Prostate Cancer Hits One in Six Men, Fuels Angst Over Testing
Aug. 8 (Bloomberg) -- One day in Chicago, Dave Bigg is about to drink a
few beers with his buddies and divvy up Cubs baseball tickets when his
cell phone rings. It's the doctor, and he doesn't like what he sees.
Bigg's biopsy looks bad. The cells from his prostate are warped and
buckled. It's cancer.

Bigg can't believe what he's hearing. He's 46 years old. He doesn't
look sick. He doesn't feel sick. Hell, he feels great -- he's training
for a triathlon. ``It was like a punch in the stomach,'' Bigg recalls.

Bigg phones his wife, Melissa. She's about to have lunch with friends
at the Cherry Pit Café, near their home in Deerfield, Illinois. She
sits in her car and screams. Cancer? How can my husband have cancer?

``You can't wrap your mind around it,'' she says. ``You look at this
healthy, energetic guy, and you can't believe it.''

This year, more than 230,000 men in the U.S. will get bad news like
Bigg's, according to the American Cancer Society. And, like him, these
men will face difficult choices about what to do next. Out of the blue,
a diagnosis of prostate cancer will throw them into the middle of a
raging medical debate over how to treat this disease -- or whether to
treat it at all.

For some, the decisions they make will determine whether they live or
die. For others, their choices will mean the difference between an
active sex life and impotence.

One man in six in the U.S. will be diagnosed with prostate cancer
during his lifetime, the ACS says. After age 40, the danger grows with
each passing year. If you live long enough, the question becomes when,
not if, you're likely to get this cancer. Autopsies show that 30
percent of U.S. men over 50 have at least some malignant cells in the
gland. For men older than 80, that figure climbs to 80 percent,
according to the ACS.

Hard to Treat

Prostate cancer kills one in 34 men in the U.S. Virulent tumors often
spread to the bone. More than 27,000 U.S. men are likely to die from
prostate cancer this year, the ACS says. This form of cancer is more
common in men than any other cancer aside from that of the skin. It's
more prevalent than cancer of the lung, which strikes one man in 13; of
the colon, which hits one in 17; or of the bladder, which besets one in
28, according to the National Cancer Institute.

Prostate cancer is difficult to treat without life-changing side
effects. The gland, which helps produce semen, is lodged deep in the
abdomen, just below the bladder. It surrounds the urethra, through
which urine and semen flow, and borders the rectum. The nerves that
control erections lie along the prostate like delicate wires glued to a
golf ball. Cut them, and a man becomes impotent. Sometimes, drugs like
Viagra can help, provided at least one of the nerves remains intact.

Slow Tumors

Most prostate tumors are slow growing and, as cancers go, relatively
benign. Some are fast moving and deadly. Doctors can't always determine
which are which.

``We have a difficult time telling which cancers are aggressive and
which are not,'' says Dr. Tomasz Beer, director of prostate cancer
research at the Oregon Health & Science University Cancer Institute in
Portland.

Statistically, prostate cancer is less lethal than many other forms of
cancer. It accounts for 9 percent of U.S. cancer deaths, whereas lung
cancer accounts for 31 percent, according to the ACS.

If the doctor says you have lung cancer, you usually have one course:
surgery, fast. If he says you have prostate cancer, your choice may not
be so apparent. Many men who learn they have prostate cancer are left
wondering how to treat it. Surgery, radiation therapy, high-intensity
ultrasound -- those are some of the options. Another is to wait, watch
and hope the cancer never spreads, a strategy known as active
surveillance.

Choose surgery or radiation, and there's a chance you'll end up
impotent. Wait and watch, and there's a chance you'll die.

Bad Odds

Undergoing a prostatectomy, the surgical removal of the gland, meant
impotence for about three in four men as reported in a study published
in the Journal of the National Cancer Institute in September 2004. One
man in seven was incontinent five years after the operation.

With radiation, the odds of impotence were about the same: 73 percent,
according to this study. The incontinence rate was lower, at 4.9
percent. Top surgeons report outcomes that are much better.

Men who undergo treatment get no guarantee their cancer won't return.
As many as 40 percent of men relapse, says Dr. Bruce Montgomery, an
oncologist at the Seattle Cancer Care Alliance.

