For some women who have found the experience of childbirth intolerable, and the experience of looking after a small baby almost beyond their capacities, the fear of further pregnancy may not only dampen any sexual drive but make contraceptive choice extremely difficult. No method is ever considered safe enough, and for some even the use of several methods at the same time does not give them a feeling of security.

Tobert has also described those women for whom all the physical and emotional functions of femininity are intolerable. Painful menstruation, premenstrual tension and frigidity are succeeded by difficult pregnancy and delivery. Later there may be a demand for sterilization, hysterectomy or relief from the unbearable symptoms of the menopause. Often referring to their mother or grandmother as having suffered in the same way, their femininity is seen as an unhappy heirloom handed down through the generations.

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Two months later Dr A. saw Miss R. for the first time. Small, dumpy and childlike, she poured forth an amazing torrent of naive and sometimes bizarre questions. ‘Was this right, was that right, should he ask her to do this, should it last so long?’ Foolishly, Dr A. did not read the counselling notes and tried to deal with these questions as they came, feeling overwhelmed, but unable to interpret to the girl that she, too, was probably feeling overwhelmed by the demands of her boyfriend. Dr A. wrote, ‘Examine next time’, and fled from the patient feeling exhausted. Interestingly, the girl had also complained of being exhausted.

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Radio frequency energy can also be conducted through tiny needles, which are inserted directiy into prostate tissue via a special catheter. The needles can riddle the BPH tissue with holes of various sizes to weaken the tissue’s grip on the urethra. Experiments using TUNA in animals have been promising, and clinical trials of this technique are under way. The TUNA device is battery-operated, and may be among the least expensive of these techniques.

Pyrotherapy

This is the least invasive of these thermal therapies; in fact, there’s not even a probe to enter the body. Here’s how it works: Multiple ultrasound waves are focused at a single point some distance away from the power source. Only the concentration point, the target where all these beams intersect, is damaged. The cumulative energy of these waves, entering the body through a broad area, is great enough to cause thermal injury to BPH tissue and to create cavities in the prostate around the urethra. A prototype system (called Pyrotech) has been tested, and clinical trials are under way. However, it is not yet certain whether pyrotherapy will be able to pinpoint the prostate tissue surrounding the urethra as precisely as it needs to—entering the body either through the abdomen or perineum—because the bony pelvis gets in the way; this may turn out to be an insurmountable obstacle.

Cryotherapy

In this treatment, instead of heat, the opposite—extremely cold liquid nitrogen—is used to freeze and kill cells in BPH tissue. Guided by transrectal ultrasound, doctors circulate the freezing liquid nitrogen through three to five metallic probes, which are placed in the prostate gland through the perineum. A special catheter works like a hot water bottle to keep the urethra from freezing. There are no long-term studies to determine the effectiveness of this procedure.

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Intravenous Pyelogram (IVP), an X-ray view of the urinary tract, can also determine urinary obstruction or the presence of tumors in the kidney. It works like a glow-in-the-dark picture: A special dye is injected, making urine visible and its path from the kidneys and out of the body easily traceable—and any blockage easy to see. Some men have severe allergic reactions to this dye, so this test is not routinely used. (Unfortunately, there is no way to predict who will have such a reaction.) It’s usually reserved for evaluating men who have blood in their urine.

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Patients in imminent danger of spinal cord compression should be treated with large doses of corticosteroids (usually a drug called decadron) for forty-eight hours. Then, depending on how your body responds to this, your doctor will make a decision on what to do next—this could mean spot radiation treatment to the spine, or something called surgical decompression, an operation to ease the cancer’s pressure on the spinal cord.

If you have not yet begun hormone therapy, now is an excellent time to begin—and fast—with immediate castration or treatment with flutamide (see above). Giving an LHRH agonist alone in this situation is not a good idea, because it can cause a surge in testosterone that could aggravate the cancer sitting so precariously in the spine.

Spinal cord compression is yet another blow in a series of unpleasant complications of prostate cancer, and it has the greatest potential to ruin quality of life—it can lead to paralysis, with an accompanying loss of bowel and bladder function. Most significantly, it can result in the loss of a patient’s independence and feeling of dignity.

