Watchful Waiting

Prostate cancers are, in general, among the slowest-growing human cancers. Since they usually occur in men who are middle-aged or older, the question arises whether the cancer will kill you before you die from something else.

Several studies have examined the natural course of prostate cancer in men who were not treated. Most were carried out in Scandinavian countries, where medical follow-up is excellent and where it is customary to treat prostate cancer much more conservatively than in the United States. In most European countries, in fact, watchful waiting has been a common approach to prostate cancer, although this tradition is gradually changing, especially in Germany, where radiation treatment has become increasingly popular. In countries with waiting lists for elective surgery, such as England and Canada, a period of watchful waiting is often administratively necessary.

The Scandinavian study that has followed men longest was carried out in Orebro County, Sweden. There, between 1977 and 1984, 223 men were diagnosed with prostate cancer. Their average age was 72, their cancers were all thought to be localized to the prostate, and the cell type was poorly differentiated (that is, more malignant) in only nine cases; this classification was prior to widespread utilization of the Gleason grading system or availability of the PSA. The men therefore fell into the category of having prostate cancers for which watchful waiting is considered a reasonable option. They were closely followed for an average of twenty-one years, by which time 91 percent of them had died.3

The percentages of living men whose prostate cancers spread beyond the capsule during five-year follow-up periods were as follows: five years, 32 percent; ten years, 47 percent; fifteen years, 55 percent; and twenty years, 64 percent. A total of 16 percent of the men died from prostate cancer, but in men who were aged 70 or younger at the time of diagnosis, the prostate cancer death rate was 22 percent.

The most surprising finding was that the spread of the cancer and the cancer-related deaths were relatively constant for the first fifteen years after diagnosis but then increased sharply. As summarized by the researchers: ''An approximately 3-fold higher rate was found both for progression and death during follow-up beyond 15 years. . . . If such patients are in their 60s or younger, disease progression that occurs after 15 or more years may be a real concern, arguing for early local treatment with a curative intent.''4

In another Swedish study, 695 men diagnosed with prostate cancer between 1989 and 1999 were randomly assigned to either watchful waiting (348 men) or prostate surgery (347 men). The average age of men in both groups was 65. In the watchful waiting group, 74 percent of the cancers were palpable but had no known spread, and 30 percent had Gleason scores of 7 or higher. At an average follow-up of 6.1 years after diagnosis, among the men being followed by watchful waiting the cancer had spread outside the prostate in 31 percent of cases, had spread to distant organs in 16 percent, and had killed 9 percent of the men. The comparable rates for men treated by surgery were 12, 10, and 5 percent, respectively.5

The mortality rates in these Swedish studies for men who were not treated for their cancers are comparable to rates reported in earlier research. A summary of six studies calculated that 13 percent of men with Gleason scores of 7 or lower who were not treated had died from prostate cancer by ten years after diagnosis. For men with Gleason scores of 8 or higher, the death rate was 66 percent.6

The most useful American study of watchful waiting has been the Connecticut study of 767 men who were aged 55 to 74 at the time their prostate cancer was diagnosed. All elected watchful waiting and were followed for twenty years, by which time 96 percent had died. The men's Gleason scores were highly predictive of their likelihood of dying from prostate cancer: men with a Gleason score of 5 or less had a 10 percent chance of dying from their prostate cancer; Gleason score 6, a 27 percent chance; Gleason score 7, a 51 percent chance; and Gleason score 8 to 10, a 66 percent chance.