Given all this, some doctors advise patients to do something radical in
modern cancer care: Wait and see. Dr. Laurence Klotz, a professor of
surgery at the University of Toronto, has been monitoring 231 men for
about seven years. If their cancer gets worse, he treats them. About
two-thirds of these patients are still waiting. Three have died of
their disease.

Worth the Wait

Over time, about 1.5 percent of men who could have been saved with
surgery or radiation but chose active surveillance instead will
succumb, Klotz says.

``I have no doubt that we will lose the occasional patient who is
curable,'' Klotz, 53, says in an e-mail.

For most men, the chance of dying from prostate cancer is so small --
and the odds of impotence and incontinence after surgery or radiation
are so great -- that active surveillance is worth the risk, he says.

How do you crunch all these numbers? Many men wind up plugging them
into computer programs called nomograms -- this many billionths of
grams, that degree of cell deformity -- to try to predict how lethal
their cancer is and find the best treatment. They must ask themselves
hard questions. Am I willing to risk dying to preserve my sex life? Can
I afford to wait?

Lucky

Bigg, who makes his living trading corn options on the Chicago Board of
Trade, says he's one of the fortunate ones. A blood test during a
routine physical provided the first, vital clue that something was
wrong. His blood showed elevated levels of prostate-specific antigen, a
marker for cancer.

That first PSA test led to a second, which led to a biopsy, which
uncovered a dangerous tumor. Bigg underwent a prostatectomy. In the
months following his surgery, he had a little trouble controlling his
bladder. He says he's fine now.

Bigg says his erections aren't what they used to be but that his sex
life is good. Now, at 49, he is cancer free. ``I was lucky,'' Bigg
says. ``I didn't have a choice.''

Weighing Advice

Men such as Will Weinstein, whose cancer wasn't as severe as Bigg's,
must weigh conflicting medical advice and balance the risks and
benefits of various treatments. Weinstein, diagnosed at 56, spent seven
months interviewing 44 doctors before deciding on brachytherapy, which
involves implanting radioactive pellets in the prostate. Ten years on,
Weinstein, a former hedge fund manager who now teaches ethics at the
University of Hawaii in Honolulu, says he can get an erection and
control his bladder.

He says that if he got the same diagnosis today, he might try active
surveillance, provided he could stomach living with cancer.

Jim Hurley, 53, has seen more than his share of this disease. Prostate
cancer killed his father at the age of 72 and struck two of his five
brothers. Both brothers have had prostatectomies, and both have
survived. When his time came, Hurley, a plasterer from New Jersey,
turned to the Internet and discovered high-intensity focused
ultrasound. HIFU hasn't been approved by the U.S. Food and Drug
Administration, and some surgeons scoff at it.

Hoping to avoid impotence, Hurley flew to Canada for HIFU. He says he
made the right choice: He can have sex and hold his urine.

Watching and Waiting

And then there's Bill Lewis, 64. A former partner at McKinsey & Co.,
Lewis took what some surgeons call the most radical route of all: He
monitors his condition with twice- yearly PSA tests and annual
biopsies. That's it. No surgery. No radiation. No HIFU. His cancer
seems to have disappeared.

On the following pages, these four men share their private battles and
intimate fears. They're speaking out because other men will face what
they have.

A fifth man, one who's well known to Wall Street, shares his thoughts
on cancer, too. His name is Michael Milken. The onetime junk bond king
of Drexel Burnham Lambert Inc., Milken has raised more than $300
million for prostate cancer research. His Santa Monica,
California-based Prostate Cancer Foundation is financing the search for
new, more-accurate tests for deadly tumors. Until researchers find one,
Milken, 60, urges men to get a PSA test.

Doctors Debate

These five stories tell a larger one. Within the U.S. medical
community, sometimes within the same hospital, a debate is taking shape
that may upend prostate cancer care. Doctors no longer agree on how to
diagnose this disease or what to do about it.

In medical terms, the PSA test -- which doesn't test for cancer but
rather for a substance associated with it -- is sensitive and
nonspecific. Translation: The test often lies. An infection or having
sex before a PSA test can artificially inflate your result. The U.S.
Preventive Services Task Force, a division of the U.S. Department of
Health & Human Services, says PSA screening often leads to
anxiety-provoking false positives and unnecessary biopsies. Neither the
agency nor the ACS recommends that doctors require routine PSA
screening. Some doctors do; others don't.

