Living with prostate cancer, said one man, is ''like being trapped inside a cage with a baby lion.'' In the beginning, the lion is small and nonthreatening, but you know that the lion will grow and may eventually devour you. This man's cancer did spread and in the end did ''devour'' him.1
Prior to the PSA era, by the time of diagnosis the prostate cancer would have already spread beyond the prostate in the majority of cases. By the 1990s, this number had been reduced to one third, and by now it is presumably significantly lower than that.
Prostate cancers that have spread at the time of diagnosis present many of the same treatment problems as cancers that recur after the initial treatment. In some cases, the recurrence is expected because of a Gleason score of 8 to 10, a PSA over 20, or other indicators of a large and serious cancer. In other cases, the recurrence of the cancer is unexpected, as when a man has a low Gleason score, a low PSA, and a small tumor. Some of these men are told by their urologists that they are ''cured'' following their initial surgical or radiation treatments, and recurrence of the cancer, when it occurs, can be a cruel shock.
It is helpful to keep in mind the magnitude of the recurrence problem. There are approximately 1.6 million men in the United States who have been diagnosed with and, in most cases, treated
for prostate cancer. They constitute 17 percent of Americans who are living with cancer. The majority of these men have regular PSA checks at least annually for ten to fifteen years. Each time they are tested, they wait nervously for the results—will this be the time their PSA is elevated, indicating the recurrence of cancer? Since the recurrence of prostate cancer is often without symptoms, there is a Kafkaesque quality to the repeat PSA tests, a mysterious internal process over which a man has no control.
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