The Prostate Monologues

by Jack McCallum

  Well, let’s let Mr. PSA address those comments himself.

  William Catalona, MD

  God of the PSA Test

  “As far as active surveillance goes . . . it’s becoming like apple pie and motherhood.”

  The photographs in Dr. Catalona’s office, located in Northwestern University’s Feinberg School of Medicine just off Chicago’s Magnificent Mile, are a notch or two above the predictable. There he is at Yankee Stadium, wearing a Yankees cap and posing with then-manager Joe Torre. Torre was his patient. There is Dr. Catalona with baseball immortal Stan Musial, who died in January 2013. Musial was a patient. There he is with Syracuse basketball coach Jim Boeheim. Boeheim was a patient.

  There’s a signed photo of the late Yankees owner George Steinbrenner. Was he a patient? “I can’t say,” says Dr. Catalona. Ditto for boxer Gene Tunney, another photo subject. There is Dr. Catalona with Senator Robert Dole. Dole was not a patient, but they became acquainted on the prostate cancer circuit. “The first time I ever met Senator Dole, he said to me, ‘Thanks for saving my life, Doctor,’ ” says Catalona. “I never forgot that.”

  Dr. Catalona is synonymous with the PSA test. In the late 1980s he was at a meeting with a group of other urologists. “The specific goal of that meeting was to lower the death rate of prostate cancer by [the year] 2000,” Dr. Catalona remembers. “There were all sorts of ideas, some of them wild. I remember there was a Japanese doctor who came up with an ultrasound probe on a toilet seat. Men would sit on it and that would test for prostate cancer. ‘That may fly in Japan,’ I told the guy, ‘but it’s not going to go over here.’ ”

  Dr. Catalona says an idea suddenly came to him during a jog on the beach when he was at the conference: Use the PSA test—which at that time was used purely as a marker of cancer progression—as a screening test. Though he hadn’t officially studied it, he firmly believed that men with more advanced cancers at the time of surgery tended to have the highest PSA levels. The idea would be to catch the cancer early, when something might be done about it.

  “I had been doing PSA testing on all my patients: BPH patients, normal patients, prostate cancer patients,” Dr. Catalona tells me. “I thought it might work. So I stood up and said, ‘I think the PSA test would be a good test for prostate cancer.’ And I got howled down.

  “See, what everyone was looking for was something like a pregnancy test. Positive you have it, negative you don’t. We all knew that some men with high PSAs didn’t have prostate cancer, and some had cancer with low PSAs. So everyone rejected the idea.

  “But then I suggested establishing the cutoff at 4. If a man had a PSA of 4 or above, he should have a biopsy for prostate cancer. I felt the PSA was more reliable than the rectal exam, the ultrasound, or anything else.”

  Most everyone shrugged, he says. But Dr. Catalona organized a study that included 1,653 patients and concluded that PSA testing detected cancer several years earlier than a DRE and could be used as a screening test. His research appeared in the April 25, 1991, issue of the New England Journal of Medicine, and William Catalona became a medical sensation. He didn’t rise to the level of Jonas Salk, Alexander Fleming, Christiaan Barnard, or Michael DeBakey, but he was featured in a Time magazine article, made the rounds of the morning talk shows, and became known throughout the urological world.

  It took a while for the proposal to wend its way to FDA approval, but in 1994 the agency recommended the PSA test as “an aid to the early detection of prostate cancer in men who had a PSA between 4 and 10.”

  Dr. Catalona’s research continued for 12 years, with the number of subjects reaching 36,000, and eventually his statistics showed that the PSA cutoff should be reduced to 2.5. Because of Dr. Catalona, prostate cancer is rarely found when PSA testing is not involved, and he says he firmly believes that “the prostate cancer death rate has come down by 44 percent in this country as a result of PSA testing.”

  You know what the USPSTF says to that: The percentage of lives saved does not compensate for the deleterious effects of biopsy and intervention. On the other hand, the majority of doctors and medical experts I talked to agree that PSA has saved lives.