Head in Sand

Dr. Patrick Walsh of Johns Hopkins University School of Medicine in
Baltimore, who invented modern prostate surgery, says the PSA test
saves lives. The U.S. death rate from prostate cancer fell 27 percent
from 1991 to 2001 because more men are getting tested, says Walsh,
author of ``Dr. Patrick Walsh's Guide to Surviving Prostate Cancer''
(Warner Books, 2001).

Bigg's surgeon, Dr. William Catalona of Northwestern University
Feinberg School of Medicine in Chicago, has performed more than 4,500
prostatectomies and is a vociferous proponent of early screening. In
1991, he showed that PSA could be used to screen for prostate cancer.

Catalona and Walsh say men should get their first PSA test at 40.
``It's such an easy thing to do,'' Catalona, 63, says. ``Otherwise,
you're sticking your head in the sand.''

`Apple Pie'

Dr. James Talcott disagrees. A professor at Harvard Medical School in
Boston, Talcott, 54, says PSA tests are so unreliable that men should
avoid them completely. Talcott, an oncologist who studies medical
outcomes, says he doesn't get PSA tests and probably never will. (He
says he does get regular rectal exams.)

PSA tests often prompt men to undergo surgery or other treatments that
leave them impotent or incontinent, even when there's little chance
that prostate cancer will kill them, Talcott says. Talcott knows this
view goes against the grain. ``Early detection is like apple pie and
motherhood,'' he says.

Doctors are forever telling us to get checked for hypertension and high
cholesterol. It's hard to imagine a woman refusing a mammogram because
she'd prefer not to know she has breast cancer. And Katie Couric
underwent a colonoscopy on NBC's Today in 2000 to raise awareness about
colon cancer screening after her husband, Jay Monahan, died of that
disease at 42.

Lewis's doctor, H. Ballentine Carter of Johns Hopkins, says many
prostate tumors are best left untreated. Often, cancers never leave the
prostate, where they pose little threat, Carter, 53, says. ``Fifty
percent of the cancers we identify are low risk,'' says Carter, who
monitors 350 patients, including Lewis.

Active surveillance isn't about ignoring prostate cancer, Carter says.
He calls his program ``expectant management with curative intent'' to
reflect his aim for a cure.

To Know or Not to Know

Many men would live just as long -- and be happier -- if they never
found out they had prostate cancer, OHSU's Beer, 41, says. Too many men
are risking impotence and incontinence to treat tumors that may never
kill them, he says.

``If you had a cancer that was never going to kill you, you'd be better
off not knowing about it,'' Beer says.

Prostate cancer doesn't care if you're rich or famous. The disease has
struck Andy Grove, former chief executive officer of Intel Corp.; John
Kerry, the U.S. senator and 2004 Democratic presidential candidate; and
Rupert Murdoch, CEO of News Corp. Prostate cancer has killed Wayne
Calloway, chairman of PepsiCo Inc.; jazz flutist Herbie Mann; Steve
Ross, chairman of Warner Communications Inc.; and rock musician Frank
Zappa. It claimed Earl Woods, golfer Tiger Woods's father, in May.

Genes Implicated

No one knows what causes prostate cancer. Dr. Bill Isaacs, a professor
of urology and oncology at Johns Hopkins, says men who are stricken
relatively young probably inherited rogue genes from their parents. The
faulty code predisposes them to the disease. If a man's father or
brother has had the disease, the odds that he'll get it narrow to one
in three, according to the ACS.

A high-fat diet may foster the disease, Carter says. Fats seem to
prompt tumor cells to divide faster.

In almost all men, the prostate tends to swell with age. Sometimes the
growth reflects what's called benign prostatic hyperplasia, a
non-cancerous enlargement of the gland.

Dr. Peter Scardino, chairman of surgery at Memorial Sloan- Kettering
Cancer Center in New York and co-author, with Judith Kelman, of ``Dr.
Peter Scardino's Prostate Book: The Complete Guide to Overcoming
Prostate Cancer, Prostatitis and BPH'' (Avery, 2005), says testosterone
is the likely culprit.

Castration Cure

Prostate cancer feeds on the male sex hormone. Until the 1980s, doctors
castrated men to starve their cancers of testosterone. Today, they use
drugs in severe cases to achieve the same results.

Bigg says he thought he was too young and healthy to get prostate
cancer. Until he got that call from his doctor, in April 2004, Bigg
says he never dreamed he'd be among those afflicted, even after his PSA
readings came back high.

