A disease fueled by testosterone

When a politician announces he has prostate cancer, what does it mean?

By Dawn MacKeen
Published April 28, 2000 4:50PM (EDT)

After watching his father die from prostate cancer in 1981, New York Mayor Rudolph Giuliani started having regular screenings for the disease, which is the second leading cause of cancer deaths in men in the United States. That may have been one of the wisest moves of Giuliani's career. On Thursday he announced that he has the disease, too.

"It is a treatable form of prostate cancer; it was diagnosed at an early stage," he said at a press conference on Thursday. Giuliani had learned the day before from his doctor at Mount Sinai Medical Center that the results of his biopsy had confirmed what a blood test had indicated two weeks earlier.

Giuliani joins an estimated 180,000 other men who will be diagnosed with prostate cancer this year, according to the American Cancer Society. He also joins other high-profile figures, like Bob Dole, Rupert Murdoch, Arnold Palmer, Louis Farrakhan, Andy Grove, Michael Milken, Joe Torre and Norman Schwarzkopf, who have fought the disease.

Many times there are no signs, and the disease is detected only after a person has a routine rectal exam or a PSA (prostate-specific antigen) blood test. And even when a man experiences pain or has blood in his urine, both common signs, the disease may go undetected because men are too embarrassed to complain, doctors say.

No one knows exactly why some men develop cancer in the prostate and others don't -- though doctors say having a close relative, like a father, with the disease makes a person genetically susceptible. It is also most common in men over age 50. (Giuliani is 55.)

"Like death and taxes, prostate enlargement is guaranteed for men as they age," says Dr. Richard Spark, professor of medicine at Harvard Medical School and author of the new book "Sexual Health for Men." And in many cases, he says, the prostate then undergoes a malignant transformation.

While the cancer is generally slow growing, it can move very quickly to other parts of the body. This year alone, estimates predict, prostate cancer will claim the lives of 31,900 men -- though fatality rates have fallen over the past decade, according to a recent study by the National Cancer Institute.

Doctors say that it is difficult to tell how bad Giuliani's case is because little information about it has been released. The mayor has declined to elaborate on his exact diagnosis and says he won't decide whether he'll drop out of the New York Senate race until he decides which treatment to pursue. His outcome, oncologists say, depends on many factors, including the grade of the tumor (also known as the Gleason score), the extent of the disease revealed in a digital rectal exam and his PSA level. How far the cancer has spread has a significant bearing on his outcome. If prostate cancer is found before it has spread, the person's five-year survival rate is 100 percent; if it has spread far in the body, then the rate is only 31 percent.

A lot has changed in the treatment of prostate cancer over the past few decades. Castration was once the main way of treating it -- obviously leaving all men who underwent the procedure impotent. Now there are numerous options depending on the seriousness of the cancer.

If the disease is truly at an early stage and is localized, the least serious of possible situations, Giuliani is likely to choose one of two very different types of treatment: radiation therapy or surgery.

"There's no right treatment in general," says Dr. Mack Roach, associate professor of urology and medical and radiation oncology at the University of California at San Francisco. "It's individualized; there's a lot of personal choice here. These different therapies have a different impact on one's lifestyle. In some patients their relationship to sexual dysfunction is a big deal. For others, they don't want to have the surgery. As best we can tell, the survival rates are about the same."

Erectile dysfunction, along with incontinence, is a common side effect of prostatectomy, the surgical removal of all or part of the prostate gland. New nerve-sparing procedures, however, can decrease the likelihood of E.D.

"There are lots of ways to treat both of those problems; people shouldn't have the impression that one or both of those side effects are inevitable or untreatable," says Dr. Ted Gansler, medical editor for patient information at the American Cancer Society. What's more, "Viagra has helped many men. And there are other treatments that have been useful, like prostaglandin, that can be injected into the penis to have an erection."

Bob Dole, a prostate cancer survivor, was diagnosed with the disease in 1991 and later underwent surgery to remove the afflicted gland. When he went public two years ago with his impotence problems, a result of the surgery, he became the poster boy for E.D. and Viagra. On Thursday, Dole offered his support to Giuliani and praised him for disclosing his illness.

Oncologists believe that patients are less likely to experience E.D. with radiation therapy, of which there are two types: external beam, which is done outside the body and is akin to getting a diagnostic X-ray, and brachytherapy, in which the doctor puts small pellets of radioactive material the size of plant seeds in the prostate. Both types of radiation kill the cancerous cells.

Giuliani's decision will also probably revolve around his schedule. He could be treated with radiation every day for a few hours or have the surgery and remain in recovery for three to five weeks. If the cancer is more serious and has spread, Giuliani is also likely to consider hormone therapy or, as a last line of defense, chemotherapy (which isn't as effective in treating cancer of the prostate as it is in treating other cancers).

Hormone therapy is really a modern day way of achieving what castration did -- stopping the production of testosterone without extreme and unpleasant surgery. Prostate cancer is a testosterone-dependent malignancy, and researchers discovered a way to turn off the production of testosterone without having to remove the testicles. The medication, given once every three months, stops the brain's hypothalamus -- where testosterone production originates -- from sending a signal to the pituitary gland, which, in turn, relays a signal to the testicles.

"Testosterone is like a fuel to prostate cancer," says Spark. "If you eliminate the testosterone, it's like shutting off the burner." While the treatment has proved effective, it, too, has side effects, which include hot flashes, fatigue and sexual dysfunction.

Giuliani says he will determine over the next few weeks which form of treatment to undergo. Spark applauds the mayor for coming forward, not only to increase awareness of the disease but also as a political strategy. "It's better that he announced it than someone from Hillary [Clinton's] camp saying he's going to be impaired because he's ill. It's better that he takes a proactive stance and says, 'This is what I have, this is what I'm doing about it and I'm going to be fine.'"

Dawn MacKeen

Dawn MacKeen is a former senior writer for Salon, and author of a forthcoming book about her grandfather’s survival of the Armenian Genocide, "The Hundred-Year Walk: An Armenian Odyssey" (Houghton Mifflin Harcourt, January 2016).

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Cancer Rudy Giuliani Rupert Murdoch