Today, Explained - Prostate of the union

Episode Date: January 25, 2024

Defense Secretary Lloyd Austin drew flak after trying to keep his prostate cancer surgery a secret. Health journalist Howard Wolinsky explains that’s super common among men, who don’t like being probed about their prostates. This episode was produced by Victoria Chamberlin, edited by Matt Collette, fact-checked by Laura Bullard, engineered by David Herman, and hosted by Noel King. Transcript at vox.com/todayexplained Support Today, Explained by making a financial contribution to Vox! bit.ly/givepodcasts Learn more about your ad choices. Visit podcastchoices.com/adchoices

Defense Secretary Lloyd J. Austin made a public appearance this week. Good day, everyone. Thanks for working across time zones. His first since he vanished without leave while being treated for prostate cancer. Now, this made news because pulling a runner is typically not the done thing for defense secretaries. But also, right down to the 911 call, Austin was trying to keep this secret. Can the ambulance not show up with lights and sirens? We're trying to remain a little subtle. Yeah, I understand.

Yeah, usually when they turn into a residential neighborhood, they'll turn them off. But they're required by law to run with them with the main street. I'm curious, if we need them to take him to Walter Reed Medical, is that possible? We're going to talk about why all the secrecy. And if you're a man of a certain age, you might already know exactly why. So we're going to answer some of your harder questions too. State of the Prostate coming up on Today Explained. This NFL season, get in on all the hard-hitting action with FanDuel,

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This is Today Explained. Hi, my name is Tyler. I am calling in regards to the prostate. Tyler is calling in regards to the prostate because we asked you guys about something. Hi, my name is Paul. I'm from Colorado. I'm calling to comment about, I think the question was, why don't men want to talk about their prostates? In general, I think the fear comes from how the exam is conducted, you know, with somebody bending over and then the doctor having to inspect from the derriere. Apparently, I don't know this myself, but as I understand it,

that prostate can be stimulated. I guess it's a good thing for the guy. I don't know personally. For me as a gay man, I think there's a lot of homophobia that's tied into that. Beyond some of this derriere discomfort, you had some big questions about a cancer that kills 3% of men. How accurate is the prostate screening process? And does it pass on from one generation to the next. I'm calling not about prostate cancer, but unfortunately about colon cancer, which really affects the same region for guys and a lack of awareness and attention to that area. It was the most foreign conversation I've ever had. And the first one I had was when I was diagnosed with cancer after my colonoscopy.

Okay, there is a lot here. And so we called up Howard Walensky, who is himself a lot. I'm a writer based in Chicago. I'm the former medical editor of Chicago Sun-Times. And I've been a newspaper guy and a writer for over 50 years. And I'm also in grad school now for a master's in public health because I've sort of become dedicated to this issue because I was so pissed off by what I saw in the way I was treated.

Thirteen years ago, I was diagnosed with low-risk prostate cancer and came this close, my fingers are close together, of having surgery that in the end, it turned out I didn't need. And it put me on a path that I never expected of creating support groups for men with low-risk prostate cancer like I have. I wonder if we can get very basic, very remedial for a second, and you can just tell us what a prostate is and who has one. The prostate itself is a gland. Often you'll hear it's the size of a walnut.

That's kind of misleading. I mean, when a boy is born, it's the size of a walnut. That's kind of misleading. I mean, when a boy is born, it's a tiny little thing. As you get older, it grows larger. So if you hear people talking about walnuts, think young. If you're talking about grapefruits, think old. So, okay, where is this gland? It's situated below the bladder and in front of the rectum, and it surrounds a part of the urethra, the tube in your penis that carries the pee from your

bladder. And so, okay, what does the prostate do? Prostate helps make some of the fluid in semen, which carries sperm from your testicles when you ejaculate. Ah, so y'all need your prostates. Humanity needs your prostates. Yeah, you need your prostate up to a point. And I should point out, too, if a man lives long enough, he's going to have prostate cancer and probably won't even know it. Something like 80% of men, 80 and above, have prostate cancer. It's a disease largely of aging. Howard, one of the reasons that we really wanted to speak to you was because you wrote a column,

and it's called, I Understand Why Defense Secretary Austin Kept His Prostate Cancer Quiet. What made you write that piece? What were you thinking? I understand why Austin would want to be quiet, but the sub-headline was to the effect that, you know, he should be more open because he could help other people. I was watching the news with one of my sons, and I said, dollars to donuts, it's prostate cancer. And my sons, I think, think that I have prostate on the brain because I'm an advocate.

