May 10, 2000 -- New York's hard-driving Mayor Rudolph Giuliani faces a decision no one, Republican or Democrat, would envy. In late April, the mayor became one of the estimated 180,000-plus men who will be diagnosed with prostate cancer this year. The disease, which killed his father in 1981, is the leading cancer killer in men Giuliani's age -- 55 -- and older.
For Giuliani, there is good news: He's young, the cancer was caught early, and it appears to be confined to his prostate. And, like the one in every five American men who face prostate cancer in their lives, he has more treatment choices than ever before. For many years, the primary option was surgery to remove the prostate, which usually cut out the cancer but often left men impotent or incontinent. Today, while surgery remains the gold standard for many physicians, men have several new treatments to choose from.
Which of the multiple treatment options should Mayor Giuliani consider? Which offers him the best chances for complete recovery? Which would allow him to resume his normal whirlwind of activity?
The mayor has a lot on his mind: running America's second-largest city, a leading role in national Republican politics, and oh yes, that small matter of the Senate campaign. So we asked some leading national experts to tell us what they'd advise Mayor Giuliani and other men in his situation to do. Here's what they said.
Patrick Walsh, MD
Director of the Brady Urological Institute at Johns Hopkins University
One of Mayor Giuliani's options is a radical prostatectomy -- the surgical removal of his entire prostate. "If cancer is confined to the prostate, there is no better way to eliminate the cancer than total surgical removal of the prostate," Walsh tells WebMD.
But what about those side effects? Neither incontinence nor impotence is a particularly attractive prospect for any man. In the early 1980s, Walsh pioneered the "nerve-sparing" radical prostatectomy, which markedly improves a patient's chances of remaining both continent and potent after surgery. This approach removes the prostate while leaving intact one or both bundles of nerves that pass along the surface of the gland and are necessary to achieve an erection.
"Twenty years ago, every man who had prostatectomy was impotent and 25% had severe problems with urinary control," says Walsh. Today, it's a much different picture. Nerve-sparing surgery can offer the patient a 40%-70% chance of keeping his sexual function. Recently, Walsh has reported on studies indicating that in the hands of a highly skilled surgeon, the potency rate is much higher, possibly as high as 86%-90%. And, he says, the likelihood of long-term urinary control problems is less than 2%.
This approach carries some risk. Microscopic invasion of tumor into nearby nerves might leave behind some cancer cells, preventing a cure. Yet many men are willing to take that gamble in order to remain virile.
Kent Wallner, MD
Associate professor of radiation oncology at the University of Washington School of Medicine and chief of radiation at the Seattle VA Hospital
Not so fast on the surgery, says Wallner, author of Prostate Cancer: A Non-Surgical Perspective. For a man in Mayor Giuliani's position, he believes the optimal treatment is likely the "seeds" type of radiation therapy, also known as brachytherapy. This treatment involves minor surgery to place radioactive implants in the prostate area, which release their radiation over time to kill the cancerous cells. Some remain permanently in place and some are temporary.
"If he has surgery, he's going to be laid up for a couple of weeks, at least, and run-down for a while after that," says Wallner. "If he has a seed implant, chances are he'd have a lot less downtime than that. With proper follow-up, surgery's success rate at curing the cancer doesn't look any better than seeds, and seeds is a hell of a lot easier."
Indeed, eight to ten years after treatment, a number of studies have shown that men who choose brachytherapy have a survival rate similar to those who choose surgery -- as high as 85%, depending on the severity of the initial diagnosis.
Men who opt for radiation treatment may also choose external beam radiation, a 10-minute procedure that applies a beam of radiation to the prostate. Some experts prefer this method because they believe it provides a uniform dose of radiation that has a better chance of killing all the cancer cells. But it must be done in a series of 36 treatments over seven weeks -- a tether that might put a crimp in Giuliani's campaign trail. Both types of radiation also pose their own risks of impotence, but the risk of impotence is lower after brachytherapy (10%-30%) than after external beam radiation (40%-60%).
