Introduction I learned I had prostate cancer six years ago. Dr. Summers, my highly experienced and knowledgeable urologist, recommended surgery or radiation therapy for my disease. As a writer, I am always open to new ideas for a book, but I decided against writing about my prostate cancer. I didn''t want to think about it any more than necessary. I wanted to get treated and move on with my life. And so, two weeks later I met with Dr. Frederick, the prostate surgeon.

As he described the details of prostate removal surgery, or prostatectomy, in which he would remove the entire prostate gland, he asked me: "Do you want me to take out one or both neurovascular bundles?" The neurovascular bundles contain the nerve and artery trunks to the prostate gland. Cutting them could render me impotent or incontinent, possibly both, perhaps for the rest of my life. I was too dumbfounded to answer. The doctor continued, "Your cancer is on the left side, so we should definitely take that bundle out. If we don''t, there''s a 30 percent greater chance of your cancer returning. Still, to give you the best chance of getting all of it, we should take the right bundle, too." He paused for a second, then asked, "What do you want to do?" Dr. Frederick was intelligent, experienced, calm, and personable.

He had performed more than five hundred robotic prostatectomies, the treatment most often recommended for prostate cancer. Based on his demeanor and attention to detail, I figured he was a good surgeon. What did I want to do? My left brain struggled to find an answer, while my right brain recoiled and cringed. I had been diagnosed with prostate cancer two weeks earlier, and everything I''d heard since then sounded worse and worse. Dr. Frederick assured me that over time, most men get some return of normal sexual and urinary functioning, but what did "over time" and "some return" mean? Although I was a doctor, I wasn''t a urologist or an oncologist, and I was as overwhelmed as any of the other 240,000 American men who face this situation each year. Listening to the doctor speak so calmly about mutilating my body seemed unreal. This was serious, permanent, no turning back stuff.

I imagined being single at sixty-six, impotent and incontinent. I couldn''t fathom it. On the other hand, I imagined dying slowly, agonizingly, of prostate cancer. Tough choices. I weighed the odds Dr. Frederick had given me. Part of me wanted to halt the debate in my head and simply say, "Okay, let''s get it over with!" I figured I probably wouldn''t become both impotent and incontinent. I''ll be okay, I told myself.

Empty words. I was in deep denial. I could not perceive myself as anything other than what I had always been. I''d had surgeries before and came out fine. Suddenly I heard myself saying, "Let''s do it." Surely I had PTSD, post-traumatic stress disorder. It doesn''t take a war to cause PTSD. Mine began with the C-word--cancer--and now with Dr.

Frederick''s graphic descriptions of severing nerves and removing prostates, my PTSD was peaking. I am not the only one to react this way. Heart attacks and suicide rates double after men receive a diagnosis of prostate cancer. You can see why.Fate rescued me from my urge to rush ahead. The hospital''s prostate surgery schedule was backed up by three months. They would call me. I told them to move me up if there was a cancellation.

I wanted to get it over with. Until then, I would just worry about how much cancer I had, whether it had already spread, whether I had made the right choice, whether I would be impotent or incontinent or both for the rest of my life, whether the surgery would save my life or ruin it . and so on, around and around in my mind. The next day, when I could think again, my mind was beset with questions. The main one: How could I make an informed decision about surgery and whether to sever the neurovascular bundles with so little information? Was there any other area of medicine that demanded such dire decisions with so little data? Here''s one example: surgery was not recommended for men whose cancer had already spread beyond the gland. With my cancer score low (more on this in Chapter 3), spread wasn''t likely, but we didn''t know for sure. If I underwent surgery and metastases were found, then the surgery would be for naught, and I might be left impotent and incontinent anyway. The whole process seemed so backward, so twentieth century.

With good reason, I realized, because it is the same method we''ve used since 1990. Before then, prostate cancer assessment was even more primitive. At this point I knew the following: the amount of prostate-specific antigen, or PSA, in my blood was high, at 15 nanograms per milliliter (ng/ml). A second test indicated a PSA level of 13.4 ng/ml. A normal level is 4 ng/ml or less. The elevated amounts of PSA in my blood meant surgery or radiation was necessary. My biopsy showed a low-grade cancer on the left side of my prostate gland.