But here's why I thought this was the case with Austin. First of all, his age. He's 70 years old. The average age for diagnosis with prostate cancer is 66. Second of all was his race. Black men have a higher incidence and a higher mortality rate from prostate cancer. So if I were a betting man, I would have bet that it was prostate cancer. Well, I did bet dollars to donuts, right? And you won the dollars. Well, I didn't even

get the donut, damn it. Why did he keep it secret? Well, of course, only he could answer that. But I can speculate that he, first of all, he was afraid. He was afraid of what was happening to him. He was making some of the biggest decisions of his life. And for all we know, he was in a bit of a panic. He keeps state secrets. That's part of his training and that's his life. And now he's dealing with a cancer. And so I suspect that his first reaction was to be secretive about it. He was in the military. And I think that it's a macho environment. And so I don't think you want to show vulnerability. I don't think you want to show vulnerability about a cancer in a sexual organ.

We asked our listeners today, Howard, was there anything they wanted us to talk about or to ask about? And one man said something he called in almost instantly. In general, I think the fear comes from how the exam is conducted. I've always been told as well that the pleasure from gay sex comes from the prostate. And for some reason, there is a lot of stigma attached to, you know, being vulnerable enough, quote unquote, to have your anus inspected in that way. I'm a woman, okay? So I don't actually know what's going on in these exams. But can you talk a bit about what happens in a prostate exam that seems to make men so uncomfortable?

Well, you're exposing your butt to the air. You bend over a table. So you're sort of vulnerable. A doctor, could be a male, could be a female doctor, puts a glove on and puts a finger or two in there and feels the surface of the prostate looking for bumps, lumps, so on. I personally, you know, I didn't find it that uncomfortable. I didn't find it that embarrassing. But it's been a number of years since I've had one. Dr. Michael Liepman, an

oncologist at the Yale School of Medicine, is here to help us dig a little deeper. Rectal examinations are helpful in some cases, but in some cases they can actually be a false positive. You can think you feel something, even if you're're very experienced and it turns out to be nothing. And so, you know, I know it's a barrier for some people who don't want to even talk about prostate cancer screening because they're worried it's going to end up in a rectal examination. To the question of having an orgasm, ejaculating with a rectal examination, I've never seen it. It's a quick examination. And I don't think it's a big concern that someone will instantly have an orgasm from having a

rectal examination. The main way that we screen people for prostate cancer is using a blood test called PSA. That stands for prostate specific antigen. It's quite accurate. It doesn't find every prostate cancer. And in fact, in people who have a lower PSA, you can still find prostate cancer. But it's a very good tool that does detect the majority of aggressive cancers at an earlier stage. Hi, my name is Keith. I live down in Southwest Florida, and I've had prostate interest for many years. I'm 75 now, but probably for the last 20 years at least, I've had elevated numbers for that and came out with a clean bill of health, even though I've had numbers on the test as high as 25. I think it was four or once, but not sure why those numbers go around.

We just said that PSA is a great test, but it is prone to fluctuation. You know, PSA is a protein that's made by the prostate, and it's made by cancerous tissue in the prostate. It's made by non-cancerous tissue in the prostate. So it doesn't perfectly distinguish between cancer and not cancer. In most people, it doesn't fluctuate. But, you know, we see this very, very commonly where there are these wide fluctuations. What does treatment for prostate cancer typically look like? The most common treatment options are, especially for low risk,