Marc Garnick, MD
Clinical professor of medicine at Harvard Medical School and a physician at the Beth Israel Deaconess Medical Center
Another treatment option Mayor Giuliani may consider -- either on its own or in combination with radiation therapy -- is hormone therapy. Male hormones such as testosterone can cause prostate cancer cells to grow, so using medications to lower the level of hormone production may shrink the cancer or slow its growth. Cancer specialist Marc Garnick, MD, author of The Patient's Guide to Prostate Cancer: An Expert's Successful Treatment Strategies and Options, treats the majority of his patients with a combination of radiation treatment (either external beam or brachytherapy) and hormone therapy.
"If you're a good candidate for surgery, you're a good candidate for radiation, and vice versa, and Mayor Giuliani is probably a good candidate for both," says Garnick. "When I see patients in this situation, if they end up opting for radiation therapy, I generally feel that all the study data suggests a survival advantage and improvement when radiation therapy is combined with hormonal therapy."
William Catalona, MD
Professor of Urology at Washington University School of Medicine and Barnes-Jewish Hospital, St. Louis
Catalona says he'd tell Mayor Giuliani what he told another famous New Yorker with prostate cancer, Yankees manager Joe Torre. "If the tumor is really contained within the prostate, surgery offers the best chance of a cure. He has a 25 to 30 year life expectancy in that event," says Catalona, who performed Torre's successful prostate surgery last year. "I think that that's probably the cleanest, best way to do it, and that's what I'd advise."
What about "watchful waiting?" Prostate cancer is slow-growing, so urologists like Catalona sometimes advise men to carefully monitor the cancer but to hold off on surgery or radiation unless the disease spreads. In the case of Giuliani and other middle-aged men, however, none of our experts thought the watchful waiting approach was safe. "We generally pursue watchful waiting with older patients, 73 or 74 or above," he says. Those men are likely to die from some other cause before prostate cancer could kill them. "At Mayor Giuliani's age, with a 25- or 30-year life expectancy," he says, "watchful waiting is likely to lead to a death from prostate cancer, which is a very unpleasant death."
Dean Ornish, MD
Clinical professor of medicine at the University of California, San Francisco and the founder and president of the nonprofit Preventive Medicine Research Institute in Sausalito
Not everyone agrees that younger patients with prostate cancer should always pursue aggressive treatment such as surgery or radiation therapy, however. Dean Ornish, who demonstrated for the first time that intensive changes in diet and lifestyle can reverse the progression of heart disease, has embarked on a randomized, controlled trial to see if a similar regimen can do the same for men with prostate cancer. He's leading a study of 125 men over two years, in which half take no special measures while the other half eat a strict low-fat vegetarian diet, follow a daily exercise plan, and reduce stress through yoga or meditation. Men in both groups are closely monitored.
It's too soon to know whether this approach will prove effective, but a lot of men who hope to avoid the side effects that go with surgery and radiation are hoping it will. "The fact is we don't know. We're trying to find out whether diet and lifestyle interventions can make an important difference. Whatever we find, these data will be very helpful to many people," Ornish told Dateline NBC News in April.
All of our experts agree that there's no easy answer for someone in Mayor Giuliani's position. Choices are difficult because of the limitations of current scientific evidence -- no one can say definitively which treatment is best. Most physicians tend to recommend the treatment that they offer: Surgeons recommend surgery, radiation therapists recommend radiation, brachytherapists recommend brachytherapy, and so on. Until there's more research, Ornish advises, there's enough epidemiological evidence to suggest that diet and lifestyle changes are advisable in combination with whatever treatment a man chooses. "In particular, a very low-fat, whole foods, plant-based diet rich in soy products should be considered," he says.
Gina Shaw, a Washington-based freelance writer, writes frequently about health and medical topics.