The likelihood of dying from prostate cancer, of course, varied widely by the age of the men at the time of diagnosis; that is, men who were older were more likely to die from other causes before their cancer could kill them. For example, among men with a Gleason score of 7, 73 percent who were 64 or younger at the time of initial diagnosis died from prostate cancer, but among men 65 or older, only 37 percent died from prostate cancer. This study, authored by Peter Albertsen and his colleagues at the University of Connecticut, was published in 2005 and should be reviewed by all men who are considering watchful waiting as a treatment option.7

The studies cited above assessed the quantity of life for men whose prostate cancers were initially not treated. Other researchers have attempted to assess the quality of life for such men. In the first Swedish study, for example, after four years of watchful waiting, 21 percent of the men had frequent urinary leakage (with half of them wearing pads), and 45 percent complained of erectile dysfunction. Similarly, a Danish study followed fifty-two men, average age 69, of whom one third had relatively malignant cell types. By approximately three years after beginning watchful waiting, 31 percent had experienced urethral stricture, 31 percent had required a transure-thral resection of the prostate for urinary symptoms, 21 percent were using pads because of symptoms of incontinence, 44 percent had been treated with hormones, 8 percent had required radiation treatment for metastases, 77 percent had impaired erections, and 12 percent were impotent. On the other hand, an American study of 310 men, average age 75, reported some cancer-related decrease in sexual function but no increase in urinary or bowel complaints five years after the onset of watchful waiting.8

Thus, for men with intermediate or severe forms of prostate cancer, it appears that the answer to the question, ''What will happen if I do nothing?'' is reasonably clear. As summarized by one research group:

It is likely that with watchful waiting, roughly 30% to 40% of men with Gleason sum 6 cancers and well over 50% of men with Gleason sum 7 cancers will be dead of prostate cancer or suffering from progressing, hormonally refractory metastatic disease within 10 to 15 years if not treated definitively, with some additional time (<5 years) added if a patient has stage T1C [not palpable on rectal exam] disease at diagnosis.

These figures are based on the assumption that men who elect watchful waiting do nothing to decrease the chances of their prostate can cer progressing. A 2005 study of forty-four men on watchful waiting who adopted major lifestyle changes, including a vegan diet, exercise, and stress management, suggested that such changes can significantly slow the progression of the cancer.9 This study is discussed at greater length in Chapter 13.

Depending on one's perspective, the outcome of watchful waiting can be viewed as a glass either half empty or half full, and men with prostate cancer still regularly choose watchful waiting as a treatment alternative. As noted in Time magazine: ''Faced with this bewildering array of draconian treatments—and their humiliating side effects—many older men and some younger ones opt for watchful waiting.'' The number of men choosing this option is, however, decreasing; in 1993-1995, 20 percent of men chose watchful waiting, but in 1999-2001, only 8 percent did so.10

The best candidates for watchful waiting are men who are over age 70 and whose cancer is in the early stages; for example, nonpalpable on rectal exam, Gleason score of 5 or less, and PSA of 5 or less. Such cancers are statistically likely to grow slowly. Other reasonable candidates for watchful waiting are elderly men with significant health problems, a life expectancy of less than ten more years, and an early-stage cancer. A study of 1,158 men who chose watchful waiting found that three quarters of them were over age 65 and had a Gleason score of 6 or less.11 Most men who choose watchful waiting get repeat PSAs and digital rectal exams at least twice a year and repeat biopsies yearly to watch for progression of the cancer.

A disadvantage of watchful waiting is living with uncertainty. You are essentially placing a bet, and if you bet wrong, you may lose the window of opportunity to cure the cancer. As Patrick Walsh observed: ''When cancer escapes from the prostate, it doesn't send out a press release announcing the event; it just goes, as silently as it appeared in your body in the first place.'' One man who bet wrong was Willet Whitmore, chief of urology at Memorial Sloan-Kettering Cancer Center in New York and regarded as one of the nation's prostate cancer experts. When he himself got prostate cancer, he chose watchful waiting, but his cancer progressed. Before he died in 1995, ''it was reported that he said he regretted the fact that he had waited too long before actively treating his disease.'' Ironically, Whitmore is most quoted today for his succinct expression of the dilemma of

Watchful Waiting

Morty is a seventy-four-year-old retired magazine editor whose prostate cancer was diagnosed two years ago. His PSA at diagnosis was 11 ng/mL and it has stayed there, plus or minus a point, for the past year. His DRE [digital rectal exam] is normal, he has no symptoms, and his scans are clean. ''After my initial diagnosis, I consulted a slew of urologists and radiation specialists," he says. ''They all told me I should get carved or get zapped. But I decided instead just to keep an eye on things. Since then, I've been in good health. I sleep through the night without having to get up to pee. I still enjoy the good life, sexually, emotionally, and in every other way. In fact, my life is even better, because I've become vividly aware of how precious each day is."