  Whatever your feelings about PSA, I’ve come to believe that the same thing Dr. Catalona says about robotic surgery—that it has been oversold—can be said about the PSA test. It is not “a simple blood test that can detect prostate cancer,” as is so often stated. Instead, I would give it this definition: “The PSA is a simple and inexpensive blood test that has a good chance of identifying prostate cancer. But it may also indicate other conditions such as BPH, and, in doing so, throw off mixed signals that result in confusion, angst, and, quite possibly, overtreatment. The results of PSA tests should be combined with serious conversations with a primary care physician and/or a urologist to determine the best course of treatment.”

  I ask Dr. Catalona if he has changed his treatment philosophy at all after five decades in practice. He doesn’t answer yes or no, but makes it clear that he knows he is the target of anti-PSA crusaders, that he’s considered in some quarters to be a dinosaur clinging to an out-of-date philosophy.

  “It’s become the party line that there is too much overtreatment,” says Dr. Catalona, “but there’s no real evidence for that. And as far as active surveillance goes, yes, more and more people are pushing for it. It’s becoming like apple pie and motherhood. Well, it’s not as much fun as people think. First of all, there is no way you can accurately tell which patients have harmless prostate cancer. You consider only one or two cores and PSA density, and you’re still wrong a third of the time.

  “And you’re supposed to get biopsied every year or every other year. For a patient with a long life expectancy, that’s too many biopsies.”

  Dr. Catalona is 70, but he continues to see patients, teach, operate, research, and offer up his convictions without evincing a sliver of doubt. “I’m glad you came out well from your robotic surgery,” he says as he escorts me out of his office, “but I still would’ve advised you that the open procedure would’ve been best.” And as I concluded the writing of this book, I was still receiving e-mails from him touting the open surgery method.

  David Lee, MD

  My Surgeon

  “When guys get diagnosed with late-stage prostate cancer, it’s the urologists, not the researchers, who have to tell them, ‘Sorry, Mr. Jones. We caught this too late.’ ”

  I am a golfer, but not one of those types who tell you that profound truths about character and the meaning of life are learned on the course. But after playing a couple rounds with Dr. Lee, I did get insight into the way he performs as a surgeon. He will not deviate from his pre-shot routine. He will not address the ball until he’s ready. He will not be distracted. He is precise in his movements. He hits the ball with the same takeaway and follow-through every time. He is scrupulous about observing the rules and rituals of the game.

  Performing a robotic prostatectomy is a technical achievement. Those who become great at it do so only after repetition, by making the same movements, following the same procedures, observing the sacred rituals of nerve sparing. After thousands of robotic prostatectomies, Dr. Lee is a bit of a robot himself, and that is intended as a compliment.

  He performs between 8 and 10 prostatectomies per week, each procedure helping to pay for those two $1.9 million da Vinci robots at Penn Presbyterian in the hope that Dr. Lee will cure patients and make that cash register sing. He still sees patients, but mostly for brief introductions and post-op follow-ups. He does not do many DREs these days, does not even write many prescriptions since his PAs can handle that.

  And that made me wonder if he has become divorced from the underpinnings of his profession, the day-to-day research and controversy that dogs this nettlesome subject of prostate cancer.

  That answer is no.

  “I feel very involved in this whole controversy, because the group that feels most strongly about prostate cancer, screening, saving lives, and preventing side effects is u
rologists,” says Dr. Lee. “That’s what I am above all. Urologists are the people who have to deal with cancer very directly. When guys get diagnosed with late-stage prostate cancer, it’s the urologists, not the researchers, who have to tell them, ‘Sorry, Mr. Jones. We caught this too late.’

  “Before PSA screening started, one of the more common presentations was guys walking in symptomatic with back pain, meaning the cancer had already spread to the spine. [Once] PSA screening started, that scenario has almost gone away. But with the task force recommendation, all of us in the profession are afraid we’re going to go back to those days.”

  Dr. Lee already offered his opinion (in Chapter 12) that, yes, biopsies can be dangerous. I ask him if death from surgery, permanent loss of sexual function, and urological difficulties are reasonable deterrents to intervention, which is the position of the USPSTF.