If you begin to feel any of the warning signs mentioned above, call your doctor immediately; don’t wait until your next scheduled appointment! This may mean the difference between remaining able to walk and being bedridden.

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Which leaves us, finally, with palliative treatment—easing symptoms and pain, and keeping up nutrition in men who don’t feel like eating. In this stage of treatment, thankfully, there is much that can be done, and you have a right to demand everything possible—medication or a procedure to ease pain or symptoms of urinary obstruction—to make the situation better.

One reason for these differences of opinion is that doctors treating men with end-stage cancer are desperate. Most of them—the best of them—care deeply about their patients, and are willing to try every last-ditch measure they can think of to help them. Say a study trumpets the benefits of the latest drug—one drug, for example, created a stir in the medical community because it was said (with debatable accuracy) to prolong life for several months. Many caring physicians will go ahead and prescribe such a medication, even though, deep down, they realize it probably won’t help. They figure that there’s a race against time, and they’re losing it. And that any effort is better than none.

Ultimately, what you decide to do, what drugs and treatments you decide to try, is up to you—as it should be. Read this material, plus any other information you can get your hands on (for some suggestions on where else to look for answers, see page 289). Talk to your doctor, and get a second opinion; talk to your family, to any other prostate cancer patients you can find, and make the best, most informed decisions you can.

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“I went in to the doctor’s office sort of full of myself,” recalls Weaver, who was 63 at the time. “I felt in great shape, I was jogging every day, doing some weights, eating well and having a good married life.” He was stunned when his doctor found the lump. “I was sort of insulted, like, ‘Me? This can’t happen to meV I had absolutely ZERO symptoms—no urinary problems, no aches, no pains, no sign of anything. It was a hidden time bomb, ticking away.” The nodule was tiny, but a needle biopsy and transrectal ultrasound confirmed that it was cancerous—and “very operable.”

Weaver, a syndicated financial columnist living in Washington, D.C., is a reporter, and he explored his treatment options just as he would research a story—chasing leads, talking to experts, putting himself in charge of getting the facts. After exploring every option, he decided to undergo surgery. His next step was to ask around until he was confident he’d found the best surgeon.

“It’s a major operation,” Weaver says. “I was in the hospital nine or ten days. (Today, most patients stay in the hospital only four or five days.) I went home with a catheter for urine for another two to three weeks.” He had some trouble with incontinence for several months, and his sex life was disrupted for a few weeks. After about a year, he was back to normal.

That was five years ago. Now, he says proudly, his PSA tests have been “absolutely, totally normal.” Several times a week, he runs three miles and works out with weights. He joined an athletic club. “My cholesterol’s 155. The HDL (high-density lipoproteins) cholesterol is 45-50. The combination, my doctor says, is just perfect. I have a pulse of 60-64, a blood pressure of 120 over 80. I feel great.”

For the last several years, Weaver has become involved in a prostate cancer support group. He has spoken and written about his experiences, and he has some advice for men in his situation.

First, he says, get a second opinion, and even a third. If you don’t like what a doctor has to say—the doctor’s success rate with impotence and incontinence, for example—”scratch his name off your list.”

Ask your doctor as many questions as you need to, so you’ll be prepared for the complications of surgery that will surely come. Because soon after surgery—if you’re not expecting these complications—they can be overwhelming, he says: “You can’t get an erection, you’re leaking urine in your pants. From youth onward, you’re made to feel that these are some of the worst possible things that can happen to a man.” Even though the impotence and incontinence were only temporary for Weaver, they still affected his quality of life for months.

And know, too, that if impotence and incontinence don’t go away, there is help, he says: “They’ve got medications, injections and devices available now that are incredible—that could give a cigar store Indian an erection!”

Weaver’s last bit of advice for men? “Have a checkup every year, with the most experienced urologist you can find. Get a PSA test and digital exam. Take charge—be responsible for your own health.” After all, “it’s your body. You’ve got to look after it.”

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