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Likewise it is useful to look at how contraceptive decisions are made and where the power base lies in the compromise. Many men were keen to explain how their decision had been made jointly with their partner. However, when given the opportunity to talk further it often became clear that one partner had relinquished more control than the other.

In the following sections some of the conscious and unconscious feelings about the common methods are dicussed.

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Questions posed by the patient may give clues as to how she feels about herself; for example, a question as to how many women suffer from infertility or have a severe emotional reaction suggests an anxiety that she herself may have anxieties about her own fertility and worries about how she will feel afterwards. It is important to give the patient the facts wherever possible, but also to look at the anxieties underlying the question.

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A year later Mrs H. recontacted the domiciliary service. She had left her husband, had a new partner and was five months pregnant. She decided to keep the baby, but felt guilty as the youngest child was still in care, and she was ashamed to tell her social worker. The doctor encouraged her to do so, and reassured her that no one would force her to have an abortion against her will.

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In one study of fifty-nine men who were followed a year after the procedure, there was no incontinence, and no men reported urinary problems; two men had bladder neck contractures, and one man developed a stricture in the urethra at the tip of the penis. About 85 percent of men reported retrograde ejaculation. Men who may not benefit from this procedure are patients with middle lobe enlargement, because the ultrasound does not work as well in tissue near the bladder neck.

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Strontium-89 is specially tailored for bone pain. Like calcium, it is taken up immediately by bone, as water is absorbed by a sponge—except this compound tends to zoom right past healthy bone and zero in on metastatic cancer. (Strontium-89 is soaked up by tumor in bone, instead of by bone marrow, at a ratio of ten to one.) Relief from pain has been reported in from half to 80 percent of patients.

Strontium-89 has a long half-life—fifty-one days—in the body; a single shot of the compound has proved effective at relieving pain for an average of six months. One advantage of this, as compared to spot radiation, is that it acts on new sites of metastasisthat crop up while it stays in the body, as well as the older sites of cancer it originally was intended to treat.

And, strontium-89 can be used in combination with spot radiation In one study, doctors found that this combined approach—strontium-89 plus spot radiation—delayed progression of pain seven months longer than radiation alone.

Side Effects. The few side effects associated with strontium-89 include the potential for bone marrow damage; this is characterized by a drop in platelets. Also, some men report a mild increase in pain for the first couple of days after receiving the injection; this can be controlled with other pain medication. And a safety note: Because this radioactive substance is excreted in the urine, for the first forty-eight hours after receiving the injection urine must be taken care of in a certain way; this means you must urinate into a special container—not into the toilet—and dispose of this as directed by your doctor.

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But that day is not here yet.

This is the part of the book we wish we didn’t have to write, and that nobody would ever have to read. When prostate cancer is advanced, when it has swept through the prostate to the lymph nodes or bone, the options for treating it are limited. Cure is no longer possible. Instead, your doctor’s goal is to stave off the cancer—to buy more time, to alleviate symptoms and, finally, to ease debilitating pain.

There are many schools of thought on treating prostate cancer that has spread beyond the prostate to the lymph nodes or bone (stage N+, M+, Di, or D2). All of them involve hormone therapy—shutting down the hormones that feed the prostate and nourish the cancer. (This is also called “hormone deprivation” therapy.) But there are huge differences in medical opinion: Should hormone therapy begin while a man still feels fine, or should it wait until symptoms begin? Should it target the hormones that most directly involve the prostate, or should it try to smother all the body’s androgen (male hormone) activity? This idea of turning off all androgens is called total androgen blockade (or total androgen ablation), and many doctors believe in it. But is this total shutdown necessary?

And what’s the best method of stopping these hormones? Think of a car going through a series of checkpoints—points A, B, C and D—to cross over a border into another country. You want to stop this car from reaching the other side. At what point do you stop it? Do you set up a roadblock at Point A, the first stop along the way? Or do you simply wall off the border at Point D, so the car can never cross over? Or do you divert the car at some point in between?

The androgens that affect the prostate reach their destination through a process, involving several steps, that begins in the brain. Medical roadblocks are now available to stop or detour this process at Point A (the brain), Point D (the prostate), or at several spots in between. Some of them work better than others, and some are more expensive. But ultimately, all of these means of hormone therapy will fail to control the cancer. This treatment failure may take years if a man is lucky and has a tumor that’s particularly responsive to hormone therapy. It may only take months if he’s not—if he has a faster-growing tumor that doesn’t respond well to hormone therapy because many of its cells are indifferent to it.

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You will be given general anesthesia, which means you’ll be unconscious during the procedure. To reach the prostate, surgeons make an incision just above the rectum. The prostate is gradually separated from the rectum, bladder, urethra and vas deferens. The seminal vesicles are removed along with the prostate, and then the bladder is linked once again with the urethra.

If a man’s PSA level goes up after a radical prostatectomy, this is an indication that there is prostate cancer somewhere. Maybe it’s a local recurrence, in the area where the prostate used to be, or perhaps it’s a distant metastasis—a tiny seed of cancer that got scattered long before the cancer was ever diagnosed.

How to tell which? Recently, Johns Hopkins investigators studied rising PSA levels in fifty-one men after radical prostatectomy. In 30 percent of these men, cancer returned locally; in 70 percent, the cancer showed up as distant metastases. Based on this study, the scientists found they can estimate which course the cancer will take using the Gleason score of the prostate specimen removed in surgery, the pathologic stage (which is based on study of the actual prostate—not just tissue samples, as in biopsy), and timing—when the PSA starts to rise.

Men most prone to distant metastases will have one or more of these conditions: Gleason scores of 8 or higher, cancer found in their seminal vesicles and lymph nodes during surgery, or a rise in PSA within a year after their surgery. Conversely, men with Gleason scores of 7 or lower, low pathologic stage, and/or increases in PSA several years after surgery most likely will have only a local recurrence of cancer. For these men, the good news is that this cancer may still be cured with external-beam radiation treatment to the prostate bed (the area where the prostate used to be.

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