterly devoid of legal or political content, Mr. Curran advised men to have a physical prostate examination every year. He also made them aware of a simple blood test, called PSA, that has recently gained popularity as an aid to catching prostate problems early, as it did for him.
On Friday, a reflective Mr. Curran said many men may have been reluctant to discuss prostate cancer because surgery can leave them unable to control their bladders. Indeed, he said, he temporarily had that trouble following his operation last September.
"People are afraid to talk about it, but what the heck, it happens," Mr. Curran said Friday. "I might as well tell them what I know -- even the women, so they could tell their husbands."
In the past, perhaps it was the reluctance of men to discuss the intimate details of body parts and functions that drove the
disease underground. Maybe, as some have argued, it was the relatively low level of federal funding into prostate cancer research and education.
Victims, doctors and researchers agree the time for a public airing is overdue. The disease will strike one in 11 men during their lifetime. That makes it almost as common as breast cancer, which will afflict one woman out of nine.
The American Cancer Society estimates that 34,000 men will die from the illness in 1992 -- the second-highest cancer death toll for men, next to lung.
High-profile figures like Mr. Dole are telling the plain truth when they say that prostate cancer is highly curable when caught early and hardly ever cured when caught late.
"We've had a lot of people who have written to say, 'You've saved my life,' " said Mr. Dole, who has urged older men to get regular screening for prostate abnormalities. "They were alerted and went to see their doctor."
Men whose cancers are caught before spreading to surrounding tissues can expect a normal life span. Once the disease has spread to other organs or bones, victims survive an average of only 2 1/2 years, according to the National Cancer Institute.
Disagreement over detection
But not everyone agrees on the best way to detect prostate cancer.
While the senator recounts how PSA tests helped alert doctors to his cancer, some authorities say the test has yet to prove its worth as a screening tool as reliable as the mammogram is for breast cancer.
The prostate test measures the amount of a protein called prostate specific antigen that circulates in the bloodstream. Elevated levels or rapid increases in PSA can signal trouble: either a benign growth or cancer.
The prostate is a chestnut-sized gland, located just below the bladder, that provides part of the seminal fluid necessary for ejaculation. Cancers are thought to result from a series of genetic changes that may begin early in life but don't usually trigger cancer until men have at least reached their 40s.
For several years, doctors have advised men over 40 to see their doctors annually for a digital rectal examination -- a procedure in which doctors insert a finger into the rectum and feel the prostate for the hard nodules that are hallmarks of a diseased prostate.
A nodule also can mean a benign growth, so the finding is usually followed by other tests such as a biopsy in which a surgeon inserts a needle into the prostate and withdraws a tissue sample for examination.
While the rectal exam remains a mainstay of early diagnosis, about two years ago some doctors started to also recommend annual PSA screenings for men over 50. This has generated its share of controversy, with some researchers arguing that routine blood tests might only lead to unnecessary surgeries and millions of dollars in health care costs.
But two weeks ago, Dr. Patrick Walsh of Johns Hopkins Hospital took the case for annual PSA screening even further -- recommending annual blood tests for men over 40 who have a family history of prostate cancer. This is because some apparently inherit a gene that puts them at a much higher risk of the disease.
Dr. Walsh, chief urologist at Hopkins' Brady Urological Institute, is an acknowledged authority in prostate surgery who pioneered a technique for removing prostate tumors without causing impotence.
The Food and Drug Administration has approved the blood test only as a means of tracking the ups and downs of already diagnosed cancers.
Studies have yet to prove that annual screening of seemingly healthy men actually saves lives. But many doctors aren't
waiting for proof.
"If you use a digital rectal examination alone, you will miss 20 [percent] to 30 percent [of the early cancers] because they are not palpable," said Dr. Robert Brookland, a radiation oncologist at the Greater Baltimore Medical Center who also serves as spokesman for the American Cancer Society in Maryland.
Two tests work together
While the blood test can also miss abnormalities, many doctors argue that the two tests together can raise the odds of detecting an early cancer.
Not surprisingly, the two tests don't always agree. And this is where a third test -- ultrasound -- comes in. Using sound waves to generate a picture of the organ, this test can help a doctor evaluate a prostate that doesn't feel hard but has produced suspicious PSA levels.
"We're doing in the realm of four or five prostate studies a day," said Dr. Roger Sanders of the Ultrasound Institute of Baltimore, a private practice at Cross Keys. "Two or three years ago, we were doing less than that in a week."
In last week's Journal of the American Medical Association, Hopkins physicians reported that rapid changes in PSA levels -- not simply the levels themselves -- can alert doctors to the possibility of an early cancer. Such changes can be noticed if doctors keep a running log of a patient's test results.
"Ultimately, just like men get a serum cholesterol test every year, every man will have a PSA beginning at age 50," said Dr. Walsh. "I thinkthis is what the future will hold."
Before recommending annual PSA screens, Dr. Barry Kramer, associate director of early detction at the NCI, would like doctors to wait a few years for early results of a 16-year study aimed at answering the only question that really matters: Does PSA actually save lives?
"Picking up [prostate] cancers at an early stage doesn't equate with saving lives," said Dr. Kramer.
His statement may fly in the face of popular wisdom, but Dr. Kramer points out that some prostate tumors grow very slowly. Men carrying these sleepy tumors will usually die of something else before the cancer spreads far enough to cause trouble.
Indeed, half of all men develop microscopic prostate cancers by the time they reach 80. By then, doctors are reluctant to treat the illness.
Dr. Kramer said even for younger patients with slow-moving cancers, operations may accomplish nothing. In the meantime, patients would be subjected to the risks inherent in surgery -- infections, blood clots, heart complications and adverse reactions to anesthesia.
The economics of testing
There is also an economic impact, he said. The NCI estimates that yearly PSA screening for every man between 50 and 74 would result in at least $10 billion in first-year health care costs -- not just from the $30 to $85 blood tests but also from the ultrasound treatments, radiation and surgeries that would follow.
"Many harmful things," he said, have resulted from medical treatments that seemed to make sense in the absence of proof. "In 100 years, people may look at what we're doing now and burst out laughing."
The argument doesn't impress Dr. Walsh, who said microscopic cancers will not raise PSA levels significantly. "It takes a lot of cancer to raise PSA," Dr. Walsh said.
For his part, Mr. Dole is persuaded that the blood test helped catch his cancer early. Even so, he said the NCI's skepticism persuaded him to retreat from a proposal to require Medicare to cover annual PSA tests for older men -- just as it covers mammograms for older women.
But he's not abandoned the idea.
"We were told that early detection would save a lot of lives," he said. "I can't make a judgment, but from the standpoint of this patient, it's out there and it ought to be explored."