Giuliani's Choices

By Ian K. Smith, M.D.

When Rudy Giuliani, New York's high-visibility mayor, revealed last week he had been diagnosed with prostate cancer, he joined 180,000 American men who will be told by year's end they have the disease. Giuliani's cancer was apparently caught in its early stages, thanks to a PSA blood test that often signals prostate abnormalities. That's good news for the mayor, since he's likely to be completely cured--and need not endure more than a brief disruption of his Senate race against Hillary Clinton.

But like other men caught in a similar bind, Giuliani must choose from several different courses of treatment, each with decided advantages and disadvantages. The most conservative choice is surgical removal of the walnut-size gland, but this comes at great risk of losing sexual function or becoming incontinent. These two primary side effects cause many men to turn the other way--especially those as relatively young as Giuliani, who will be 56 on May 28. Although surgeons are getting better at protecting the nerves that control erection, even in the most skilled hands there's still a 30% chance of temporary impotence.

Radiation treatment, the second major option, may be as effective as surgery and is often used in combination with it. It's delivered by high-energy beams that zap the prostate or by radioactive pellets the size of rice grains implanted in the prostate. Radiation carries risks similar to surgery in terms of incontinence and impotence.

Lower on the list is a promising new treatment--though far from the most effective--in which the cancerous cells are freeze-killed. It's also unlikely that Giuliani will choose hormonal therapy, which prevents the male hormones from stimulating further prostate growth. It can be used together with other therapies, but it's more common when the cancer has spread.

Recovery time varies with each treatment, but with surgery and/or radiation--Giuliani's likeliest options--I wouldn't be surprised to see him back on the campaign trail within a month.

Like other celebrities who have spoken openly about their prostate cancer--Senator Bob Dole, General Norman Schwarzkopf, singer Harry Belafonte--Giuliani is delivering a powerful public lesson in the lifesaving importance of annual checkups that include both a PSA blood test and the infamous gloved-finger rectal exam. After his father died of prostate cancer at age 73, Giuliani started his screening early, a practice recommended for any man with a family history of the disease. Tests by the mid-40s are a good idea for other high-risk groups as well, especially African Americans, who have a 34% higher prostate-cancer rate than whites.

PSA screening probably played a key role in reducing prostate-cancer deaths in the past decade--by 16% among whites and 11% among African Americans. But as effective as the test is at detecting the cancer in its early stages, it isn't perfect. Other prostate conditions such as inflammation (prostatitis) can elevate PSA levels, so a biopsy may be necessary, as it was in Giuliani's case. When I was late for school, my mother liked to say the early bird catches the worm. When it comes to prostate cancer, early screening can mean the difference between life and death.

For more on prostate cancer, visit the American Cancer Society at cancer.org E-mail Dr. Ian at ianmedical@aol.com