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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