Bigg is quiet for a guy who makes his living shouting ``buy'' and
``sell'' on the floor of the CBOT. He's 5 feet 11 inches (1.8 meters)
tall, weighs 200 pounds and is barrel- chested from a lifetime of
swimming. Bigg is bald, with a fringe of close-cropped hair. In
profile, he looks a little like Bruce Willis. On the CBOT floor, he
wears a lightweight blue trading jacket and carries a stack of folded
papers with calculations for options prices -- his ``shopping list,''
he calls it.

Bigg's story begins in 2003. Melissa Bigg, now 52, had taken a
part-time job at a local Starbucks, which offered better health
insurance than the coverage Bigg was buying for the family. He went in
for a physical, grudgingly. He'd seen a doctor once in the previous 20
years, for strep throat.

PSA Test

During the exam, the doctor drew blood for a PSA test. PSA normally
leaves the prostate through ducts leading to the urethra. Cancerous
prostate cells leak above-average amounts of PSA into the bloodstream.
PSA is measured in nanograms, or billionths of a gram, per milliliter.
For a man of 45, a PSA reading of more than 2.5 ng/ml is cause for
concern, Walsh says.

Bigg's PSA reading came back at 3.6. He says he wasn't alarmed. He'd
been biking hard to train for a triathlon, which he'd heard could
inflate PSA numbers. ``I was ready to blow it off,'' he says.

Then, four months later, Dave's younger brother Steve got wind of his
PSA results. Steve happens to be a urologist. He told Dave to get
tested again.

This time, Bigg's results were even worse -- around 4 ng/ml. Bigg's
doctor told him to get a biopsy, and he agreed. Working on the CBOT has
taught him a few things. ``I'm a believer in the trend,'' he says.

Prostate Biopsy

In a biopsy, a doctor harvests cells by inserting an ultrasound probe
into the rectum, along with a gun that shoots a hollow needle through
the rectal wall and into the prostate. The needle returns a core sample
of tissue about a half inch (15 millimeters) long. Most doctors take a
dozen cores.

A biopsy hurts. ``They stick a staple gun in your a.s,'' says Charles
``Chip'' Baird, managing director of North Castle Partners LLC, a
Greenwich, Connecticut-based private equity firm. Baird, 53, had his
prostate removed in 2004.

Bigg's doctor sent the sample to a pathologist, who examined the cells
under a microscope. Pathologists look for cells that are misshapen. The
more deformed those cells are, the worse the cancer is. Pathologists
assess the patterns and assign what's called a Gleason grade, from 1 to
5. The score is named for Dr. Donald Gleason, the pathologist who
devised this system in 1966.

A Gleason grade of 1 indicates the malignant cells are close to normal.
A score of 5 means the cells are almost unrecognizable as prostate
cells -- a sign of severe cancer.

Gleason Sums

Most men have cells that fall into at least two categories, so
pathologists add the grade for the most-prevalent type to the grade for
the second-most-prevalent type for a combined Gleason score, or sum.
Hence, a 2 is the best Gleason score (1 + 1), and 10 is the worst (5 +
5).

Because the first number in the Gleason score indicates the more
prevalent cell type, you're better off if the first number is the lower
of the two. A Gleason 4 + 3 is worse than a Gleason 3 + 4, for example.
In the latter, most of the cells are Gleason 3, not 4. As a rule, a
Gleason sum of 6 or less means that the cancer is treatable. A sum of 8
or more suggests cancer cells have escaped the prostate.

Bigg's Gleason grades were bad: 4 + 3, for a combined score of 7. When
Bigg and his wife got home that day, they held each other. Dave called
his brother and asked his advice.

``I told my brother, `If you don't have surgery, you're crazy,''' Steve
says. ``Dying of prostate cancer is one of the worst deaths you can
possibly have.''

`The Man'

Steve recommended Dave see Catalona at Northwestern, who removed the
prostate of New York Yankees Manager Joe Torre in 1999. Steve Bigg had
a connection, too. He'd trained under Catalona. ``He's the man,'' he
says.

Prostate surgery takes practice. Results vary from surgeon to surgeon,
and it's not always easy to get in to see a top doctor. No U.S.
government agency or organization tracks how many of the patients a
doctor treats end up impotent and incontinent. Patients have to trust
what their doctors tell them.