are active surveillance, which is close monitoring of the cancer, which is what I do, radiation therapy, and radical prostatectomy. In some men, it's hormonal therapy, which is androgen deprivation therapy. So successful treatment to me is the right treatment for the right patient at the right time. Every person is different and every treatment and every plan has to be different. And so for some people, it's not treating the cancer. And some people, it's careful monitoring and doing what we call active surveillance. In others, it is local treatment to the prostate involving surgery to remove the prostate or radiation. In some cancers that we find, they have spread beyond the prostate. And then it's really a multimodal

treatment involving systemic therapy, hormonal therapy, and potentially chemotherapy and other treatments. So prostate cancer is interesting because it is one where you are balancing multiple risks. You're balancing the risks of the cancer itself, the risks from the treatment, and every person's preference. We know that the cancers that are ultimately lethal and aggressive probably start at a younger age. They could be as early as 30s or 40s or 50s. Most men are diagnosed with prostate cancer in their 60s in the US, and that's usually because they haven't been screened earlier. So the guidelines from the American Neurological Association and other organizations recommend at least the consideration of getting a PSA

test at age 45 and earlier if you have a stronger family history. So if you have a first degree family relative, a father or a brother, or a known strong family history of cancer, or black or African American ancestry, those are considered higher risk groups for which screening could be done as early as 40. Howard, you know, all of this, the worry around the test, the secrecy around when you're diagnosed, you don't want to tell people, it makes me wonder whether prostate cancer is maybe even deadlier than it needs to be

because so many men really don't want to have awkward conversations with their doctors or don't want to have awkward conversations with their doctors or don't want to get a test that sounds, to me, profoundly uncomfortable. You know, all I have to tell you is, could it be any worse than what the doctors do to women with vaginal exams? Absolutely not. Point taken. Thank you, sir. I'm going to get in so much trouble with our listeners, but women do tend to

man up a lot better than men. So I think one of the reasons that we're, we want to have this conversation for our listeners and we want to talk about this is because we want to sort of draw attention to the fact that this diagnosis doesn't have to be the end of the world. And the test itself doesn't have to be the end of the world. And the test itself doesn't have to be the end of the world. It's just sort of wrapping your head around, okay, buddy, this is going to be uncomfortable for a while. But, you know, if I can disagree with you a little bit. Sure, sure.

You've earned it. Okay. I mean, I'm on something called active surveillance. I maybe once a year have a PSA test. And my doctor told me I have about the lamest cancer he's ever seen. Those were the words. But, you know, when you're getting into this, you know, well, there's two comparisons. On the one end of the spectrum, like me, it's the sleeping lion. On the other end, with advanced cancer, it's the snarling tiger.

You know, there's a huge difference, but you are where you're at, and so you're going to take that seriously. You know, the challenge is that a proportion of them are dangerous and many of them are not. We encourage people to stay up to date on screening. But in fact, guidelines suggest that we should not screen people over the age of 75 or people with less than a 10-year life expectancy because finding cancers and treating them might not improve their life, might not improve their longevity. That was Howard Walensky.

Howard's going to be back with us. And we're going to say goodbye to Dr. Michael Liepman of the Yale School of Medicine. Stick around. Support for Today Explained comes from Aura. Aura believes that sharing pictures is a great way to keep up with family, and Aura says it's never been easier thanks to their digital picture frames.

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with our new favorite and recently played games tabs. And to top it all off, quick and secure withdrawals. Get more everything with FanDuel Sportsbook and Casino. Gambling problem? Call 1-866-531-2600. Visit connectsontario.ca. Support for Today Explained comes from Ramp. If you're a finance manager, you're probably used to having to toggle between multiple disjointed tools just to keep track of everything. And sometimes

that means there's limited visibility on business spend. I don't know what any of that means, but ramp might be able to help ramp is a corporate card and spend management software designed to help you save time and put money back in your back pocket. Ramps accounting software automatically collects receipts categorizes your expenses in real time, you can say goodbye, Thank you. business needs, and you can have peace of mind. And now you can get $250 when you join Ramp. You go to ramp.com slash explained, ramp.com slash explained, ramp.com slash explained. Cards are issued by Sutton Bank, a member of the FDIC, Prostate of the Union. Today's guest is Howard Walensky. He's a medical writer from Chicago. He writes the Active Surveiller Substack.

