Should you put your sex life before beating cancer
Peter Gordon felt perfectly well when he underwent a full health check after moving to a new GP practice.
Despite having no symptoms, a simple blood test revealed he had raised levels of an enzyme linked to prostate cancer, and he was soon undergoing surgery to remove his prostate gland.
Would the cancer have killed him No one knows for sure, but research suggests that most prostate cancers are so slow-growing that men will die from other causes, such as heart disease or another cancer, or even old age.
'It wasn't just sex that suffered. He no longer put a protective arm around my shoulder and stopped holding my hand,' said Andrea Gordon of her husband Peter
But what is certain is that the fallout of surgery nearly ended 72-year-old Peter’s marriage.
A healthy sex life had always been important to his relationship with his wife, Andrea Kon.
But after the operation seven years ago, Peter, a photography lecturer, became impotent and Andrea says her formerly loving husband became a distant stranger.
‘It wasn’t just sex that suffered,’ she says. ‘He no longer put a protective arm around my shoulder and stopped holding my hand.
'It felt as though a coldness was demolishing our relationship; that I was married to a stranger,’ recalls Andrea, who’s 67.
‘Yet when I tried to talk to him about it, he’d say he was too tired.’
Every year, around 35,000 men in the UK are diagnosed with and treated for prostate cancer, making it the most common cancer affecting British men.
Many are told they require surgery to remove the prostate, a walnut-sized gland that sits just below the bladder.
But because the prostate is close to vital organs and nerves, operating carries risks of impotence and incontinence.
Mike Hollingsworth refused to have his prostate removed
Just last month, Mike Hollingsworth, the former TV executive who was married to Anne Diamond, said he’d refused to have his prostate removed because it was likely to mean the end of his love life.
‘I would rather lead a full life in every way than simply limp on; limp being the operative word,’ he said.
Weighing up the pros and cons of getting tested for prostate cancer is becoming one of the most difficult decisions facing healthy middle-aged men today.
And now a growing number of experts are warning that thousands of men like Peter risk suffering severe side-effects — notably sexual dysfunction — as a result of treatment for a disease that may never have posed a real threat to their lives.
Just three in every 100 men over the age of 50 are at risk of dying from the disease, yet around eight out of ten men are left impotent after surgery while three in every 20 men have bladder problems.
Prostate cancer is often initially diagnosed through a PSA (prostate specific antigen) test.
This simple blood test, first introduced in the U.S. in the mid-1980s, picks up abnormally raised levels of a naturally occurring enzyme.
Raised levels are a signal that the prostate is unhealthy, though most often as a result of one of a number of relatively common benign disorders, such as an inflamed or enlarged prostate, and more rarely as a result of cancer.
The test is available on the NHS to any man over 50 who requests it — and it may seem to be something that every responsible man should have.
Indeed, in the U.S., the test has been done routinely in men aged 50 to 75 since a prostate cancer screening programme was introduced in 1988.
Now, however, U.S. experts are publicly expressing hostility to the screening programme.
It’s been condemned by one of the PSA test pioneers as ‘a huge public health disaster’, and in October, the authoritative Preventive Services Task Force (an independent panel that reviews preventative health care schemes) controversially recommended that men do not undergo routine prostate cancer screening.
The reasons for America’s unravelling faith in this preventive programme are based on solid medical evidence — and raise important questions for men in Britain, too.
For a start, a PSA test provides far less information than many realise.
Not only does it fail to distinguish between benign prostate disease and cancer, it also cannot tell the difference between the vast majority of cancers which are slow-growing and will never cause harm, and the much smaller number of aggressive cancers that kill.
Indeed, large numbers of men — one in three in their 40s, rising to seven out of ten in their 80s — have cancerous tissues in their prostate, and for the majority this will cause no harm at all.
For every man saved as a result of having a PSA test, another 48 men are treated unnecessarily because they don’t have life-threatening cancer, according to a major study published in 2009 in the New England Journal of Medicine.
The study followed 182,000 men aged 50 to 74 in seven European countries who were screened for prostate cancer.
The findings have shaken the clinical world: not only does it prove that the PSA test saves just a few lives among those who take it, but the test also brings ‘a boatload of hassle factors and fear, some unnecessary treatment, some resulting complications, and even a very few deaths,’ as Dr Gilbert Welch, professor of medicine at the authoritative Dartmouth Institute for Health Policy & Clinical Practice, put it.
Peter Gordon’s experience seems to bear this out. A urologist friend recommended that he ignore his first PSA test, which came back with a high score.
His friend told him he believed such tests to be ‘unreliable’.
Peter’s second test, two years later, showed that his PSA levels had fallen by nearly half.
However, after suffering symptoms of painful urinary retention in 2003, he had a biopsy, whereby a small amount of the tumour is obtained for investigation via a ‘gun’ inserted into the rectum that fires needles through the rectal wall.
It doesn’t sound pleasant, and according to a multi-centre study published in the British Medical Journal last week, it sometimes isn’t.
This found one in four men complains of pain and infection as well as bleeding a week after the procedure. Two weeks after the test, one in five men say they would not have another such investigation.
For every man saved as a result of having a PSA test, another 48 men are treated unnecessarily because they don't have life-threatening cancer
‘This is the very first study where men have been asked to describe their experience of having a biopsy, and GPs should consider discussing these concerns with male patients in the context of having a PSA test,’ says lead researcher Dr Derek Rosario, senior lecturer in cancer studies at the University of Sheffield.