—David Bostwick et al., Prostate Cancer prostate cancer treatment: ''If cure is necessary, is it possible, and if cure is possible, is it necessary?''12

In actual practice, watchful waiting is evolving today into nothing more than delayed treatment for many men. The reason, according to Judd Moul, is that ''the men just can't stand to see their PSA values going up. Either the patients, their doctors, or a combination of both together get cold feet.'' Thus, one study of men who chose watchful waiting reported that 53 percent had abandoned the strategy and sought treatment within two years; other studies too have reported significant dropout rates from watchful waiting.13

Additional insight on the effectiveness of watchful waiting as a treatment strategy should come from the large Prostate Cancer Intervention Versus Observation Trial (PIVOT) being run by the federal Department of Veterans Affairs. This trial registered 731 men between 1994 and 2002, and results should be available by 2008.

TEN FACTORS TO CONSIDER

Choosing a treatment for your prostate cancer will be easier if you systematically consider each of the following ten factors:

1. The severity of your cancer: As described in Chapter 2, prostate cancers can be divided into four groups on the basis of risk of recurrence and progression:

• Low risk: Not palpable on rectal exam (T1) or, if palpable, occupies less than half of one lobe (T2a); Gleason score 6 or below; and PSA less than 10.

• Intermediate risk: Palpable and occupies more than half of one lobe (T2b) or is in both lobes (T2c); or Gleason score of 7; or PSA of 10 to 20.

• High risk: Cancer has spread beyond the capsule of the prostate but not to the seminal vesicles (T3a); or Gleason score of 8 to 10; or PSA greater than 20.

• Very high risk: Cancer has spread to seminal vesicles (T3b) or lymph nodes (N+), or has metastasized to bones or other distant organs (M+).

The severity of the cancer can be further refined by consideration of the number of biopsy cores positive for cancer, the percentage of each core containing cancer, and the velocity with which the PSA has risen. The severity of your cancer should be the single largest determinant of your treatment choice.

2. Your life expectancy: will treatment extend it?: How long you are likely to live is the second-most important factor in making a treatment decision. As noted in the accompanying box, treatment decisions for a 50-year-old man who is expected to live an additional twenty-five or more years may be quite different from decisions for a 70-year-old man whose life expectancy is less than fifteen more years. Be aware that these life expectancy projections are averages for the entire American male population, and that many medical and lifestyle factors modify these numbers. For example, studies have shown that a 40-year-old man will lose 3.1 years of life if he is overweight as measured by body mass index (BMI 25-29) and 5.8 years of life if he is obese (BMI 30 or more), compared to men of normal weight. If he is both overweight and a smoker, he will lose 6.7 years, and if obese and a smoker, he will lose 13.7 years.14

In a review of the studies on cancer recurrence, rates of metastasis, and deaths attributable to prostate cancer, it seems very likely that active treatment extends the life of most, but not all, men who choose it over watchful waiting. At this time, there is no evidence that either surgery or beam radiation has an advantage over the other in this regard; the lower death rates reported with surgery appear to occur because surgery is more likely to be offered to younger men with less serious forms of cancer. Insufficient information is available to determine whether seed radiation extends life more readily than the other treatments, but data so far do not suggest that it does.