Catalona says about 85 percent of his prostate surgery patients in
their 50s can get erections afterward. Walsh at Johns Hopkins says men
who come to him in their 40s and 50s have a 90 percent chance. ``It can
take a little Viagra,'' says Walsh, 68.

Get It Out

Bigg told Catalona that he wanted the cancer out, whatever the cost. He
says he cared more about surviving than he did about sex. He and his
wife have two grown children, ages 22 and 18, and didn't want any more,
so Bigg didn't bank his sperm. Men still produce sperm after a
prostatectomy, but the sperm no longer reach the urethra, the canal
that runs through the penis.

Bigg had to wait for the biopsy holes in his prostate to heal before
Catalona could operate. ``That's the longest two months of anyone's
life,'' Melissa Bigg says.

Bigg hit the pool, hard. Just before surgery, he placed second in his
age group in the 100-yard butterfly in the Illinois Masters Swimming
Association championships. He swam faster than he had in high school.
``What's scary is that you can feel so good and have this,'' Bigg says.

Bigg went in for surgery on a Monday in May.

Men who opt for surgery have Walsh to thank. The first documented
prostatectomy was performed at Johns Hopkins in 1904. For the next 78
years, the surgery virtually guaranteed that a man would never have
intercourse again. Many became incontinent, and 2 percent died within
30 days from loss of blood. Surgeons didn't know where the erectile
nerves were. Nor had anyone completely mapped the veins around the
prostate.

Mapping Nerves

Then Walsh came along and traced the erectile nerves in stillborn
fetuses, in which the nerves are easier to see. He also figured out how
to tie off veins that lie along the prostate, limiting blood loss. In
March 1982, he removed the bladder and prostate from a 67-year-old man
with bladder cancer. Walsh had never seen a patient remain potent after
the procedure. This man got an erection 10 days later.

Since then, Walsh has done 4,000 nerve-sparing prostatectomies. He says
he's never been bored. ``There is much more variability to the male
anatomy than there is to every golf course in the world,'' Walsh says.
A prostatectomy is major surgery and often runs five hours or more.

Halfway through Bigg's operation, Catalona called Melissa Bigg and told
her things looked good. Bigg's cancer hadn't spread. For the first time
in months, she felt relieved.

Not Like 16

Bigg was discharged from the hospital that Wednesday. He wore a
catheter for a week while his urethra, which has to be cut, healed. He
took a month off from work to recuperate. For the first three months
after his surgery, Bigg leaked urine when he screamed on the trading
floor. Since then, he's had no problems, he says.

Bigg and his wife say the surgery hasn't diminished their sex life.
``Erections aren't what they were like when I was 16, but they weren't
anyway,'' Bigg says.

``I have no complaints,'' Melissa Bigg says.

Men whose cancer is less dangerous than Bigg's must grapple with
conflicting opinions and weigh the potential risks and benefits of
various treatments.

When Weinstein, the former hedge fund manager, was diagnosed 10 years
ago, his Gleason score was a moderate 6: 3 + 3. He concluded that his
cancer didn't pose an immediate threat to his life. Divorced and
interested in a new relationship, he didn't want to risk impotence.

Hospital Visits

Weinstein set out to learn as much as he could. He had the resources:
After working as a managing partner at Montgomery Securities, the San
Francisco brokerage that's now part of Bank of America Corp., he became
a financial adviser to the billionaire Pritzker family, which controls
the Hyatt hotel chain. These days, Weinstein splits his time between
San Francisco and Honolulu.

``I drove people crazy,'' Weinstein says. ``I spent seven months on the
phone and on planes.'' He still has the rainbow of colored ID cards
from all the hospitals he visited.

Weinstein says some of the surgeons he talked to didn't impress him. In
a 79-page account of his experience that he shares with men who call
for advice, he says one doctor talked to him on the phone for all of 15
minutes before recommending surgery.

Weinstein spoke to Intel's Grove, who chose to treat his cancer by
having radioactive seeds injected temporarily in his prostate.
Weinstein says Grove told him that the survival statistics were skewed
in favor of surgery because men whose cancer had breached the prostate
-- harder cases, in general -- often ended up being treated with
radiation.

Clueless Docs

Weinstein's conclusion, after visiting 30 doctors in the U.S. and
corresponding with 14 abroad: ``There are 8,500 urologists in the U.S.,
and 8,200 don't have the faintest idea what they're talking about.''

