Journal Health and Fitness Writer
Ignorance, embarrassment, fear, and silence are helping prostate cancer kill men in America. Especially men of color -- blacks and Hispanics in particular.
A small gland about the size and shape of a walnut situated under the bladder, the prostate is the source of much confusion among men and much debate in the medical community.
Prostate cancer is the most common cancer found in men, but most men don't really know much about their prostate. They know it is associated with their penis. They know that when something goes wrong with the prostate gland, sexual function and the ability to urinate are affected. Most men have heard about the dreaded digital rectal examination, a customary part of prostate-cancer screening that requires the doctor to insert a finger in the rectum to check the size of the prostate gland. That is where most men's knowledge stops.
Many men who know that much fail to act on the information, to get screened. When they do ask a doctor for advice, they may receive mixed messages because contention abounds about when or even
whether to screen for prostate cancer.
Many doctors, including those at the National Cancer Institute, say scientific evidence is not conclusive that screening for prostate cancer is worthwhile. In addition to the digital examination, screening typically involves a blood test called the PSA, which measures the level of a protein, the prostate specific antigen.
"We really struggle with how to make general recommendations about screening when the evidence is somewhat equivocal," says Dr. Patricia A. Nolan, director of the Rhode Island Department of Health. "We agree that it is very important to detect prostate cancer while it is still in the prostate gland. I don't think anybody is arguing about that."
Some cancer screenings, such as the Pap test for cervical cancer and those for colon cancer have clear goals: detect a problem before it becomes cancer. "We know enough about those diseases to be able to make very good projections about what will happen if you don't treat it. We don't have that kind of information about prostate cancer," Nolan says.
The Rhode Island Department of Health does not urge screening for prostate cancer as it does for breast, cervical, and colon cancer.
"We don't have a general recommendation [for screening] at this time that the United States has agreed on for prostate cancer," Nolan says. "That makes it more difficult."
Many major medical organizations, such as the American Cancer Society and the American Urological Association, suggest that primary care doctors take the lead by advising men on whether prostate-cancer screening is appropriate for them. This is fine for men who have a primary care physician and fine if the doctor is prepared to provide the latest and best information. "Primary care practitioners themselves are somewhat baffled about how to apply the current knowledge to the individual patient," Nolan says.
While the science is being sorted out, many men, especially men of color, fail to get prostate examinations until it is too late. "Our best information indicates there are major barriers to minority men, particularly African-American men, seeking out the services that they need to detect prostate cancer early," Nolan acknowledges.
"Not only do we have to help African-American men find primary care . . . we have to help the primary care providers counsel this group to make decisions about when they need testing and what kind of testing they need," she says.
Programs to address these and other issues are in the planning stages, but the absence of strong, vocal advocacy groups leaves precious funding for screening programs vulnerable to budget cuts, as demonstrated recently by Governor Swift of Massachusetts when she cut the budget for prostate programs by 86 percent.
Program development is also complicated by the fact that the Hispanic population comprises an array of cultures. Programs that make sweeping generalizations are doomed to failure.
SOLUTIONS ARE
needed soon. Every three minutes, prostate cancer is diagnosed in the United States. A man dies from prostate cancer every 15 minutes. In Rhode Island alone, two men are diagnosed every day. No one is sure why, but black men have the highest incidence of prostate cancer in the world, a rate 60-percent higher than white men.
National figures indicate that Hispanic men develop prostate cancer at about the same rate as white men. However, the low incidence rates for Hispanic men may not be accurate. "Information [about ethnicity] is not always collected or is not standardized across hospitals so we have an undercount," says Dr. John Fulton, associate director of the Division of Disease Prevention and Control for the Rhode Island Department of Health.
Using an accepted census technique of identifying Hispanics by surname, he reanalyzed cancer-death statistics for Rhode Island: "When we applied those names to the Rhode Island Cancer Registry and the cancer death certificates, we found a substantial proportion who on the basis of this criteria were Hispanic, but were not listed as Hispanic in the registry," Fulton explains. The number of cancer cases that were ostensibly Hispanic nearly doubled, but were within mainstream cancer rates for the state.
African-American and Hispanic men are often diagnosed when prostate cancer has progressed beyond the point of cure. When diagnosed early, the five-year survival rate for prostate cancer is nearly 100 percent.
"Early detection is absolutely important," says Dr. Barry S. Stein, director of the Rhode Island Hospital Prostate Center, "but men are reluctant to come in for medical care. If not for women, men would never come in for care. Latino men are worse than Caucasians, and the African-American man is probably worse than that at coming in for routine care.
"I personally believe that half of it is male reluctance, and I see it in any man," Stein says. "In the first place, men really don't want to know if they have prostate cancer."
NO ONE IS CERTAIN
why African-American men are so loath to be screened. "I believe there is a lot of distrust among minority groups for mainstream medical care," Stein says.
Over the last decade, without much success, he has participated in free national screening programs for minorities. "We did our best to get minority groups in, and we did everything we could to reach them. We were willing to take our screening to wherever they wanted us -- whatever worked for them. No matter what we did, we could not get minorities to be screened."
As director of the Prostate Cancer Center at the City of Hope Clinical Cancer Center outside Los Angeles, Dr. Mark H. Kawachi is on the frontline of the battle to screen Hispanic men. "Language is the important issue," says Kawachi, a fellow of the American College of Surgeons. "When physicians and other health-care providers can't speak Spanish, there is a real level of distrust and fear.
"Particularly in the area of prostate cancer, a lot of social and moral issues dealing with a man's perception of his masculinity are threatened. Because we can't explain it in a language they understand, they feel more threatened that they will lose their body image and their masculine relationship with their spouse. All of those things become major deterrents to seeking care," Kawachi says.
City of Hope, designated by the National Cancer Institute as a comprehensive cancer center, the highest accolade in cancer research, makes a concerted effort every year to offer free screening to Hispanic men. Out of 350 men screened each year, typically fewer than 15 are Hispanic.
Part of the problem with screening is what happens after.
Standard treatments for prostate cancer include surgical removal of the prostate gland and radiation by seed implants or external beam radiation.
Kawachi and a few other physicians across the United States are offering
an alternative to traditional cancer surgery that Kawachi says may encourage screening: laproscopic radical prostatectomy.
He says that after they undergo prostate surgery, men have a wish list
:
cancer cure, bladder control, and restoration of potency. "LRP provides all of the benefits of traditional prostatectomy but minimizes all of the side effects that men are so fearful of," says Kawachi, who has performed 187 of these LRP operations, more than anyone in the United States.
Of great distinction, he says, the urinary catheter required after prostate surgery can be removed after a few days, rather than a few weeks.
"The advantages [of the LRP operation] are huge," according to Kawachi. Maybe someone in the Hispanic or African-American population will learn about the minimally invasive procedure and say, 'The treatment options look so damned good, maybe I'll go get checked,' " says Kawachi.
But before treatment options are even considered -- indeed, before any diagnosis can be made -- men must be screened, doctors say.
"Sometimes the PSA is elevated and there is nothing to it," Stein says. "The patient goes through workups and gets scared, and there is nothing there. On the other hand, we do find a tremendous amount of prostate cancer that we never would have found so early. We have gone from three-quarters incurable to three-quarters curable in my career, and the only reason for that is the PSA. It's been a major change."
P. Elizabeth Anderson can be reached at 277-7363 or at
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