  “I’ve seen them talk about death from surgery being 1 in every 200, and that is absolutely ridiculous,” he says. “Maybe 25 years ago, but definitely not now.

  “As far as continence goes, guys do really, really well. Certainly there are exceptions, but across the population, continence returns. The ED part is definitely not as consistent.

  “The crime of the Preventive Services recommendation is that they pin all the negative consequences on whether or not you’re even going to get detected. They’re basically telling you to put your head in the sand and say, ‘I don’t want to know anything.’ The more reasonable approach is, get your PSAs, get your biopsy if you need it, find out what your Gleason is, then make an informed decision. Because I guarantee that if people stop getting PSAs we’re going to miss Gleason 7s, 8s, and 9s, and that is serious.”

  Which brings this around to my case. Gleason 6 (that had later progressed to a Gleason 7). Localized. Near that active-surveillance border of age 65. Should I have had surgery? Wouldn’t it be safe to assume, I ask Dr. Lee, that I would not have died of prostate cancer? And if so, could the argument be made that I should not have been biopsied in the first place?

  He thinks about that for a moment.

  “You could make that argument,” he says finally. “But this is cancer. Even the Gleason 6s can make a lot of progress and start hurting people over time. And how do you know what you are until you get a PSA? Okay, you had that level of cancer and you made a decision. Another guy who’s 50-some years old [might delay] getting his PSA and come up with a Gleason 8 on the biopsy. If that guy doesn’t get treated in the next two or three years, he’s probably going to die. And even in the population between 65 and 75, we still want to pick out those guys with aggressive disease because surgery will have a positive impact.

  “I am certain that the USPSTF recommendation against PSA testing can have serious, damaging effects.”

  Damaging economic effects for Dr. Lee, too. Several years ago he did 480 robotic prostatectomies in one year, but in 2012, the number dwindled to 420. “I have no doubt it’s a direct result of the task force,” says Dr. Lee. “I worry about the guys we might be missing.”

  Take it for what it is. Dr. Lee is a surgeon. His medical philosophy, his estimable reputation, and his bank account have been forged, by and large, behind the controls of a robot.

  But I can only say this about him: I trusted him with nothing less than my life, and I would trust him with the lives of my sons and my grandson. There’s not much higher compliment you can give a man than that.

  CHAPTER 14

  ... In which the author talks to a golfing immortal and a Viagra pioneer and ruminates on other celebrities who have died from prostate cancer, as well as others who are living with it

  GOLF WASN’T MUCH OF A MANLY SPORT until Arnold Palmer came along in the mid-1950s. He stalked around the golf course like a hunter in search of big game, attacking the course more than playing it; sneered at seemingly impossible shots, stepped up to the ball, flicked away his cigarette, took a vicious weekend-golfer flail at the ball, and watched it sail inevitably greenward. He won 62 PGA tournaments and was even more dashing in the ones he lost. His Marlboro Man persona helped to sell golf, which can be a soul-crushing bore, to the masses and to television.

  Do you want to watch a small ball hit in the air by a bunch of guys who look like insurance agents?

  No, but we could always watch Arnie. Women loved him; men wanted to be him.

  Count my father among them. He took me to see Arnie—everybody called him that, for a Marlboro Man can’t have a handle like Arnold—play an exhibition match near our home in New Jersey, right around the time that Dad was teaching me the game. Jack McCallum Sr. was infatuated, as were millions of others, by Arnie’s common-man ambience, his balls-out confidence, his bravado, his ability to convey the idea that you didn’t have to belong to a country club to be a golfer.

  And so my father would’ve given anything to be with me when I interviewed Arnie at his office at Bay Hill Club and Lodge, the resort he owns in Orlando, Florida, a place where the top pros still come by just to converse with the man they call the King. Though the 84-year-old Palmer sometimes pauses between words and thoughts, he remembers everything about his prostate cancer, which was diagnosed in 1997.

  “When that PSA test came out, my doctor recommended it right away,” says Palmer. “We did it every year from the beginning. My belief is that you should always know everything about your personal health.