Weinstein opted for permanent radioactive seeds. The seeds are actually
titanium capsules the size of rice grains, with bits of radioactive
iodine, palladium or cesium inside.

Radiologists image the prostate with ultrasound and then use a computer
to figure out how many seeds they need to radiate the gland. As many as
150 are implanted, says Dr. Peter Grimm, co- founder of the Seattle
Prostate Institute. They're placed through a needle inserted near the
scrotum.

The advantage of seeds, Grimm says, is that patients are on their feet
the next day. Continence isn't a problem because the internal urinary
sphincter -- one of two sphincters that control urination -- isn't
removed, as it is in surgery. Urination can be frequent or urgent for a
few months, but then it returns to normal.

No Magic Bullet

What's more, 80 percent to 90 percent of patients who choose seeds are
usually able to have sex afterward, Grimm says. Their erections are
unlikely to be as good as they had been before. ``There's nothing
perfect,'' Grimm, 54, says.

Grimm and his partners were among the first to use seeds, in 1986. One
of their early patients was Grimm's father, Huber, in 1988. He had a
Gleason grade of 6 and a palpable tumor. Almost 20 years later, Grimm's
dad is still cancer free.

One of Grimm's partners, Dr. John Blasko, treated Weinstein. Everything
went smoothly, Weinstein says. When a friend -- the funniest person he
knows -- showed up afterward and started cracking jokes, Weinstein
laughed so hard that one of the seeds dislodged and passed out in his
urine. He found it in a screen used to catch such errant seeds and put
it in a special radiation-proof capsule that Dr. Blasko had given him.

Weinstein says urination was painful and urgent for about six months.
During that time, he traveled by private jet, rather than on commercial
airlines, on business trips because he was afraid he'd get stuck
waiting to use the toilet. He'd tell his limo driver to take back roads
so he could stop to relieve himself.

Pit Stop

One time, in Sonoma County, California, he asked to use the bathroom in
a convenience store. When the owner refused, Weinstein walked out and
urinated on the side of the building. Today, Weinstein says he's cancer
free, potent and continent.

Hurley had seen prostate cancer kill his father and ravage two
brothers, and he knew he didn't want to go through surgery. When his
time came, Hurley, 53, says an operation seemed extreme. Hurley is 6
feet, wiry and, he says with a laugh, happily divorced. He says he
wasn't ready to risk surgery and not being able to have sex.

``Ripping it out of my stomach seemed like a radical thing to do,'' he
says. ``It's like blowing up a mosquito with a stick of dynamite.''

Trip to Canada

Hurley had to educate himself. ``Before the diagnosis, I didn't even
know what the prostate was,'' he says. He turned to the Internet and
ran across HIFU. These machines use ultrasound powerful enough to
destroy prostate tissue. It works like a magnifying glass focusing
sunlight and is accurate to the millimeter. HIFU is popular in Europe
and is currently undergoing clinical trials in the U.S.

When Hurley told friends he was considering a trip to Canada, where
HIFU is approved, they said he was crazy. ``You'd be astounded by the
resistance,'' he says.

Some U.S. urologists dismiss HIFU. ``I think it's a hammer looking for
a nail,'' Walsh says.

``It's never been tested in a thoughtful clinical trial,'' Scardino
says. ``They don't have any good data. There's a lot of marketing and
hype.''

Dr. John Warner, medical director at Maple Leaf HIFU Co., a Canadian
company that operates an HIFU machine in Toronto, says HIFU is the
future. A urologist, Warner is no stranger to surgery. He's removed 800
cancerous glands.

``It's only a matter of time before this becomes state of the art in
North America,'' Warner, 48, says.

Not Much Data

Because it's so new, fans like Warner have little data with which to
promote HIFU's effectiveness. A study by doctors in Germany, reported
in the journal Urology, showed that 93 percent of men with tumors
confined to the prostate had negative biopsies up to five years after
HIFU treatment. Five years is a short time when dealing with prostate
cancer.

Hurley's urologist recommended surgery or radiation treatment. Hurley
wanted more opinions. A health-care consultant in Seattle, a woman who
had survived breast cancer, reviewed his Gleason scores and recommended
HIFU, the treatment he'd seen on the Internet. ``It sounded so
humane,'' Hurley says.

Hurley flew to Toronto on March 29, a Wednesday. He had a preoperative
appointment shortly after he landed. Maple Leaf HIFU arranged for a
room at the Westin. The next afternoon, Hurley went in. The doctors
gave him an epidural to keep him still and a sedative to make him
sleep. The procedure took just under 2 hours.