However, because biopsies frequently miss areas of cancer, the cancer could also be on the right side, and it may have already spread, too. We didn''t really know. On digital rectal exam, my prostate was smooth without any tumors palpable along the posterior side of the gland. This was good, yet the cancer could have spread in a different direction beyond the reach of the doctor''s finger. The cancer could be huge on the forward, anterior side of the gland, and we would not know it. Multiple prostate surgeons told me that these questions do not matter, because if the biopsy detects one area of cancer, other cancers likely exist elsewhere in the gland. Pathology examinations of men''s prostate glands after surgical removal proved this. Therefore, the only reliable treatment was the complete removal of the prostate gland by prostatectomy.

This is what many urological surgeons say to their patients. In other words, the way the system works is that the doctors doing the biopsy and delivering the diagnosis are almost always urologists, many of whom are prostate surgeons. Hence, most men receive the recommendation one would expect from a prostate surgeon: prostatectomy. Yet more and more today, experts disagree with this approach. Not every diagnosis of prostate cancer requires aggressive treatment. As Prostate Cancer Breakthroughs will explain, other and often safer options do exist for the great majority of men diagnosed with prostate cancer. If you have been recently diagnosed with prostate cancer, you might be thinking like I did--go ahead, cut out the damn cancer and be done with it. Yet even if you agree to surgery or radiation therapy, these are not always cures.

The cure rate for these methods is around 75 percent. The cancer returns about 25 percent of the time. The other disturbing fact is that in doctors'' efforts to eradicate all degrees of prostate cancer, prostate surgery or radiation is frequently recommended and performed on men who don''t need these aggressive treatments. It is estimated that of the nearly 100,000 American men who undergo radical treatment for prostate cancer each year, 85,000 do not actually need it. Where did I stand in this continuum? At this point, I didn''t know. My work in medicine has included general medicine, pain research, psychiatry, psychopharmacology, and research into how to prevent the medication side effects that kill 150,000 and hospitalize one million Americans a year. What did I know about prostate cancer? Very little. I asked Dr.

Summers, "Can we do other tests to better clarify the picture? Perhaps an MRI?" This standard test is performed in the diagnostic workups of people who undergo surgery on their knees, lungs, hearts, brains, and just about everywhere else in the body. Why not the prostate? "Unfortunately, MRIs are not helpful for prostate cancer," Dr. Summers explained. "The prostate is situated so deep in the pelvis, an MRI would not be able to give us a clear picture of the cancer." Three weeks later, I was having lunch with a group of men, none of them doctors, but instead prostate cancer survivors. I learned from them that advanced diagnostic tests do indeed exist, and the fellows encouraged me to get them. These men had been where I was now, with a cancer diagnosis and a frightening lack of details. I got the tests, and the results changed everything for me.

Six weeks from the day I received my diagnosis of cancer, I finally knew what I had, where it was, and whether it had spread. I also learned that with my low grade cancer, I had time to deliberate about the best way to proceed. In fact, most men diagnosed with prostate cancer have time to obtain other tests and other opinions and to consider multiple treatment options. In the great majority of men, prostate cancer is slow-growing and slow to spread. There is usually time to obtain a thorough medical assessment, which most men with prostate cancer do not receive today. And there is time to consider other, less invasive treatments that can remove a localized cancer with far less damage, which most men today never hear about. Unfortunately, when most men receive the diagnosis "cancer," their instinct is to decide quickly and try to get rid of it as soon as possible. Family members tend to think the same way.

This is why so many men choose aggressive therapies such as prostatectomy or radiation treatment, each of which can cause serious, often lifelong damage to a man''s sexual functioning or bladder control. The problem with this approach is that it provides inadequate information and leads to the overtreatment of 85,000 men annually. This is how it usually goes: Elevated PSA levels and/or a.