Howard, you were diagnosed with prostate cancer. Tell me about how that went. I told you it a hundred times. I'm happy to tell it a hundred and 101. I dragged my wife along with me and we meet with a doctor and he says, and he's probably said it a thousand times, he says, I have good news and I have bad news for you. The bad news is you have cancer. He didn't tell me I had low-risk cancer. You have cancer. The good news is I have a cure

if you come to my operating room next Tuesday. So the pressure was on to have an operation. But remember, you know, I was the medical editor of the Chicago Sun-Times, so I had already done my homework and found that there was something called active surveillance. And, you know, if they found something, I was going to see, get a second opinion. And so I, you know, got turned away. Well, I pushed away this doctor,

the first doctor, and I went to see the second one. Second one said, you know, you're the poster child for active surveillance. He said, I predict in 10 years your cancer will not have grown. Well, it was even better than that. 10 years went by and no cancer had been seen in any following biopsies. They had a total of six biopsies, and only one was positive. It must have been on a bad prostate day. But, you know, it still has implications because, you know, you're suddenly a cancer patient. We've talked a lot about how when men are diagnosed, they may keep it secret. They may not want to tell anyone. What was your inclination when you got your diagnosis?

You already knew a lot. You were, you know, you're a health reporter. How comfortable were you telling people? I was of a mindset of sharing a story. And so when I got diagnosed with prostate cancer, I started sharing my story in Facebook. And suddenly I got a deluge of phone calls from brothers and husbands and uncles and fathers of female friends of mine in Facebook. And so, you know, I'm not a doctor, but I can share with them my experience. And there's been, you know, since that time, there's been a lot more research, a new generation or two of doctors who are more accepting of active surveillance. And so,

remember, back when I got diagnosed, only 6% of us went on active surveillance. Now it's up to 60%. In the state of Michigan, it's 90%, which is where it should be. We're still lagging behind Sweden and UK. We did an episode of Today Explained last year about menopause. It is not something that women used to talk about. It is not something that historically has been a big topic of conversation. But as time has gone on, you're actually seeing women in the public eye talk a lot about menopause. It's something that's going to happen to all of us. We might as well get it

out there. Are there any notable men who have discussed a prostate cancer diagnosis where you think, oh, the situation may actually be changing and evolving here. We might be getting more comfortable with this. You know, it's interesting. I don't know, you probably remember Senator Bob Dole. In my many years of public service, I've never been afraid of fighting for what I believe is right. One of the most difficult battles I ever faced was when my doctor told me a couple of years ago that I had prostate cancer. He kind of made it okay for men to talk about prostate cancer. I'm asking all men to see their doctor for an annual checkup, not only for prostate cancer, but for all problems such as heart disease and colon cancer that hit men especially hard.

The Congress is filled with these guys with prostate cancer. They don't talk about it. But Bob Dole made it okay. He even ran for president after he had been treated for prostate cancer. I think that was a first. Well, I mentioned Bob Dole, Harry Belafonte. I'm going to add two more, two people that Secretary Austin can identify with, Colin Powell and his fellow General Storm and Norman Schwartzkopf. All four of these people that I mentioned were open about having prostate cancer. Arnold Palmer, the golfer, Warren Buffett, the zillionaire, Elton John. I mean, it's like an honor roll of people in sports, in entertainment, politics to some degree, you know, are open about it. And so I wrote an open letter that I published in a newsletter I do called The Active Surveyor.

And a lot of people, you know, prominent people in the prostate community signed it. Basically, we wrote to Secretary Austin that we had his back. We would support him, but we wished that at some point he would share his story so he could show leadership and help other men feel comfortable with their diagnoses. And, you know, in a lot of ways, you know, he blew it. But maybe there's time for him to redeem. That was Howard Walensky, author of The Active Surveiller Substack. Thanks to him and to all from the prostate community

who called in. We really did love hearing from you. Thanks also to Dr. Michael Liepman of the Yale School of Medicine. Victoria Chamberlain produced today's episode. Matthew Collette edited. David Herman engineered. Laura Bullard fact-checked.

Noelle King, that's me, explained today. you