  “My readings started at zero, went up to 1, then 2, then 3, and when it reached 4, my doctor said, ‘That’s the point when you get it checked.’ So they did six cores on one biopsy. I tell you what, that’s no fun. Then they did six more the next year. Nothing. Then they did six more the next year. And finally they found it. The third year, they found it.

  “When I found out, I was in San Diego at a PGA tour event. ‘Arn, I’m sorry to tell you,’ my doctor said when he called me, ‘but it looks like you have prostate cancer.’ That was on Friday night. I called my wife, who was here in Florida, and said I’d be right home. I had flown my airplane. [Of course a Marlboro Man like Palmer piloted his own plane.] Picked up my wife and daughter, Amy, and flew to the Mayo Clinic on Sunday. I had a major physical on Monday, a prostate exam by my surgeon on Tuesday, and on Wednesday morning he operated on me. I spent Thursday in the hospital, and on Friday I flew back to Florida.”

  Palmer went public with his cancer. He went at it with ferocity, the same way he went at his opponents on the golf course. The Eisenhower Medical Center in Rancho Mirage, California, now includes the Arnold Palmer Prostate Center. He has done PSAs about PSA. If you ask him about cancer, he dives in with both cleats.

  I ask Arnie if he is aware of the ongoing dialectic about whether men should get PSA screening. “I am,” he says, “and I think it’s bullshit! In the hospital room next to me at the Mayo Clinic was a 29-year-old minister. He was having the same procedure as I had. So don’t tell me that this is an old man’s disease. [It’s not impossible that a 29-year-old man had prostate cancer but it would be extremely rare.]

  “If I hadn’t had those PSAs, I wouldn’t have had any idea what was going on inside my body. We were constantly on the watch, and it turned out it was good that we were. I got it done quickly. For whatever it’s worth, I’m still here.” And he taps the table.

  I ask Arnie if he still gets PSA tests and DREs.

  “DREs? Is that where they go up your ass?” he asks. “Yup, still get them, too.”

  Some perspective on the Palmer visit is necessary. Celebrities who become spokespersons for causes have a lot of power. They can do good and they can do bad. I have no idea if Palmer’s coming forward to speak about prostate cancer has saved a single life or caused a single man to undergo what some would call a needless procedure. But I admire him for speaking up.

  Also, chronicling the stories of celebrities who die of a certain disease does not make that disease more important than any other potentially fatal disease or more important than any other cancer. In Chapter 15 we will hear from “regular” people who have had pr
ostate cancer. But the reason that we look at celebrities and disease so often is that their symptoms, treatment, and recovery are so public. You can learn from them, and that is the value. With a little Googling, for example, I stumbled upon the entire postsurgery lab report for actor Dennis Hopper, who died of prostate cancer in 2010.

  As for Arnie’s treatment, well, his getting three biopsies before any cancer was found is precisely what opponents of PSA testing say should not be done, particularly since he was 68 at the time. They say don’t keep looking and looking and biopsying and biopsying otherwise healthy men until something is found.

  But, look, this is Arnold Palmer. His proactive approach—get diagnosis on Friday, get in your airplane on Saturday, get the damn thing taken out on Wednesday—was a function of his aggressive personality. Watchful waiting was mentioned as an option, he says, but he is not a watchful-waiting kind of guy any more than he was a guy willing to pass up a challenging shot on the golf course. He made his choice and he has complete peace of mind because of it.

  Palmer now looks at cancer the way he once looked at worthy opponents. It’s the disease counterpart of Jack Nicklaus, except that Palmer hates cancer and he does not hate Jack. Nearly three years after his prostate was removed, Palmer’s wife, Winnie, died of cancer.

  “It was peritoneal carcinoma,” he says, not even pausing to get out the phrase. “The cancer was between her stomach and the ovaries. It was undetectable. It was a terrible thing.

  “And [daughter] Amy had breast cancer. She had 27 positive nodes. [Again, the specific number comes to him easily.] Her doctor, all the doctors, were very skeptical about her chances. Well, she got treatment and she’s fine. Four children. Six grandchildren. She was just here visiting me.”