Doctors sell prostate cancer patients on surgery as the only way to treat the disease once and for all, but evidence is mounting that, in a high percentage of surgery cases, the cancer soon comes back.
As smoking has declined, prostate cancer has overtaken lung cancer as the biggest cancer killer of men in the Western world. One in 12 will develop a clinically significant prostate disease in their lifetime. Each year, some 10,000 men in the UK and more than 40,000 in the USA die of the disease.
The scandal of prostate cancer is not just the burgeoning incidence of the disease, suggesting that something in the Western lifestyle is proving deadly to the male constitution, but also the ruinous way in which modern medicine treats it.
In the vast majority of cases, the so-called 'treatment' leaves the patient worse off than having the disease - incontinent, impotent and likely, in 40 per cent of cases, to have the cancer return.
Doctors have been using the same treatment methods for over 30 years. Despite this, a recent Lancet review candidly admits that 'the optimal treatment for localised prostate cancer is still not known' (Lancet, 1997; 349: 906-10).
The conventional therapy is the traditional trio of surgery, radiation and drugs. The most common surgical technique is transurethral prostatectomy, or TURPS, in which the prostate is cut or burned away by an instrument inserted down the penis. Surgery is recommended for both prostate cancer and benign prostatic hyperplasia (BPH), non-life-threatening age-related enlargement of the prostate.
The side-effects of surgery are both severe and debilitating. In addition to possible prolonged bleeding from the prostate itself, many men are rendered permanently incontinent. Furthermore, a staggering 80 per cent will be made impotent as well (J Natl Cancer Inst, 2000; 92: 1582-92). There is considerable anecdotal evidence that doctors choose to withhold this devastating information from their patients before they operate.
New surgical techniques such as cryotherapy (freezing) and so-called 'nerve-sparing surgery' don't appear to appreciably reduce these side-effects either (J Urol, 1996; 156: 115-21; JAMA, 2000; 283: 354-60).
Although doctors often suggest otherwise, surgery is not guaranteed to solve the problem of prostate enlargement. Worse, there is a significant risk of recurrence of both BPH and cancer.
A study by the Mayo Clinic in the US showed that prostate cancer returned within a year in more than 8 per cent of the men they treated. This rate of recurrence rose to 40 per cent 10 years after the surgery (US National Cancer Institute Statement, July 2001).
Radiotherapy has an equally unimpressive record. This treatment is applied either externally by X-rays or internally with the use of radioactive implants (also called brachytherapy).
Radiation is frequently called upon to solve the recurrence problem after surgery, but a recent analysis has shown this to be of 'limited efficacy' (Int J Radiat Oncol Biol Phys, 2002; 53: 269-76). And, of course, it comes with a host of side-effects, including bowel and urinary problems as well as impotence.
The conventional drug treatment for prostate cancer is not the standard cancer chemotherapy (which is believed to be largely ineffective), but uses drugs that block male hormones, principally testosterone. This is because prostate cancer is thought to need testosterone in order to grow.
It is claimed that drug therapy can improve survival rates by up to 20 per cent. However, it's been found that, after a certain time, the drugs will often stop working - and some prostate cancers don't respond to hormones at all (Prostate Cancer Prostatic Dis, 2002; 5: 13-5).
As a recent study by Sweden's Karolinska Institute admits, hormone therapy has turned out to be 'disappointing'. Indeed, the report concluded, 'No decisive breakthrough in the pharmacological treatment of prostate cancer has occurred in the last 60 years' (Lakartidningen, 2000; 97: 3466-9).
Because prostate chemotherapy destroys male hormones, it is sometimes referred to as 'chemical castration'. Predictably, its main side-effect is to curtail sexual functioning. But it also causes osteoporosis, nausea and severe anaemia, and has even killed people through liver toxicity.
Because of the high cost of hormone-blocking drugs, doctors may recommend actual physical castration as a cheaper option; particularly in the UK, this is considered the 'gold-standard' treatment for advanced prostate cancer (Br J Hosp Med, 1993; 49: 710-1, 714-5).
