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--:-- Noel King: Defense Secretary Lloyd J. Austin made a public appearance this week. Good day, everyone. Thanks for working across time zones.
--:-- Noel King: 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.
--:-- Noel King: 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.
--:-- 911 Operator: 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.
--:-- Noel King: I'm curious. If we need them to take him to Walter Reed Medical, is that possible?
--:-- 911 Operator: 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.
--:-- Noel King: So we're going to answer some of your harder questions, too. State of the Prostate, coming up on Today Explained.
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--:-- Noel King: This is Today Explained.
--:-- Tyler: Hi, my name is Tyler. I am calling in regards to the prostate.
--:-- Noel King: Tyler is calling in regards to the prostate because we asked you guys about something.
--:-- Paul: 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?
--:-- Paul: 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.
--:-- Paul: 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.
--:-- Paul: 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.
--:-- Noel King: the most foreign conversation I've ever had. And the first one I had was when I was diagnosed with cancer after my colonoscopy.
--:-- Noel King: Okay, there is a lot here. And so we called up Howard Walensky, who is himself a lot.
--:-- Howard Walensky: 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.
--:-- Howard Walensky: 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 and the way I was treated.
--:-- Howard Walensky: 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.
--:-- Howard Walensky: 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.
--:-- Noel King: 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.
--:-- Howard Walensky: The prostate itself is a gland. Often you'll hear it's the size of a walnut. That's kind of misleading.
--:-- Howard Walensky: I mean, when a boy is born, it's a tiny little thing. As you get older, it grows larger.
--:-- Howard Walensky: So if you hear people talking about walnuts, think young. If you're talking about grapefruits, think old.
--:-- Noel King: So, okay, where is this gland? It's situated below the bladder. and in front of the rectum.
--:-- Noel King: And it surrounds a part of the urethra, the tube in your penis that carries the pee from your bladder.
--:-- Howard Walensky: And so, okay, what does the prostate do? Prostate helps make some of the fluid in semen, which carries a sperm from your testicles when you ejaculate.
--:-- Noel King: Ah, so y'all need your prostates. Humanity needs your prostates.
--:-- Howard Walensky: Yeah, you need your prostate up to a point.
--:-- Howard Walensky: 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.
--:-- Howard Walensky: Something like 80 percent of men, 80 and above, have prostate cancer. It's a disease largely of aging.
--:-- Noel King: 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.
--:-- Howard Walensky: What made you write that piece? What were you thinking?
--:-- Howard Walensky: 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.
--:-- Howard Walensky: I was watching the news with one of my sons and I said dollars to donuts it prostate cancer
--:-- Howard Walensky: And my sons I think think that I have prostate on the brain because I an advocate
--:-- Howard Walensky: 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.
--:-- Howard Walensky: Second of all was his race. Black men have a higher incidence and a higher mortality rate from prostate cancer.
--:-- Howard Walensky: So if I were a betting man, I would have bet that it was prostate cancer.
--:-- Noel King: Well, I did bet dollars to donuts, right? And you won the dollar. Well, I didn't even get the donut, damn it.
--:-- Howard Walensky: Why did he keep it secret? Well, of course, only he could answer that. but I can speculate that, first of all, he was afraid.
--:-- Howard Walensky: 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.
--:-- Howard Walensky: He keeps state secrets. That's part of his training, and that's his life.
--:-- Howard Walensky: And now he's dealing with a cancer. And so I suspect that, you know, his first reaction was to be secretive about it.
--:-- Howard Walensky: You know, he was in the military. And I think that, you know, it's a macho environment.
--:-- Howard Walensky: 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.
--:-- Noel King: We asked our listeners today, Howard, was there anything they wanted us to talk about or to ask about?
--:-- Listener: In general, I think the fear comes from how the exam is conducted.
--:-- Listener: I've always been told as well that the pleasure from Gasex comes from the prostate.
--:-- Howard Walensky: and for some reason there is a lot of stigma attached to, you know, being vulnerable in a quote-unquote to have your anus inspected in that way.
--:-- Howard Walensky: 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?
--:-- Howard Walensky: Well, you're, you know, you're exposing your butt to the air.
--:-- Howard Walensky: You bend over a table, you know, so you're sort of vulnerable.
