A pair of studies published this week found that a routine test for prostate cancer fails to save many lives and leads a significant number of men to undergo needless, and often damaging, treatments. In a May 2000 "Assessment," David Plotz deconstructed the petulant gland's abrupt surge in fame, to the point that prostate cancer had become "America's favorite malignancy." The article is reprinted below.
Just three years ago, newspapers were declaring prostate cancer the "hush-hush man-killer," "the silent enemy," and "the disease that dare not speak its name." Last week, New York Mayor Rudolph Giuliani held a press conference to announce his prostate cancer. Intel CEO Andy Grove took the cover of Fortune to chronicle his struggle against the disease. Joe Torre's prostate helped spur the New York Yankees to a World Series title. Gen. Norman Schwarzkopf can't stop talking about his gland. On April 27, Larry King devoted an entire show to Giuliani's prostate—an hour that included Sam Donaldson describing how he examined his groin in the shower and King urging his male viewers to get a prostate exam, the "old-fashioned digital, the finger in the rectum."
The disease that dare not speak its name has become the disease that won't shut up.
Breast cancer remains a cause célèbre, and the colon—sponsored by Katie Couric—is making headlines, but prostate cancer has become America's favorite malignancy, Cancer Enemy No. 1. The number of articles about the prostate has quintupled in the past five years. Research funding has quadrupled. You can't turn around without bumping into a famous prostate cancer survivor (Marion Barry, Sidney Poitier, Bob Dole …)
But why should the nasty little gland be so trendy now? The prostate, after all, has always been with us, and it's still doing the same tedious work. A gland the size of a walnut wrapped around the urethra, it hangs just below the bladder, in front of the rectum, and above the penis. It has one important job: It produces seminal fluid ejaculated during orgasm. That fluid nourishes sperm on their journey to the egg.
Perhaps because its cells divide frequently, the prostate is prone to malignancy. About 180,000 American men are diagnosed with prostate cancer every year, and more than 30,000 die of it. After lung cancer, it is the deadliest cancer for American men, killing three out of 100.
Prostate cancer is capturing the popular imagination partly because there is more of it. Prostate cancer diagnoses doubled in the United States from the mid-'70s to the mid-'90s. The graying of the population explains some of this increase. American men are living longer, and almost every man who lives long enough develops prostate problems. The overwhelming majority of American men who reach 80 suffer from benign prostatic hyperplasia, an expansion of the prostate that causes urinary discomfort. And most men who live long enough also suffer from prostate cancer. According to an American Cancer Society book, one-third of men in their 40s have prostate cancer—usually too small and too slow-growing to notice—while 80 percent of men in their 80s have it.
Aggressive screening also helps explain the increase. The key diagnostic test, the PSA, has been commonly used only since the late '80s. The American Cancer Society recommends that men begin annual prostate tests at age 50. African-Americans, whose prostate cancer rate is double that of whites, should begin at 40 or 45, as should men with a family history of prostate cancer. (Men in the United States, perhaps because of diet, have the highest prostate cancer rates in the world. Men in Asia have the lowest.)
Prostate cancer is a satisfying target because it is eminently curable. Prostate cancer death rates have dropped 16 percent this decade. If cancer has not spread beyond the prostate, surgical removal of the prostate is nearly 100 percent successful. Radiation therapy is almost as effective, curing more than 80 percent of patients and causing fewer side effects. When cancer has spread beyond the prostate, treatment is more drastic. Doctors must reduce testosterone levels to starve the tumors. This requires either anti-androgen drugs or surgical castration, both of which destroy the sex drive.
Despite their success fighting prostate cancer, doctors disagree vehemently about whether men should be tested routinely. Prostate cancer is generally slow-moving and dimwitted. Even left untreated, it does not kill most of the people who have it: In most cases, the malignancy confines itself to the prostate and causes few if any symptoms. (Oncologists like to say that you are more likely to die with prostate cancer than of prostate cancer.) The slow growth of most prostate tumors means that many patients diagnosed with prostate cancer will never be bothered by the disease. But, understandably, few patients risk refusing treatment once they know they have cancer.
This poses a dilemma, because prostate cancer treatment has terrible side effects. Surgery leaves most patients impotent and a significant percentage incontinent. Radiation frequently causes impotence and bowel problems. As a result, some medical organizations, including the National Cancer Institute, do not recommend routine prostate testing. They argue that it leads to harmful treatment of many men who would otherwise never be bothered by their slow-growing cancer. The American Cancer Society, which does favor testing, counters that not testing endangers men with fast-growing cancer. Their tumors may not be discovered till too late. The ACS also notes that improved surgical techniques are making side effects less heinous: Some surgeons claim that less than 20 percent of their patients suffer impotence and less than 5 percent suffer incontinence. (Most oncologists and surgeons agree that men whose life expectancy is less than 10 years should not undergo surgery or radiation. The therapies are too destructive, and the patients are more likely to die from other causes than from their untreated cancer.)
Prostate cancer is also benefiting from a vigorous public-relations campaign spearheaded by Michael Milken. The former junk-bond dealer was diagnosed with serious prostate cancer as soon as he came out of prison in 1993. After successful treatment, he threw himself into prostate promotion, doing for prostate cancer what breast cancer victims did for their disease. He endowed a foundation, CapCURE, to fund research. (It has distributed more than $50 million in grants.) He and other prostate cancer victims have lobbied Congress and the National Cancer Institute to boost government funding for prostate research. The NCI has hiked prostate funding to more than $130 million annually, up from $31 million in 1992, but that lags far behind the nearly $400 million the NCI doles out for breast cancer, which kills about the same number of people. The prostate campaigners have persuaded famous men to go public about the prostate, enlisting Arnold Palmer and Harry Belafonte to discuss their glands and George Foreman to pose for "Real men get it checked" ads.
The psycho-sexual anxiety of boomers fuels prostate-mania. Boomer men are entering their peak prostate cancer years. Many have just passed the 50-year mark, and the rest are rapidly approaching it. They're already paranoid about preserving their health and vitality. Prostate cancer terrifies boomers because it so threatens sexual potency. We are living in a hypermasculine age. Guns, pro-wrestling, gangster rap saturate the pop culture. Testosterone has become a hot drug, with the New York Times Magazine and Time singing cover hymns to its magical, machoizing properties. But prostate cancer negates masculinity. It leaves healthy men impotent and incontinent. It unmans. Is it any wonder boomers obsess over it?
(Some commentators argue that Giuliani's prostate cancer makes him a better candidate exactly because it strips his hard edge and makes him seem vulnerable.)
Above all, the prostate craze represents a rare triumph for America's culture of shamelessness. Men didn't talk about their prostates a generation ago: It was unseemly and embarrassing. Thousands of men avoided treatment and probably died because of it. But now reticence is passé. The president's sex organs are analyzed in public, sex therapy occurs in prime time, no one blinks at nudity, profanity, or violence. This culture of blab and revelation—otherwise so icky—mercifully airs out the prostate closet. Not talking about the prostate killed people. It stopped men from thinking about it. Talking about it—in the most graphic terms—scares men, sends them to the doctor, and gets them treated. It is surely awkward to watch Larry King rapture over his rectal exams. Just remember that his ass may be saving someone else's.