3. Your willingness to live with uncertainty: Some men are more willing than others to live with uncertainty. Retired General Norman Schwarzkopf is one who is not willing, as he emphatically explained: ''I'm not a type-B personality who knows I have a cancer growing inside of me and can live with the knowledge.'' Not surprisingly, Schwarzkopf chose surgery as his treatment. He falls into the category of men who say, ''I want the cancer out, preferably by yesterday.''15

Surgery provides the most information about prostate cancer: its actual size; the true Gleason score based on the entire cancer; whether the cancer extends into or beyond the capsule; and whether it has already spread beyond the margins of resection or to the seminal vesicles or lymph nodes. Equally important is the fact that the PSA following surgery can be used as a predictor of cancer recurrence. By contrast, radiation treatment provides no information about the exact pathologic stage of the cancer, and the postradiation PSA is a less accurate predictor of recurrence, especially in light of the possibility of a PSA bounce. Hormone treatment may also interfere with the accuracy of the PSA as a predictor of recurrence. For some men, having this information is less important, and they are willing to accept some uncertainty in return for what they perceive to be the advantages of other forms of treatment.

The problem of uncertainty following prostate cancer treatment

Life Expectancy Table

The following are U.S. life expectancy data based on 2002 mortality statistics and published by the Center for Disease Control and Prevention in 2004. Life expectancies in Canada and Western Europe are approximately one year longer.

Your life expectancy is age:

are age:

White males

Black males

40

77.4

72.8

45

77.9

73.5

50

78.5

74.6

55

79.3

76.0

60

80.3

77.6

65

81.6

79.6

70

83.3

81.8

75

85.3

84.5

80

87.7

87.5

85

90.7

90.8

90

94.1

94.5

Note: Life expectancies are averages for the entire white and black male population. If you have heart problems, hypertension, high cholesterol, diabetes, other serious illness, or are overweight, a smoker, use alcohol excessively, do not exercise, and/or your parents and grandparents died relatively young, deduct a few years from the life expectancy table. If you have none of these factors, add a few years. source: E. Arias, United States Life Tables, 2002, National Vital Statistics Reports 53 (2004): 1 -6.

was assessed in a study of fear of recurrence in men undergoing surgical, external beam radiation, or seed implant radiation treatment. Prior to treatment, the men in all three groups had approximately the same level of fear. Two years after treatment, the men who had undergone surgery had the least fear of recurrence, and those who had been treated with either beam or seed radiation scored approximately 10 percent higher on the fear assessment scale. These results are similar to the findings of better post-op mental health in men who were treated by surgery, compared to those treated by beam radiation, as described in Chapter 3.16

4. Quantity versus quality of life: Treatment decisions for prostate cancer often involve deciding between the possibility of living longer but not as well and living well but not as long. For example, watchful waiting for a man with a low-risk cancer promises a relatively satisfactory quality of life at least initially, but a definite possibility that he will not live as long as if he were treated. Conversely, choosing surgery may provide a longer life but one with a high probability of at least partial impotence and other side effects.

5. Sexual function: The relative importance of sexual function must be considered when making treatment decisions. For some men, it may be the single most significant factor. It is known that, following treatment for prostate cancer, men are more likely to retain acceptable sexual function if they are younger and if they functioned well prior to treatment. However, for the majority of men, the prognosis is poor; as summarized by one research group, ''in reality, most [prostate cancer] survivors experience severe and lasting sexual dysfunction and dissatisfaction.''17 Being diagnosed with prostate cancer is, in fact, less traumatic for men who already have some impotence, as opposed to men who still have active sex lives; the former have less to lose.

For a man whose first priority is to preserve sexual function, none of the choices are attractive. Even watchful waiting carries a long-term risk of increasing sexual dysfunction, either from the expanding tumor or from the hormone or radiation therapy that usually becomes necessary as the cancer progresses. However, men who opt for watchful waiting do preserve their existing sexual function for the immediate future, in contrast to all other treatment options.

Figure 2. Percentage of Men Reporting Impotence Following Beam Radiation and Surgical Treatment for Prostate Cancer. source: Data from A. L. Potosky, W. W. Davis, R. M. Hoffman, et al., Five-year outcomes after prostatectomy or radiotherapy for prostate cancer. Journal of the National Cancer Institute 96 (2004): 1358-67.

Figure 2. Percentage of Men Reporting Impotence Following Beam Radiation and Surgical Treatment for Prostate Cancer. source: Data from A. L. Potosky, W. W. Davis, R. M. Hoffman, et al., Five-year outcomes after prostatectomy or radiotherapy for prostate cancer. Journal of the National Cancer Institute 96 (2004): 1358-67.