The following day, he had an exam and flew home to New Jersey. By
Tuesday, he was back on the scaffolding applying plaster.

Agony

There was one complication. Hurley had to wear a catheter to keep his
urethra clear of dead prostate tissue that might migrate there. Two
weeks after that catheter was removed, a piece of tissue got lodged. He
rushed to Overlook Hospital in Summit, New Jersey; tossed his truck
keys to the parking valet; and waited for three hours in the emergency
room, in agony from being unable to urinate.

Finally, a doctor inserted a new catheter. When Hurley left the next
day, he found the valet had lost his truck. ``It was craziness,''
Hurley says ``But it's a small price to pay.''

Like Hurley and Weinstein, Lewis wasn't about to let the doctors make
up his mind for him.

A Rhodes scholar with a Ph.D. in theoretical physics, Lewis worked for
U.S. Defense Secretary Robert McNamara in the 1960s, trying to figure
out how the U.S. should spend money to win the Cold War. He later
became associate provost at Princeton University. He joined McKinsey in
1982 and became head of the McKinsey Global Institute, the firm's
economic think tank, in 1990.

Up in the Air

When Lewis was diagnosed with cancer, he'd just retired from McKinsey
and was writing a book about why some countries are wealthy and others
aren't. He and his wife, Jutta, had purchased land near Carmel,
California, where they planned to build a house.

``All these plans were up in the air all of a sudden,'' Lewis says.
``It was quite a jolt.''

Lewis is the epitome of a man aging well. He has a head of gray hair,
and he retains a lanky build that helps on the squash court. One of his
biggest worries was that prostate cancer would change his sex life.

``Sexuality is very much a part of personality, and until that dies, I
didn't want to change my personality,'' he says.

Lewis's biopsy suggested his cancer was relatively benign. His
urologist took 14 cores from his prostate, and only one hit cancer. His
Gleason score was a moderate 6. The diagnosis, though better than many,
left Lewis to choose among treatments, all of which had disadvantages.
His doctor recommended a prostatectomy.

Old Microscope

Lewis set out to learn all he could. He got out his kids' old
microscope and looked at slides of his biopsy tissue, comparing it with
samples put on the Internet by Stanford University to see if he agreed
with the pathologist.

He spoke with men who'd had surgery. He talked to doctors at the
University of California, San Francisco, about new radiation
techniques. Doctors in Florida told him about cryotherapy, in which the
prostate is turned into an ice ball to kill the cancer inside it.

Lewis concluded that for him, the risk of incontinence after surgery
was one out of three, and that the risk of impotence was about the
same.

``The chances are two out of three that you'll get at least one of
them,'' Lewis says. ``That didn't sound attractive.''

Then, in June 2003, almost a year after his first abnormal PSA test,
his squash partner gave him a booklet by Carter at John Hopkins that
had a section on active surveillance.

Right Answer

Lewis had heard about Carter's program. He was impressed that a doctor
at Hopkins, an institution known for its prostate surgeons, would be so
interested in active surveillance. ``He had the answer I was looking
for,'' Lewis says.

Jutta Lewis says she tried not to think about her husband's cancer. She
says she believed he would tease out the critical information and
present it to her to discuss. ``I trust him to do the best job anyone
can do,'' she says.

After three years of active surveillance, Lewis's cancer seems to have
vanished. ``It hasn't shown up in any of three subsequent biopsies,''
he says.

Carter says as many as 30 percent of the men who are diagnosed with
prostate cancer would be eligible for his active surveillance program
because their cancers aren't that severe. Today, just 2 percent of the
men who come to Johns Hopkins with the disease enroll with Carter.

No Deaths

Of those who have signed up, 55 percent are still monitoring their
tumors. A third of the men have exhibited changes that prompted Carter
to treat them. About 7 percent became so uncomfortable knowing they had
cancer in their bodies that they chose treatment even though their
tumors appeared stable. No one in Carter's program has died of prostate
cancer.

Klotz at University of Toronto says he plans to recruit 2,100 patients
to study active surveillance.

Looking back, Lewis suspects he had an infection in his prostate. His
biopsy just happened to hit the trace of cancer that so many men carry
around later in life, he says. ``Our bodies have cancers coming and
going all the time,'' Lewis says.

