Prostate cancer is largely a disease of our age. Two centuries ago it was rare: patients died before the cancer manifested itself. The body is constantly under construction and in decomposition, cells die and are replaced by new ones. This constant renewal allows organs to function normally. If certain cells do not die and change in such a way that they start multiplying abnormally and develop into a malignant tumour, we speak of cancer. But there is huge variation within that diagnosis. These days many men are told that they have prostate cancer, but by no means all of them die of it, or if they do it is only much, much later.
A good example of this is the case history of former French president Frangois Mitterrand (1916-1996). He was first diagnosed with prostate cancer in 1981 at the age of 65 and he died at the age of 79. Celebrated musician Frank Zappa (1940-1993) was unfortunately diagnosed too late, and died of the disease. The same happened to Prince Claus von Amsberg (1926-2000), husband of Queen Beatrix of the Netherlands, whose ordeal began with his diagnosis in 1998. He had an operation, but this was not radical enough, and subsequent microscopic examination showed that prostate cancer cells were still present, requiring a course of radiotherapy. A side-effect of the radiotherapy was that the draining of urine from the kidneys to the bladder became impeded, and hence one kidney had to be removed. The prince then developed intestinal problems that necessitated a colostomy, and from then on his condition went into a downward spiral, finally resulting in an embolism of the lung and a heart attack. In contrast, the Bond films actor Roger Moore was treated in time.
Mitterrand’s experience shows that there is a form of prostate cancer that develops so slowly that it may be twenty years before the growth becomes life threatening. When such a process begins only at a late stage in life, at the age of 65, for example, the patient may experience some discomfort, but very frequently has no symptoms at all. With such a virtually benign form of prostate cancer one can live for years without any problem or symptom. Some urologists call these types of cancer ‘pussycats’, as opposed to the ‘tigers’, highly malignant and dangerous prostate cancers. Tigers can sometimes, but not always, be recognized by the pathologist by microscopic analysis when the diagnosis is made. The higher the Gleason sum score — named after the scientist who devised the best method of grading prostate cancer — the greater the chance that the cancer is a tiger.
In the spring of 1949 the philosopher Ludwig Wittgenstein felt more tired than usual and was found to be suffering from anaemia. At the end of the summer, on a visit to the United States, he became very ill and had to be admitted to hospital. He was not frightened of a diagnosis of a serious illness, but did dread an unnecessary prolonging of his life, leaving him to await death for years in a state of complete helplessness. What’s more, he was frightened of dying in America and exclaimed to his host and ex-colleague Norman Malcolm: ‘I don’t want to die in America. I am a European. What a fool I was to come.’ At first no sign of a serious disease was found, but back in England he was proved right. He wrote in a letter to Malcolm:
I have prostate cancer. But it sounds much worse than it is, as there is medication which, so they tell me, may alleviate the symptoms of the disease, so that I may live for years yet. The doctor tells me that I may be able to work again, but I can’t imagine that. I wasn’t at all alarmed when I heard that I had cancer, but I was when they told me that they could treat me, because I have no desire to go on living. My wish was not granted. I’m being treated by everybody with the greatest kindness and I have a terribly kind doctor, who is no fool.
The man who wrote in his diary in 1930 ‘Very often or almost always I’m frightened to death’, showed not a trace of fear when death approached.
For forty years Anatole Broyard was an editor, literary critic and essayist on the New York Times. At the age of 69 he was told that he had prostate cancer. He gives an account of this period in Intoxicated by My Illness, the main message of which is: ‘I would advise every sick person to evolve a style or develop a voice for his or her illness. In my case I make fun of my illness.’ Although the writer states that after hearing about his fatal disease he loses all belief in the irony of the human condition as such, he clings to his ironic perspective, which the diagnosis of cancer does not destroy. On his first visit to the specialist he takes a seat in the waiting room. Full of appreciation he studies the tasteful decor and counts himself fortunate that the doctor who designed this room is to be his doctor. The doctor comes in and asks Broyard to follow him to his room. He finds himself in a completely impersonal room with an equally impersonal consultant. He decides to change doctors: ‘I found another urologist. He is brilliant, famous, a star and my response to him was so positive that my cancer immediately went into remission. My only regret is that he does not talk very much — and when he does, he sounds like everyone else.’
Broyard would like his urologist to develop a little more depth and have a bit of a sense of humour, a doctor who would appreciate both the comedy and the tragedy of his illness: ‘I find an irresistible desire to make jokes. When you’re lying in the hospital with a catheter and iv in your arm, you have two choices: self-pity or irony. If the doctor does not get your ironies, who else is there around?’ His friends find it difficult to take this step. You don’t make jokes about a serious illness. Is irony lost on cancer? In Case Histories: Essays on Literature and Medicine, Arko Oderwald writes that irony is one way of making fun of society’s lies about a disease. ‘Apart from that, in an ironic book about illness, the (self-)irony means that there are still a few laughs, which makes reading it a lot more pleasant than all those autobiographical accounts that cannot detach themselves from immediate experience.’
More and more reports are published about nutrition and the appearance of full-blown prostate cancer, or the transformation from a pussycat into a tiger. The use of soya proteins, vitamin E and a low — fat diet supposedly protect one from prostate cancer. Precisely how that works is not yet known. As far as fats are concerned, those deriving from red meat receive a very bad press, while fish oil with its polyunsaturated fats is not seen as harmful. The average selenium level in the Western diet is 40 micrograms, which is very little: the World Health Organization recommends between 50 and 200 micrograms a day. Ivan Wolffers, a professor of medicine, makes it clear that he feels little affinity with alternative medicine, but ‘if people are really at rock bottom and for example apply endive leaves to their back with a bandage over them because they think that can restore their strength, I think: if it gives those people some peace of mind, what harm can it do?’
‘Blessed is he who pees well to his dying day. No one now need suffer the agonies people once had to endure: that is a consoling thought’, writes Ceronetti in The Silence of the Body. In his view prostate disease remains a huge drama, but at the same time he maintains that the great advance in medical science is not so much the controlling of pandemics, but the reduction in urological agony. He adds that many people live by results. ‘Doctors and patients crawl from
lab result to lab result, as if everything were quantifiable, but once someone has the examination result (of, say, the Prostate-Specific Antigen or psa test) in his hands, he can never regain his innocence, he knows too much.’ How true that is! How little is written about the right not to know. . .