However, since there have been no prospective randomised trials of the treatment options, there is little evidence that any medical intervention currently on offer actually prolongs life. As a statement from the US National Cancer Institute bluntly put it, 'It is not known if the potential benefits of prostate cancer screening outweigh the risks, if surgery is better than radiation, or if treatment is better than no treatment' (US National Cancer Institute Statement, October 2000).
This may explain why, besides surgery, radiation and drugs, there is a fourth treatment - do absolutely nothing. The official medical term is 'watchful waiting'. There is evidence to show that this is often the best option.
In the biggest study to date, 60,000 Americans diagnosed with localised prostate cancer in the 1980s were followed for 10 years to compare the effects of different treatments.
For men with minor to medium-stage cancer, there were just as many men still alive after no treatment as after surgery. Radiation treatment appeared to actually increase death rates. Only in cases of initially serious cancers did there appear to be any (albeit slight) survival advantage of 'aggressive therapy' over watchful waiting (Lancet, 1997; 349: 906-10).
However, even these findings - which were effectively proving that having no treatment was as good as or better than any treatment - were soon attacked as 'exaggerating the benefits of treatment' (Lancet, 1997; 349: 1551-2).
Some experts are now beginning to concentrate on prevention - mainly by diet. Even such bastions of the cancer Establishment as the Sloan-Kettering Cancer Center in New York are contemplating dietary manipulation as a 'treatment strategy' (Semin Urol Oncol, 1999; 17: 154-63).
Despite the initial medical scepticism, evidence of a connection between diet and prostate cancer has been getting stronger year by year.
There is relatively good evidence of an association with a high-fat diet, although recent studies suggest that reducing fat intake does not have a marked preventative effect (Curr Opin Urol, 2001; 11: 457-61).
There appears to be a stronger connection with dairy foods. Studies in the US and Sweden have shown that a high consumption of dairy products can increase prostate cancer risk by 50 per cent. The culprit doesn't appear to be the fat content of milk but - perhaps surprisingly - the calcium. One of calcium's effects in the body is to reduce vitamin D levels, and vitamin D is one of the many micronutrients known to prevent prostate cancer (Cancer Causes Control, 1998; 9: 559-66).
In fact, diets high in vitamins A and E as well as vitamin D all appear to significantly reduce the risk of prostate cancer. Virtually all of the 100 or so surveys of prostate cancer incidence to date have shown this link. To use the jargon, these vitamins, together with the mineral selenium, appear to be powerful 'chemopreventing agents' (Can J Urol, 2000; 7: 927-35).
In laboratory tests, these vitamins have been shown to inhibit prostate cancer cell cultures. They've also proved able to slow down the progress of the disease in experimental animals infected with human prostate cancer cells. However, such results do not necessarily apply to humans (Urologe A, 2000; 39: 304-8).
In terms of active prevention, most of the research has been into vitamin E and selenium. The first major study on vitamin E was carried out in Finland, where men aged 50-70 years were given 50 mg of vitamin E daily (about three times the Recommended Daily Allowance or RDA) for more than five years.
Compared with a control group of men not given the nutrient, the supplemented group had over 30 per cent fewer diagnoses of prostate cancer and over 40 per cent fewer prostate cancer deaths (J Natl Cancer Inst, 1998; 90: 440-6). Later analyses have slightly modified the original findings, revealing that only men who were initially deficient in vitamin E actually benefited (Urology, 2002; 59 [Suppl 1]: 9-19).
In the first major study on selenium supplementation, which began in 1983 and ran for more than 10 years, 1000 American men were given 200 mcg of selenium a day (three times the RDA of 70 mcg) for an average period of about five years.
The results were remarkable. All of the men in the treatment group showed a massive reduction in the incidence of three major cancers - lung, colon and prostate. The incidence of prostate cancer alone was reduced by more than half (JAMA, 1996; 276: 1957-85).
Since then, a number of similar trials have found, in general, the same results, including one study from the prestigious Harvard Department of Nutrition run by Professor Walter Willett. He and his team found that the higher the level of selenium in the body, the lower the risk of advanced prostate cancer. In specific terms, the risk was reduced by as much as a third.
The herbal approach
If you haven't managed to prevent prostate cancer, and wish to avoid conventional treatments, what can you do?