When treatment options other than watchful waiting are compared, radiation treatments preserve sexual function better than surgery for at least the first two years. Fourteen or more studies have compared sexual function after beam radiation and surgery, with the former being found superior every time. Although far fewer studies have compared seed radiation to surgery, they also suggest that seed radiation has an advantage in preserving sexual function for at least the first year following treatment.18

For the longer term, the advantage of radiation treatment over surgery in preserving sexual function appears to decrease. The multisite Prostate Cancer Outcomes Study followed 981 surgery and 286 beam radiation patients for five years after treatment. The study defined impotence as an ''erection insufficient for intercourse.'' At two years, 82 percent of men who had had surgery were impotent compared to 50 percent of those who had had beam radiation. At five years, 79 percent of men who had had surgery were impotent compared to 64 percent of those who had had beam radiation.19 These results, shown in Figure 2, reflect the growing awareness that surgery produces immediate impotence but then gradual improvement that may continue for two years or longer, whereas radiation treatment produces a slow decline in sexual function that may continue for five years or more.

Although seed therapy, based on early reports, was thought to produce less sexual dysfunction than either beam therapy or surgery, this reputation has not held up over time. A study comparing sexual function in 154 men treated with seed therapy and 60 men treated with surgery reported that ''sexual function was better with BT [brachytherapy] initially but these differences did not persist at a longer follow-up.'' In a study that compared all three therapies, men who had undergone seed therapy rated themselves slightly lower on sexual quality of life than men who had undergone either beam therapy or surgery.20 One reason may be patient satisfaction, which is included in quality-of-life scales. If men choose seed therapy because they expect to retain sexual function but then are disappointed, this dissatisfaction will be reflected in low scores on self-rating questionnaires. Conversely, men who choose surgery expecting to have severe sexual problems sometimes find that the problems are not as bad as they feared, and such men may be comparatively satisfied.

A serious problem in comparing seed therapy with other therapies on any outcome measure is that seed therapy increasingly is accompanied by beam therapy. In 1999 half of all men treated with seed therapy also had beam therapy. Hormone therapy is also being used increasingly often with both seed and beam therapy. In such cases sexual function is invariably lower, usually much lower, than without the second therapy. In a summary of studies of men under age 60, beam therapy alone produced an impotence rate of 50 percent, but beam therapy plus hormones produced a rate of 80 percent. Similarly, seed therapy alone produced an impotence rate of 57 percent, but for seed therapy plus hormones, the rate was 86 percent.21

What about Patrick Walsh's claims that ''at Johns Hopkins . . . 86 percent of men who undergo surgery are potent''? This frequently cited number is the result of a small study of relatively young men, median age 57, who had early-stage cancers. In almost all cases (89 percent), it was possible to remove the cancer and preserve both nerves. A total of fifty-nine men provided questionnaire data over an eighteen-month period, but only twenty-four men returned all ques tionnaires; the study has been criticized on other methodological grounds as well.22 What this study does show is that young men with early-stage prostate cancer retain sexual function when both nerves are preserved; unfortunately, most men with prostate cancer are not this young, and it is sometimes not possible to preserve both nerves because of the size of the tumor.

In summary, if preserving sexual function for the near term is your first priority, your best bet is watchful waiting combined with a lot of luck. Your next-best option is beam or seed radiation alone, which will provide a modest advantage over the surgical option for at least a year or two, although not necessarily for long periods. With surgery, preserving both nerves, if possible, provides a reasonable chance for sexual function, especially for younger men, whereas preserving just one nerve is not auspicious. The worst options for sexual function are surgery with neither nerve preserved, beam and seed radiation together, and any hormone therapy; the incidence of impotence with all of these is very high.

