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A.As you indicate, colon cancer is a major public health issue. It is the fourth most common cancer diagnosed in the United States, accounting for about 130,000 new cases and 55,000 deaths per year. Overall, about 6 percent of the population will eventually develop colon cancer.

A.Symptoms of colon cancer include a change in bowel habits, rectal bleeding, abdominal pain or symptoms because of anemia (such as shortness of breath or fatigue). However, colon cancer may cause no symptoms early on. By the time symptoms develop, the cancer may be at an advanced stage that is not easily curable.

We know that the vast majority of colon cancers develop in polyps, small growths of abnormal tissue on the inner lining of the colon. Thus, screening for colon cancer entails searching for precancerous polyps and removing them — not waiting for cancer to occur. This mode of polyp removal has been shown to dramatically reduce the incidence of colon cancer. In addition, screening of stool for microscopic amounts of blood has been shown to help prevent colon cancer. Patients found to have a positive test undergo colonoscopy, allowing for earlier diagnosis and removal of precancerous polyps and/or cancer.

It is recommended that colon cancer screening begin at age 50, since the incidence of colon cancer increases dramatically after this age. Some patient groups require earlier screening, including patients with a family history of colon cancer and those with inflammatory bowel disease.

Apart from the removal of precancerous polyps, there currently is no proven way to prevent colon cancer. Some studies are looking at possible therapies that may prevent polyps from forming or transforming into cancer. The preventive strategies being tested include fiber supplementation, increased intake of folate, increased intake of calcium, and regular use of certain NSAIDs (nonsteroidal anti-inflammatory drugs) of the COX-2 inhibitor class. Doctors and researchers are eagerly awaiting the outcome of these studies.

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In a recent Today Show interview on NBC, Schwarzkopf went so far as to say that with universal screening, prostate cancer would be virtually preventable, and that with early detection, the side effects of treatment were minimal or nonexistent. However, sweeping statements and exuberant optimism about wiping out prostate cancer misrepresent the realities of the disease, and of its detection and treatment.

Indeed Schwarzkopf’s public enthusiasm for widespread prostate cancer testing masks an anguished debate in the medical community about exactly which men should be tested for prostate cancer. This debate intensified when a simple blood test to detect prostate cancer — the prostate specific antigen, or PSA, test — became widely available about a dozen years ago.

The argument that detecting cancer early will improve the chances of survival is a basic, intuitive one. But sometimes this “truism” is more apparent than real. For example, it can be legitimately argued that colon cancer is largely preventable by screening. Screening with a fecal occult blood test or tests like a colonoscopy can detect polyps or cancer. When detected, these polyps or cancers can be surgically removed quickly and efficiently, essentially without risk or negative side effects.

For prostate cancer, unfortunately, the story is more complex.

Prostate cancer — although not necessarily a life- or health-threatening type — is extremely common. The current estimate is that at least 11 million American men have prostate cancer in some form. Only a fraction have been diagnosed. Each year, about 40,000 men die of prostate cancer in this country. Signs of prostate cancer are found during the autopsies of almost all men age 90 or over who die of other causes; the figure is about 40 percent for men aged 40 to 49. In other words, there is a large discrepancy between the number of men who have some form of prostate cancer and the number of men whose life or health is threatened by it. This fact is critical when it comes to evaluating the need for mass screening and the options for treatment.

Given the above reality, universal screening of all men over age 50 will pick up substantial numbers who have a “dormant” prostate cancer — meaning they have a form of the disease that will never progress to a life-threatening stage. These men with dormant prostate cancer then hazard the discomfort, risk and expense of follow-up evaluations such as biopsies, as well as the more significant risks associated with hormonal, radiation and especially surgical treatment, if cancer is detected. Results of biopsy specimen analysis can sometimes indicate if a cancer is likely to be aggressive, but this is far from certain.