Milken, the onetime junk bond king, has made fighting prostate cancer
his life's work. In 1993, when Milken was 46, he went for an overdue
physical. He had just finished a 22-month prison term for securities
fraud. He asked his doctor for a PSA test. Prostate cancer had just
killed Warner's Ross, a friend, and he wanted a test himself. The
doctor told Milken he was too young to worry.

Grim Results

``Humor me,'' Milken said. He has lost 10 close relatives to cancer,
including his father (melanoma) and his mother-in-law (breast cancer).

The results were terrible. Milken's PSA was 24 ng/ml, six times the
level that usually prompts concern. Milken had a biopsy, and his
Gleason score came back at a 9 out of 10. The bad news cascaded. The
cancer had traveled to his lymph nodes. The doctors told Milken to get
his affairs in order.

Instead, Milken did what many educated, wealthy people do: He
networked. A friend recommended he see Dr. Stuart ``Skip'' Holden, a
urological oncologist at Cedars-Sinai Medical Center in Los Angeles.
Another friend, Dr. Neal Kassell, a neurosurgeon at the University of
Virginia, suggested talking to Dr. Andrew von Eschenbach, then director
of prostate cancer research at the University of Texas M.D. Anderson
Cancer Center in Houston. Dr. Eschenbach was studying men who had
cancer in their lymph nodes but not in their bones -- Milken's
situation exactly.

Major Donor

Soon, Holden put Milken on hormone-deprivation therapy to starve his
cancer of testosterone. Then he had Milken's prostate and pelvic lymph
nodes radiated over the course of eight weeks. Milken adopted a strict
diet. He avoided saturated fats found in meat and began eating more
soy. His PSA dropped to zero. Today, he's still in remission.

``I wouldn't be here today if it wasn't for PSA,'' Milken says, sipping
a purple smoothie containing -- among other things -- pomegranate
juice, soy protein, lemon zest, selenium, blueberries, vitamin E and
green tea, all reputed cancer fighters.

His Prostate Cancer Foundation has given money to more than 1,200
researchers, many of them working on ideas that are too far out for
other charities to support.

This year, the foundation reassessed its priorities and decided to
focus on two things: finding a blood test or other biomarker that gives
more clues about prostate cancer's progression than PSA does and
getting more drugs into human trials, especially for cancers that
return.

``Where we have been really stuck is in effective treatment for men
with recurrent disease,'' says Leslie Michelson, the head of the
Prostate Cancer Foundation.

All Clear

All of the men in this story remain cancer free. Weinstein, like
Milken, is trying to avoid a recurrence by watching what he eats.
Weinstein has adopted a mostly vegan diet. He avoids fats, except for
olive oil, and takes green tea extract, milk thistle, saw palmetto and
selenium, all reputed cancer fighters.

Lewis takes selenium and lycopene, a substance found in tomatoes. He
and Jutta built their house in Carmel, and Lewis finished his book,
``The Power of Productivity: Wealth, Poverty, and the Threat to Global
Stability'' (University of Chicago Press, 370 pages, $28). They split
their time between Washington, D.C., and California. The new house
abuts wilderness, which Bill plans to explore. He still gets annual
biopsies and twice-yearly PSA tests with Carter at Johns Hopkins.

Hurley got his first post-HIFU PSA test recently and it was a scant
0.2. His reading indicates that the cancer is gone. Prostate cancer can
return years later, usually in the lymph nodes or bones, even after a
prostatectomy. Nerve-sparing HIFU can leave some prostate tissue
behind. The upside is that Hurley is continent and potent, no Viagra
needed.

Ruby and Diamonds

Bigg is back in the pool. He was set to compete in the Masters World
Championships at Stanford University in August.

Around her neck, Melissa Bigg wears a ruby encircled by diamonds. Ruby
is Dave Bigg's birthstone; diamond is hers. The necklace was a 23rd
anniversary present from Bigg. He says the charm symbolizes how he felt
during his battle with cancer: surrounded by her love.

Five men, five stories. No two are alike. Every man who confronts
prostate cancer -- and there will be many -- faces decisions no one
else can make.

``The medical community didn't have a clear-cut recommendation for
me,'' Lewis says. ``You have to take the management of your disease
into your own hands.''

These men did, and so far, it's paid off.

To contact the reporter on this story:
Anthony Effinger in Portland, Oregon
aeffinger@bloomberg.net