6. Urinary function: Problems with urinary function should also be considered when making treatment decisions. For many men, the possibility of being partially or completely incontinent causes greater fear than impotence. Even dripping urine and wearing a pad may have, according to a survey of Medicare patients, ''a more significant effect on patients than loss of sexual function.''23

Multiple comparisons of urinary function following surgery and beam therapy have shown that surgery produces significantly more urinary leakage. In one study, 29 percent of men who had had surgery wore pads to stay dry compared to only 4 percent of men who had had beam therapy. Another study reported that urinary function was worse in men who had had surgery immediately following treatment, but then gradually improved during the first year to almost equal the urinary control of post-beam radiation patients.24

Although leaking and other symptoms of urinary incontinence are unusual following radiation treatment, irritative urinary symptoms are not. Such symptoms include frequency, urgency, having to get up several times at night, and trouble starting the urinary stream. Such symptoms appear to be especially common following seed therapy. In one comparative study two years following treatment, men who had had seed therapy complained of irritative urinary symptoms much more often than men who had undergone beam therapy or surgery.25

In summary, leaking urine and other symptoms of incontinence are common following prostate surgery, but usually improve over time. Irritative urinary symptoms are more common with radiation treatments, especially seed therapy, and these may persist.

7. Bowel function: Prostate cancer treatments may injure the bowel wall, which is located immediately adjacent to the prostate. Comparative studies have consistently shown that this damage is more likely to happen during radiation, especially seed therapy, than during surgery. Bowel symptoms may include diarrhea, urgency, fecal soiling, cramping, and bleeding. In one comparative study of men two years following treatment, 17 percent of those who had been treated with seed therapy assessed bowel difficulties as being a moderate or serious problem, compared to 5 percent of men who had undergone beam therapy and 3 percent of men who had had surgery.26 Bowel symptoms are worse immediately after radiation, then improve over time but may take as long as two years to stabilize.

8. Access to a competent doctor: The accessibility of competent urologists, surgeons, radiologists, and oncologists is another factor to consider when making a treatment decision. If you have access to only one such specialist, or if your health insurer dictates your choice, your treatment decision may be made for you. Relatively few men have the resources to call the physician of their choice and say, ''I would like to be scheduled for treatment by you next week and, incidentally, I would like to donate $100,000 to your department research fund.'' The men who are able to do so always get an appointment.

You should look for a treating physician who is competent and caring, who is interested in you and your problem. He or she should be board certified and not have been subject to any medical disciplinary actions. This information is available from state medical boards and appears on some Internet websites. The best way to find a competent physician is to ask for recommendations from everyone you know who has any connection to the medical profession. Widely advertise the fact that you have prostate cancer, so that your friends, and your friends' friends, will help you identify the most competent physicians. One book on prostate cancer cleverly suggests calling the secretaries and nurses in the local department of urology and asking, ''Who at your institution would you choose to treat your father?''27 Another source of helpful information is the local prostate cancer support group.

Further, you want a treating physician who performs this procedure on a regular basis. Urologists should be doing at least twenty-five radical prostatectomies per year, and radiation oncologists should be doing at least fifteen seed or beam therapies per year. Multiple studies have shown that high-volume urologists generate significantly fewer immediate and long-term postoperative complications. At the far end of the high-volume spectrum are urologists such as William Cat-alona at Washington University, Patrick Walsh at Johns Hopkins University, and Peter Scardino at Memorial Sloan-Kettering Cancer Center, who have done, respectively, at least 3,478, 2,494, and 1,000 radical prostatectomies.28 It is both legitimate and important to ask a potential treating physician approximately how many procedures he or she did last year, and for how many years he or she has been doing them.

It is unfortunately not possible to ask your potential treating physician some of the most crucial questions. These include: How much do you usually drink the night before you treat patients? Are you having an affair with a nurse or technician in the operating room or radiology department that will distract you? Have you done this procedure so often that you are bored and spend most of the time thinking about your golf game or investment portfolio?

For men having surgery, one other question to ask your physician is, Who will assist you in surgery? A radical prostatectomy is a technically difficult procedure that may last four hours or more. The ideal assistant is another board-certified urologist. In university teaching hospitals, the assistant is often a urology or general surgery resident in training who may or may not be competent. If you are having your surgery at a university medical center, you may have to accept that fact.