--:-- Howard Walensky: 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.
--:-- Howard Walensky: I personally, you know, I didn't find it that uncomfortable. I didn't find it that embarrassing.
--:-- Dr. Michael Liepman: Rectal examinations are helpful in some cases, but in some cases they can actually be a false positive.
--:-- Dr. Michael Liepman: You can think you feel something even if you're very experienced, and it turns out to be nothing.
--:-- Dr. Michael Liepman: 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.
--:-- Dr. Michael Liepman: To the question of having an orgasm ejaculating with a rectal examination, I've never seen it.
--:-- Dr. Michael Liepman: It's a quick examination. And I don't think it's a big concern that someone will, you know, instantly have an orgasm from having a rectal examination.
--:-- Dr. Michael Liepman: The main way that we screen people for prostate cancer is using a blood test called PSA.
--:-- Dr. Michael Liepman: That stands for prostate-specific antigen. It's quite accurate.
--:-- Dr. Michael Liepman: 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.
--:-- Keith: Hi, my name is Keith. I live down in southwest Florida, and I've had prostate interest for many years.
--:-- Keith: 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.
--:-- Keith: I think it was four once, but not sure why those numbers go around.
--:-- Dr. Michael Liepman: You know, we just said that PSA is a great test, but it is prone to fluctuation.
--:-- Dr. Michael Liepman: You know, PSA is a protein that's made by the prostate, and it's made by cancerous tissue in the prostate.
--:-- Dr. Michael Liepman: It's made by non-cancerous tissue in the prostate, so it doesn't perfectly distinguish between cancer and not cancer.
--:-- Dr. Michael Liepman: In most people, it doesn't fluctuate, but we see this very, very commonly where there are these wide fluctuations.
--:-- Dr. Michael Liepman: What does treatment for prostate cancer typically look like?
--:-- Dr. Michael Liepman: 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.
--:-- Dr. Michael Liepman: Radiation therapy and radical prostatectomy. In some men, it's hormonal therapy, which is androgen deprivation therapy.
--:-- Dr. Michael Liepman: So successful treatment to me is the right treatment for the right patient at the right time.
--:-- Dr. Michael Liepman: Every person is different, and every treatment and every plan has to be different.
--:-- Dr. Michael Liepman: 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.
--:-- Dr. Michael Liepman: In others, it is local treatment to the prostate involving surgery to remove the prostate or radiation.
--:-- Dr. Michael Liepman: 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.
--:-- Dr. Michael Liepman: So, prostate cancer is interesting because it is one where you are balancing multiple risks.
--:-- Dr. Michael Liepman: You're balancing the risks of the cancer itself, the risks from the treatment and every person's preference.
--:-- Dr. Michael Liepman: We know that the cancers that are ultimately lethal and aggressive probably start at a younger age and they could be as early as 30s or 40s or 50s.
--:-- Dr. Michael Liepman: Most men are diagnosed with prostate cancer in their 60s in the US and that usually because they haven been screened earlier
--:-- Dr. Michael Liepman: 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.
--:-- Howard Walensky: 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.
--:-- Howard Walensky: 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 get a test that sounds, to me, profoundly uncomfortable.
--:-- Howard Walensky: No, I have to tell you, could it be any worse than what the doctors do to women with vaginal exams?
--:-- Howard Walensky: Absolutely not.
--:-- Howard Walensky: Point taken.
--:-- Howard Walensky: I'm going to get in so much trouble with our listeners, but women do tend to man up a lot better than men.
--:-- Howard Walensky: So I think one of the reasons that 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.
--:-- Howard Walensky: And the test itself doesn't have to be the end of the world.
--:-- Howard Walensky: It's just sort of wrapping your head around, okay, buddy, this is going to be uncomfortable for a while.
--:-- Howard Walensky: But, you know, if I can disagree with you a little bit.
--:-- Howard Walensky: Sure, sure. You've earned it.
--:-- Howard Walensky: Okay. I mean, I'm on something called active surveillance.
--:-- Howard Walensky: I maybe once a year, have a PSA test.
--:-- Howard Walensky: And my doctor told me I have about the lamest cancer he's ever seen.
--:-- Howard Walensky: Those were the words.
--:-- Howard Walensky: But when you're getting into this, well, there's two comparisons.