Contrary to what Schwarzkopf says in his interviews promoting prostate screening, a substantial number of men undergoing treatment for prostate cancer still do suffer from incontinence and impotence, at least temporarily, despite the advances in what has been called “nerve sparing” surgery.

Is prostate cancer screening good public-health practice? The answer requires more than the TV soundbite opportunity given to Schwarzkopf. For men with a family history of prostate cancer, regular screening after 50 may be desirable. Also, black Americans have a higher rate of prostate cancer than whites, so they are more likely to benefit from screening. But there is no medical consensus to support a call for universal prostate cancer screening, primarily because there is no evidence at hand that early or universal prostate screening saves lives.

The lack of enthusiasm for Schwarzkopf’s universal screening recommendation was evident this week in San Diego when the American Medical Association decided against adopting guidelines for early prostate cancer detection. Those voting against this recommendation cited the lack of evidence-based benefit. The AMA decided to refer the guideline proposal to its board of trustees for additional study.

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This year, an estimated 180,000 American men will be told they have prostate cancer. Every one of these men, and the women who love them, should know about Dr. Jerome Groopman’s essay “The Prostate Paradox,” published in the May 29, 2000 New Yorker, before they make a decision on what action, if any, to take after this diagnosis.

Groopman, a professor at Harvard Medical School, walks us step-by-step though the facts about this form of malignancy and the options for — and consequences of — treating it. While we often hear celebrities (such as Bob Dole, Michael Millken and Gen. Norman Schwartzkoff) tout the benefits of the PSA test, we do not frequently hear these realities:

Prostate cancer in some form is very common in men, particularly as they age. More than 50 percent of men who die in their 80s of other causes have clinical signs of prostate cancer at autopsy. More than 30 percent of men carry occult (asymptomatic) prostate cancer by age 50.

Not all prostate cancer is life-threatening. While almost 200,000 men will be diagnosed, about 32,000 will actually die this year from the disease.

The consequences of the traditional forms of treating prostate cancer — surgery and/or radiation — can be devastating. Incontinence and impotence are frequent resulting effects of such treatment. Indeed, as Groopman notes, the frequency of untoward side effects may be greater than previously reported, particularly in the upbeat presentations about “nerve-sparing surgery.” Patients tend to underreport the problems they are experiencing, in a subconscious effort not to disappoint their doctors about the outcome.

While it initially may appear on diagnosis that the “do-something” option is the only viable one, Groopman’s commentary will cause newly diagnosed prostate cancer patients to ask themselves some very philosophical questions about the risks, uncertainties and importance of quality of life.

Information on the type and aggressiveness of a prostate cancer (the Gleason score) is useful in the decision-making equation, but ultimately, newly diagnosed prostate cancer patients must make a decision on incomplete information: For example, they do not know if the cancer is life threatening or not. They do not know exactly what the degree of treatment-related debilitation will be — although they should assume it would be considerable and perhaps permanent. They do not know for sure if the cancer has spread beyond the gland, which means that whatever treatment they undergo and the consequences they suffer would not prolong their lives. Is treatment, without the promise of cure and with the likelihood of at least temporary impotence and incontinence, worth it — in return for possibly avoiding a prolonged and painful premature death? Or is “watchful waiting” the preferable option, where a man chooses regular medical monitoring of the cancer’s possible progression instead of treatment?

Perhaps the bottom line is best summarized by a quote that appears at the end of Groopman’s essay: Dr. James Talcott, a medical oncologist and the director of the Centers for Outcomes Research at the Massachusetts General Hospital Cancer Center in Boston, has analyzed different interventions for prostate cancer, weighing issues of quality of life against survival. He notes, “I tell my patients to do thought experiments ? try to imagine your life after a radical prostatectomy [where the prostate gland is surgically removed], where you are impotent. Try to imagine your life after radiation therapy, where you suffer with urinary or bowel irritation. Then imagine that you’ve done nothing, just been closely monitored. In each scenario — surgery, radiation or just observation — then imagine that the cancer has come back. Which bullets are you wiling to take?”

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