For men choosing surgery, it is useful to ask your physician about his or her opinion of nerve sparing. This procedure has been practiced for more than twenty years and is known by all board-certified

Select a Urologist, Not a Philosopher

In Intoxicated by My Illness, Anatole Broyard said that he would like to discuss his prostate with his urologist ''not as a diseased organ but as a philosopher's stone____Is there an Urdesire, an archeology of passion that antedates or predates the prostate?'' You are about as likely to find such a person as you are to find a lawyer who plays Bach's Goldberg Variations while helping you with your will, or a plumber who discusses T. S. Eliot's poetry while fixing your sink. They exist, but they are very rare creatures.

Competent urologists, rather, are highly skilled craftsmen—and that is exactly what you want. They may or may not be good at talking to you, although you should expect them to answer your questions. Medical students who are good at talking often become psychiatrists, and, as a psychiatrist, I can tell you that you certainly do not want one of us operating on your prostate.

urologists. Whether or not one or both nerves can be spared depends on the size and position of the cancer, which will not become known until the prostate is being removed. Beware of blanket promises.

Beware also of statistics. If your treating physician overwhelms you with data on how skilled he or she is, or how illustrious the department of urology or radiology is, get another opinion. It is possible to produce advantageous treatment statistics by accepting only easy cases, and some urologists have followed this course. If you are married, it is useful to have your wife join you for interviews with possible treating physicians; women often have better insights than men do. All treating physicians are biased toward their own treatment, but you want to avoid those who are zealots.

9. Access to a good hospital: It is vital to have your prostate cancer treated in a hospital that performs many such procedures each year.

These high-volume hospitals have been shown in studies of radical prostatectomy to have fewer surgical deaths and fewer postoperative complications; the same is presumably true for radiation treatment as well. The quality of nursing and anesthesia should also be a matter of serious interest. For men undergoing radiation treatments, ask how modern the equipment is and compare with what you are told at other hospitals; radiation equipment is constantly being improved and upgraded.

The fifty best hospital departments of urology, as published in 2005 by USNews.com, are listed in the box nearby. Be aware that the ranking depends heavily on reputation, which among medical professionals rests largely on research status. Thus, it is possible to have a highly rated hospital that has excellent research but not necessarily excellent clinical care.

Another useful list of hospitals is that of cancer centers designated by the National Cancer Institute. These are hospitals where major cancer research is taking place; it will usually, but not always, include prostate cancer research. As of late 2005, there were sixty-two designated cancer centers, including the well-known Dana-Farber Cancer Institute in Boston, Memorial Sloan-Kettering Cancer Center in New York, M. D. Anderson Cancer Center in Houston, and Fred Hutchinson Cancer Research Center in Seattle. A list of these centers by state can be accessed on the Internet by going to the home page of the National Cancer Institute (www.cancer.gov) and clicking on ''Treatment,'' then on ''Treatment Facilities.''

Still another list of cancer treatment facilities is the National Comprehensive Cancer Network, nineteen affiliated facilities that are described on the website of the coordinating organizations (www.nccn.org). All of these lists, however, suffer from the same limitation: exemplary cancer research is not necessarily accompanied by exemplary clinical care.

10. Convenience and cost: The convenience and cost of prostate cancer treatment options are practical but crucial considerations. Compared to radiation, surgery entails a more prolonged recovery, during which time work and regular activities must be curtailed. The accessibility of the treatment unit should be weighed; having to stay in a hotel in a distant city for several weeks to have beam therapy will be

The Fifty Best Hospitals for Urology in 2005

This ranking is based on a variety of factors, including reputation among medical professionals, ratio of nurses to patients, mortality ratio, and equipment.

