Fly Well

Pythons, figs, donuts, and broccoli

August 1, 2010

Dr. Jonathan Sackier In Monty Python’s hilarious “Mouse Problem” sketch we hear that “Mr. A,” who wished to remain anonymous, was in fact, “Arthur Jackson, of 32A Milton Avenue, Hounslow, Middlesex.” This column aims to help readers avoid metaphorical granite lurking in the overcast, not to needlessly terrify. My “anonymous” female correspondent states that my articles frighten her. But, Julie Walker of 421 Aviation Way, Frederick, Maryland—relax, today’s article is just for the boys! Prostate cancer, the most common male malignancy and second leading cause of death, merits our attention, gentlemen.

Contrary to popular belief the bladder, not fuel tanks, limits flight endurance. Applied to its base, forward of the rectum, is the prostate—a solid organ the size and shape of a fig. Clothed in a capsule, the prostate lobes encircle the urethra, the tube conveying urine from the bladder, rather like a donut but without the jam in the middle. The prostate adds substances to semen and plays a role in regulating bladder control.

Prostate cancer develops when cells divide in meaningless and uncontrolled fashion. The biggest risk factors are being male (!), aging, and family history. Men of African descent have twice the risk of Caucasians, whereas Asians and Native Americans are less exposed. Smoking is bad, as is a fat-rich diet. Eating cruciferous vegetables—from the mustard family, such as kale and broccoli—as well as tomatoes reduces the risk.

With age, “benign prostatic hyperplasia” (BPH) or enlargement causes symptoms: contemplating the writing on the wall before urination, no more fire hose, intermittent flow suggestive of a leaky gasket, and nocturnal bathroom visits. Cancer may present similarly, so any urinary behavior change merits attention. If it spreads into adjacent organs, the bloodstream, or lymph nodes, it produces other symptoms—for instance, spinal deposits causing unremitting back pain.

On examination, no disease may be apparent until a finger is inserted where the sun don’t shine. The latex-clad medical digit feels the prostate’s size and consistency: when normal, smooth, and firm but somewhat squishy (a technical term, I assure you); when cancerous, hard and knobbly (another technical term).

PSA, Prostate Specific Antigen, is commonly mentioned. This enzyme, detected by blood test, may imply cancer is present. However, BPH, prostatic, or urinary tract infections and certain drugs can also elevate PSA while in some cancers it is normal. PSA levels vary with age and from laboratory to laboratory. It is a useful diagnostic tool in men with a family history and to monitor patients after treatment—a rising level may indicate recurrence. Dr. Richard Ablin, who discovered PSA in the 1970s, concurs that widespread screening at age 50 with PSA is counterproductive.

The next step will be an ultrasound-guided needle biopsy, microscopically inspecting the retrieved tissue, and ascribing a Gleason score to the two most common cell patterns; higher numbers indicate nastier tumors. Bone or CAT scans may also be in order.

If side effects outweigh benefits (length and quality of life), not treating the cancer is appropriate; many more men die with prostate cancer rather than from it. While the lifetime risk of prostate cancer is one in six, death risk is one in 34.

Prostate cells are stimulated by testosterone so tumor growth and spread might be prevented with drugs impeding testosterone function. While effective, such “hormonotherapy” may reduce libido, induce facial hair loss, hot flashes, and an inexplicable urge to ask for directions when lost.

If cancer is confined to the prostate, surgical removal of the gland is an option, perhaps under laparoscopic guidance with tiny incisions, maybe using a robot. Zapping with external radiation, proton beams, or by implanting radioactive seeds (brachytherapy) is another approach, and cryotherapy—freezing the malignant tissue—is being evaluated. When the disease has metastasized (spread), other treatments may be considered.

If diagnosed, consider and research all the options; each has merits and drawbacks. Obtain several opinions and choose the right treatment for you. Improved awareness, earlier detection, and more effective therapies in the past 20 years have improved survival from 67 to 92 percent. Eight of 10 cancers are found when still confined within the glandular capsule, making treatment easier. As with so many diseases, awareness and early diagnosis are your friends.

For the FAA this is not a specific disqualifying condition (Part 67). Report the diagnosis, providing history and physical, operative, and pathology reports; discharge summary; and current condition statement at your next FAA physical exam. If no spread is evident, PSA is normal, and treatment is complete with no lingering side effects, your AME, with FAA or regional flight surgeon approval, may issue a 12-month medical certificate. The FAA will then provide a formal letter specifying requirements for continued certification. Until improved screening and better therapies appear, eat well, have regular checkups, and think about broccoli and figs!

Julie, as you sit in your AOPA office, overseeing the production of this magazine, although you don’t have a prostate, I am sure there is someone you love who does, so please share this copy of AOPA Pilot with them. Monty Python gave us many a laugh; prostate cancer is not quite so amusing.

Jonathan M. Sackier has practiced medicine in the United States for more than 20 years. E-mail the author at jonathan.sackier@aopa.org .