Furthermore, the biopsy itself is ‘relatively inaccurate’ as a diagnostic tool, says Dr Mike Kirby, Professor of Health and Human Sciences at the University of Hertfordshire.
But it’s what happens next to the 48 men who undergo unnecessary and invasive procedures for every one whose life is saved that is the real cause for concern.
A substantial number are recommended ‘active surveillance’, involving regular PSA tests and an annual biopsy.
This may seem the easy option compared with surgery. But, in practice, it can cause high levels of anxiety.
‘Most men don’t like living with uncertainty and tend to want to get the treatment over and done with,’ says Dr Kirby.
Nor is it just the men themselves who think like this.
Tim Glynn, an American lawyer who had a biopsy in 1997, following a PSA test.
Diagnosed with prostate cancer at the age of 47, he opted for ‘watchful waiting’ on the advice of an expert in the disease.
But the decision caused mayhem in his life, since his wife and colleagues were ‘scared witless’ and insisted that he get treated immediately.
Dr Michael Rawlins, chairman of the National Institute for Health and Clinical Excellence (NICE), thinks such a dilemma is best avoided.
He recently revealed he’d been given a PSA test several years ago without his knowledge. He had a biopsy, which turned out to be negative.
‘But if cancer had been detected, I would have faced an awful choice,’ he says.
‘Would I want to have it removed, or would I have gone for watchful waiting, with all the anxieties of that’
Dr Rawlins no longer has PSA tests.
The consequences of PSA testing were unequivocally spelt out by research published in September.
This found that while 17 per cent of men were impotent before having their prostate removed, the numbers had risen to 65 per cent two years after the operation.
Every year, 5,000 British men undergo prostate removal, and Peter Gordon was one of them.
After he was found to have a ‘moderately aggressive’ form of prostate cancer, the decision was made to carry out a prostatectomy — removal of the prostate gland.
Other treatments, depending on severity, include radiotherapy or brachytherapy, in which tiny radioactive seeds are implanted in the prostate gland (this is the treatment that Mike Hollingsworth is having).
Both techniques can cause similar side-effects to surgery.
After his operation in 2004, Peter was discharged from hospital with advice from the ward sister ‘to resume normal lovemaking as soon as he felt like it’, recalls Andrea.
Any problems, she told him, could be sorted by reading erotic literature or renting a blue video.
But to their dismay, the couple discovered Peter was impotent. They approached their GP and Peter was prescribed Viagra. But sadly it wasn’t successful, says Andrea.
‘Cialis (a drug similar to Viagra) worked beautifully for several years. In fact, it worked until a few months ago when Peter started suffering headaches and nausea.
'We’ve since maintained our strong and loving relationship with hugs and kisses.’
Impotence is just part of the story, according to Sandy Tyndale-Biscoe, chairman of the Prostate Cancer Support Federation, an organisation that represents 47 local patient support groups.
While erectile dysfunction can be helped with Viagra-type drugs, other consequences cannot be treated.
‘The prostate gland is a vital part of a man’s sexual apparatus, and removing it means that ejaculation is impossible,’ says Mr Tyndale-Biscoe.
‘For many men who’ve been treated for prostate cancer, myself included, that involves a huge change to the intensity and enjoyment of sex.’
Dr Kirby says far too many clinicians will ask their patients, ‘Is everything all right’, and then discharge them without any further advice or support. ‘It is a dreadful omission,’ he adds.
Other couples have a better experience. Salesman Gary Hazlehurst, who lives in Wolverhampton, had a prostatectomy in 2008 at the age of 48 after finding blood in his urine. Tests then showed the presence of a large, aggressive tumour.
‘As I gradually began to recover from the operation and went back to work, my wife and I decided to try being sexual and took Levitra, a drug like Viagra, and it was very frustrating when nothing happened and really terrible to think that we could never have sex again,’ recalls Mr Hazlehurst.
Fortunately, he was still in touch with ‘an amazing, committed hospital team who from the start talked about sexual function in a very calm, matter-of-fact way.
‘When Levitra didn’t work, I was able to try another drug, which works sufficiently for us to be able to have sex regularly. It isn’t the same as before, but I’m glad to say it’s very enjoyable.’
Neither Gary nor Peter regrets having the surgery. But given the risk of severe side-effects and expert opinion swinging against the PSA test, should we be ditching it
Far from opposing PSA testing, patient groups in the UK are keen to improve the current approach.
‘It’s not the test that’s rubbish: it’s what’s done with the result,’ says Mr Tyndale-Biscoe.
‘The PSA test is a very good indicator of poor prostate health, and something every man over 50 should feel is the right thing to do.
'But you don’t need to rip out the engine of a car every time there’s a blip with the oil drive.’
As chairman of the Prostate Cancer Support Federation, he is working with the University of Warwick and the Institute of Cancer Research to establish a better decision-making process.
Known as ‘Riskman’, the study aims to enable GPs to provide much more accurate ‘risk-based’ screening for prostate cancer, where the PSA test will be only one in a range of risk factors — including age, family history, urinary symptoms, results of a rectal digital examination, and ethnicity. It is hoped this will avoid any unnecessary biopsies and treatment.
‘Of course we need improvements in the way care is provided,’ adds Mr Tyndale-Biscoe.
‘But my view is that every man should have the PSA test and everything that is recommended after that.
'It’s far better to put up with side-effects than risk dying from prostate cancer,’ he says.
The NHS Cancer Screening Programme has published a guide on PSA testing, visit www.cancerscreening.nhs.uk/prostate/prostate-patient-info-sheet.pdf