1. Johns Hopkins Hospital, Baltimore

2. Cleveland Clinic

3. Mayo Clinic, Rochester, Minn.

4. UCLA Medical Center, Los Angeles

5. New York-Presbyterian Univ. Hosp. of Columbia and Cornell

6. Barnes-Jewish Hospital/Washington University, St. Louis

7. Massachusetts General Hospital, Boston

8. Memorial Sloan-Kettering Cancer Center, New York

9. Duke University Medical Center, Durham, N.C.

10. Stanford Hospital and Clinics, Stanford, Calif.

11. University of Texas, M. D. Anderson Cancer Center, Houston

12. University of California, San Francisco Medical Center

13. Methodist Hospital, Houston

14. University of Michigan Medical Center, Ann Arbor

15. Northwestern Memorial Hospital, Chicago

16. Clarian Health Partners (IU and Methodist Hospitals), Indianapolis

17. Vanderbilt University Medical Center, Nashville

18. Hospital of the University of Pennsylvania, Philadelphia

19. Lahey Clinic, Burlington, Mass.

20. University of Iowa Hospitals and Clinics, Iowa City

21. NYU Medical Center, New York

22. University of Virginia Medical Center, Charlottesville

23. William Beaumont Hospital, Royal Oak, Mich.

24. Parkland Memorial Hospital, Dallas

25. Yale-New Haven Hospital, New Haven, Conn.

26. Shands at the University of Florida, Gainesville

27. University of Miami, Jackson Memorial Hospital

28. Christ Hospital and Medical Center, Oak Lawn, Ill.

29. St. Luke's Medical Center, Milwaukee

30. University of Wisconsin Hospital and Clinics, Madison

31. University of Pittsburgh Medical Center

32. Ohio State University Hospital, Columbus

33. Sentara Norfolk General Hospital, Norfolk, Va.

34. Abbott Northwestern Hospital, Minneapolis

35. University of North Carolina Hospitals, Chapel Hill

36. Rush University Medical Center, Chicago

37. Henry Ford Hospital, Detroit

38. Sarasota Memorial Hospital, Fla.

39. University Hospitals of Cleveland

40. Texas Heart Institute at St. Luke's Episcopal Hospital, Houston

41. University of Colorado Hospital, Denver

42. Brigham and Women's Hospital, Boston

43. University Hospital, Cincinnati

44. Advocate Lutheran General Hospital, Park Ridge, Ill.

45. Lancaster General Hospital, Pa.

46. University Medical Center, Tucson, Ariz.

47. F. G. McGaw Hospital at Loyola University, Maywood, Ill.

48. University of Minnesota Medical Center, Minneapolis

49. Memorial Hermann Hospital, Houston

50. St. Elizabeth Hospital Medical Center, Youngstown, Ohio source: Best Hospitals 2005, Urology, USNews.com, http://www.usnews.com (click on ''Rankings and Guides,'' then on ''Best Hospitals,'' then on ''Urology'').

less pleasant and more expensive than having seed therapy or surgery at a local hospital.

Except for watchful waiting, all treatments for prostate cancer are expensive. An analysis of total costs for the initial workup, treatment, and six months of follow-up in the mid-1990s reported them to be as follows:29

Since these costs were based on data from 1993 to 1996, the costs today would be still higher.

Ascertaining who will pay the costs of treating your prostate cancer varies from complex to Byzantine. If you are 65 or older, you are covered by Medicare, part A, for the costs of hospitalization; you may also be covered by Medicare, part B, for the costs of the treating physicians. However, you have to pay a deductible and approximately 20 percent of the cost (the copayment), and you have to use physicians who accept Medicare assignment (most do). If you are an armed forces veteran, you may be eligible to use programs at military or Veterans Administration hospitals (the treatment program at Walter Reed Army Hospital in Washington, D.C., for example, is excellent). Or you may be able to use Tricare coverage for most treatment costs by other providers who participate in the Tricare program.

If you have private insurance, such as Blue Cross/Blue Shield or Aetna, coverage for costs varies widely by your specific plan and your location. The insurance plans of large companies usually offer more generous coverage than the plans of small companies. In some plans, you are restricted to using a select list of hospitals and physicians, whereas other plans allow you to choose your own. Virtually all plans pay only a ''reasonable and customary fee,'' which is determined by zip code and varies by region. You will almost certainly

Treatment

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