Prime minister "joins the club" of Israelis with most common male cancer

2,250 new cases are diagnosed and 380 men die of it every year.

By JUDY SIEGEL-ITZKOVICH
Prime Minister Ehud Olmert, 62, is one of the six Israelis who are informed on an average day that they have prostate cancer - the most common malignant tumor in men in this country. According to the Israel Cancer Association (ICA), which has for some time been planning a symposium for prostate cancer patients at Kfar Hamaccabiah on November 15, 2,250 new cases are diagnosed and 380 men die of it in Israel every year. US presidential candidate and former New York mayor Rudolph Guiliani is a survivor, and former French president Francois Mitterrand, in whom it was diagnosed at a late stage, died of the disease. The main function of the walnut-sized prostate gland, which is part of the male reproductive system, is to store and secrete a clear, slightly alkaline fluid that comprises 10 percent to 30% of the volume of the seminal fluid that, along with sperm, constitutes semen. The rest of the seminal fluid is produced by the two seminal vesicles. The prostate also contains some smooth muscles that help expel semen during ejaculation. To function properly, the gland requires male hormones, the main one is testosterone, which is produced mainly by the testicles. But ironically, while testosterone is needed by the prostate, it can also be its downfall -- as many years of exposure to testosterone is one of the causes of prostate cancer. The longer the exposure, the higher the risk, so older age is a risk factor. But having a first-degree relative (father, son or brother) who had prostate cancer is also a danger, as family history increases the risk of contracting it. So does smoking (Olmert is well known to be a cigar smoker), and obesity, eating overly fatty food and drinking excessive amounts of alcohol are also believed to increase risk. The main symptoms are difficulty or pain in urinating (although frequent urination ironically can also be a sign), blood in the urine or semen and a drastic decline in sexual function. Dr. Avivit Neumann, an oncologist who specializes in cancer "from the waist down" at Meir Medical Center in Kfar Saba, told The Jerusalem Post after Olmert's press conference that "I am sure he will be healthy. It was diagnosed at a very early stage. I welcome his openness in telling the whole country and the world." She added that Israel has excellent urological surgeons who perform radical prostatecomies -- the surgical removal of prostate glands. It is performed here as retropubic open surgery, in which the surgeon removes the whole gland through a single incision in the lower abdomen about 12 centimeters long. But in some countries abroad, especially France, urologists have begun performing it by laparoscopy (keyhole) surgery in which some five cuts are made. In this more challenging technique, the surgeon makes five small incisions and uses a tiny camera and specialized instruments to remove the prostate. In an even newer laparoscopic technique, the surgeon removes the prostate with the help of several robotic arms that mimic his hand movements and allow for more precision. There is a surgeon in Holland who is performing "enucleation" of the prostate, in which the tumor itself is removed from the gland, while the organ remains intact. But he has performed only a handful of cases. It was not clear why Olmert chose to undergo annual screening for prostate-specific antigen (PSA) and other routine tests at Sheba Medical Center at Tel Hashomer, where his microscopic tumor was discovered, rather than at Hadassah Medical Center in Jerusalem, where he lives and where his predecessor Ariel Sharon was treated for his strokes. Some observers suggested that Olmert preferred to go out of town to preserve his privacy. Neumann said that complications of radical prostatecomy include temporary or permanent incontinence (loss of control of urination and defecation) and impotence. In addition, the patient becomes sterile, so patients may deposit semen in a sperm bank if they want children. "A very good urological surgeon who performs nerve-sparing surgery avoids this complication in 90 percent of cases if the patient doesn't suffer from high blood pressure, diabetes or other conditions," she added. "Sometimes, if the tumor is near the nerve, preserving it could be very difficult. About 2.5% of patients develop mild incontinence and about 0.5% significant incontinence." No long-term drug ingestion is required after prostate surgery. Sheba urologist Dr. Ya'acov Ramon, who appeared at the press conference along with the prime minister's personal physician, Dr. Shlomo Segev of Sheba, will apparently be the one to perform Olmert's operation within a few months. He said that after hearing his options, Olmert decided to have the tiny tumor removed in surgery rather than just wait to see if it developed or to undergo chemotherapy or radiotherapy instead. Olmert will also decide if the anesthesia will be regional (an epidural) or general that puts him out. Prostate surgery patients usually stay in the hospital for about three days. Although biennial mammography screening of women for breast cancer is universally accepted, testing all men over 50 for their prostate-specific antigen (PSA) count -- the level of a component in the blood naturally found in semen and produced by the prostate -- is not accepted, as it has not been proven to save lives. It costs the health fund only some NIS 16, but there are men with high PSAs who don't have prostate cancer and others with low PSAs who do have it. The survival benefit is not statistically significant. Some men have high PSAs because of benign inflammation of the prostate, which causes annoying symptoms but is not cancerous. ICA director-general Miri Ziv said that her association, just like the American Cancer Association, recommends that all men over 50 and those with a family history or risk factors for prostate cancer consult with their physician about whether to undergo testing. "It can save a life, but it can also make a person miserable. Researchers are trying to refine parameters to learn who is at risk. Overdiagnosis and performing biopsies unnecessarily can cause harm. Only 16% of men with prostate cancer will have symptoms, and only six percent will die of it. As it is a slow-growing cancer, many men with the tumor will die from another cause without knowing they have it. We are not for automatic screening. We have held workshops for doctors to keep them informed." Over 500 men had registered for next month's Kfar Hamaccabiah symposium, but due to Olmert's announcement, the ICA expects many more will want to attend. "It is very good that the prime minister spoke openly," said Ziv. "I know of many well-known people who kept their prostate cancer a secret. Men should consult with their doctors and get advice. What they do is up to them." The Israel Medical Association wished Olmert a "quick recovery" and congratulated him on his "courage" for announcing his diagnosis to the public. It added in a statement that suitable state measures are needed to determine the medical condition of a prime minister and inform the public. "The decisions of national leaders can decide the fates of many people and sometimes of the whole nation. Therefore, the leader must forgo in advance some of his privacy, including the part relevant to his health," the IMA said. His personal physician owes his first allegiance to his patient, it said, and he should not be put in the position of a conflict of interest between the patient's privacy and proper disclosure to the nation. "Therefore, means are needed to examine the prime minister's medical condition and transmit relevant medical information to the public." Dr. Eric Klein, head of urologic oncology at the Cleveland Clinic's Glickman Urological and Kidney Institute in the US, said that "when opting for prostatectomy, it's important that you not only know your surgeon's experience, but also understand the risks and side effects of surgery and your long-term outlook." A recent study he conducted found that patients of surgeons who have performed more than 1,000 prostatectomies are about 10% more likely to be cured of their cancer than those whose surgeons have done 250 to 999 of the procedures and 30% more likely than those whose surgeons have done fewer than 50. "Most patients can expect a return to regular physical activity within a few weeks, regardless of how the surgery's done, and good results with continence and potency, according to Klein. More information on prostate cancer can be obtained (in Hebrew) at www.cancer.org.il.