One answer, until very recently, was a Chinese herbal remedy marketed under the name of PC-Spes (spes is the Latin word for 'hope'). It's a formula of eight plants: chrysanthemum, liquorice (Glycyrrhiza glabra), Baikal skullcap (Scutellaria baicalensis), saw palmetto (Serenoa repens), Isatis indigotica, Panax pseudoginseng, Rabdosia rubescens and the root fungus Ganoderma lucidum.
PC-Spes took the world of prostate cancer by storm. From the time it first came onto the market in the USA about six years ago, prostate cancer sufferers turned to it in their thousands - mainly through word of mouth.
The effect it appeared to have on prostate cancer was dramatic. Patients said that it not only reduced the annoying symptoms of the early stages of the cancer, but also the pain of advanced cancer. Men for whom conventional hormone therapy had failed also claimed to derive benefit from this herbal remedy.
A few cancer specialists were sufficiently intrigued to mount some serious scientific studies on PC-Spes.
In 1998, one US hospital reported their experience with the herbal formula in a handful of patients who had refused conventional treatment. In every case, there was objective evidence of benefit in the form of significant declines in both testosterone and PSA levels (N Engl J Med, 1998; 339: 785-91).
This was followed by a survey of more than 100 prostate patients, 77 per cent of whom said they had found PC-Spes to be beneficial. They also showed huge declines in PSA levels, taken as a sign of cancer regression. No clinically significant adverse effects were seen (Mol Urol, 1999; 3: 333-6).
Also, a team at the Oncology Division of New York Medical College published the results of a study of rats injected with 'aggressive' human prostate cancer cells. Conventional treatments are generally not successful in such animals, but PC-Spes produced an overall 50 per cent reduction in cancer and, in a third of the rats, the cancer completely disappeared. No side-effects were seen. It's wise to remember, of course, that animal studies may not apply to humans (Int J Oncol, 1999; 14: 713-9).
Another hospital trial followed in 2000, involving 14 seriously ill men for whom chemical and actual castration had failed. Doctors found that 3 g/day of PC-Spes significantly improved their quality of life and reduced the pain of the disease. Again, there were no side-effects (BJU Int, 2000; 85: 481-5).
Later that year, doctors at the University of California Medical Center in San Francisco gave PC-Spes to 70 progressive prostate cancer patients, some of whom were not responding to conventional treatment. Again, the results were positive. Most of them showed reduced PSA and testosterone levels, and a few even achieved a regression of the cancer. In this study, some side-effects were recorded - mostly breast tenderness and diarrhoea, plus a few cases of allergic reactions and deep-vein thrombosis - which were all considered to be 'acceptable' (Clin Oncol, 2000; 18: 3595-603).
Another hospital study - from Boston's Dana-Farber Cancer Institute, linked to Harvard - found similar results to the earlier studies. They concluded that 'PC-Spes is a well-tolerated and active treatment for prostate cancer' (Urology, 2001; 57: 122-6).
To date, there have been over a hundred published studies on PC-Spes, almost all confirming its benefits. Nevertheless, last February, PC-Spes was suddenly withdrawn from sale.
The official state laboratory of the California Health Department had tested a sample of PC-Spes and claimed to have found 'undeclared prescription drug ingredients that could cause serious health effects if not taken under medical supervision'. The drugs were warfarin (an anticoagulant) and alprazolam (a benzodiazepine), which are available only on prescription and sold under the names Coumadin and Xanax, respectively. This investigation came on the heels of reports that traces of the synthetic oestrogen diethylstilboestrol (DES) had been detected in some batches of the herbal formula.
What seems most puzzling is why these compounds had evidently not been discovered before in any of the earlier PC-Spes studies. However, an official question mark had been raised about PC-Spes, and the US authorities lost no time in banning it.
The manufacturer of PC-Spes, a California company called BotanicLabs, strongly deny that their product was knowingly contaminated, saying that the chemical signatures of natural herbal compounds may mimic prescription drugs. Some observers also suspect dirty tricks. 'We don't have complete control of the supply chain,' said BotanicLabs in May.
But, within a month, the firm had closed down. PC-Spes is no more.
'This is a tragedy,' says Frank Wiewel of People Against Cancer. 'It's signed the death warrant for 15,000 men worldwide whose disease has been kept at bay by PC-Spes.'