--:-- Howard Walensky: On the one end of the spectrum, like me, it's the sleeping lion.
--:-- Howard Walensky: On the other end, with advanced cancer, it's the snarling tiger.
--:-- Howard Walensky: You know, there's a huge difference, but you are where you're at, and so you're going to take that seriously.
--:-- Howard Walensky: You know, the challenge is that a proportion of them are dangerous, and many of them are not.
--:-- Howard Walensky: 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.
--:-- Howard Walensky: because finding cancers and treating them might not improve their life, might not improve their longevity.
--:-- Noel King: 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.
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--:-- Noel King: It's Today Explained, Prostate of the Union.
--:-- Noel King: Today's guest is Howard Walensky. He's a medical writer from Chicago. He writes the active surveiller Substack.
--:-- Howard Walensky: I've told you 100 times. I happy to tell it 101 I dragged my wife along with me and we meet with a doctor And he says and he probably said it a thousand times he says, I have good news and I have bad news for you.
--:-- Howard Walensky: The bad news is you have cancer. He didn't tell me I had low-risk cancer. You have cancer.
--:-- Howard Walensky: The good news is I have a cure if you come to my operating room next Tuesday.
--:-- Howard Walensky: So the pressure was on to have an operation.
--:-- Howard Walensky: 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.
--:-- Howard Walensky: And, you know, if they found something, I was going to get a second opinion.
--:-- Howard Walensky: And so I, you know, got turned away.
--:-- Howard Walensky: Well, I pushed away this doctor, the first doctor, and I went to see the second one.
--:-- Howard Walensky: The second one said, you know, you're the poster child for active surveillance.
--:-- Howard Walensky: He said, I predict in 10 years your cancer will not have grown.
--:-- Howard Walensky: Well, it was even better than that.
--:-- Howard Walensky: Ten years went by, and no cancer had been seen in any following biopsies.
--:-- Howard Walensky: They had a total of six biopsies, and only one was positive.
--:-- Howard Walensky: 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.
--:-- Noel King: We've talked a lot about how when men are diagnosed, they may keep it secret. They may not want to tell anyone.
--:-- Howard Walensky: What was your inclination when you got your diagnosis? You already knew a lot. You were, you know, you're a health reporter.
--:-- Howard Walensky: How comfortable were you telling people?
--:-- Howard Walensky: I was of a mindset of sharing a story.
--:-- Howard Walensky: And so when I got diagnosed with prostate cancer, I started sharing my story in Facebook.
--:-- Howard Walensky: And suddenly I got a deluge of phone calls from brothers and husbands and uncles and fathers of female friends of mine in Facebook.
--:-- Howard Walensky: And so, you know, not a doctor, but I can share with them my experience.
--:-- Howard Walensky: 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.
--:-- Howard Walensky: And so remember, back when I got diagnosed, only 6% of us went on active surveillance.
--:-- Howard Walensky: Now it's up to 60%. And state of Michigan, it's 90%, which is where it should be.
--:-- Howard Walensky: We're still lagging behind Sweden and UK.
--:-- Noel King: We did an episode of Today Explained last year about menopause. It is not something that women used to talk about.
--:-- Noel King: It is not something that historically has been a big topic of conversation.
--:-- Noel King: But as time has gone on, you're actually seeing women in the public eye talk a lot about menopause.
--:-- Noel King: It's something that's going to happen to all of us.
--:-- Noel King: We might as well get it out there.
--:-- Howard Walensky: 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.
--:-- Howard Walensky: We might be getting more comfortable with this.
--:-- Howard Walensky: You know, it's interesting.
--:-- Howard Walensky: I don't know. You probably remember Senator Bob Dole.
--:-- Senator Bob Dole: In my many years of public service, I've never been afraid of fighting for what I believe is right.
--:-- Senator Bob Dole: 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.
--:-- Senator Bob Dole: He kind of made it okay for men to talk about prostate cancer.
--:-- Senator Bob Dole: 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.
--:-- Howard Walensky: The Congress is filled with these guys with prostate cancer. They don't talk about it.
--:-- Howard Walensky: But Bob Dole made it okay.
--:-- Howard Walensky: He even ran for president after he had been treated for prostate cancer. I think that was a first.
--:-- Howard Walensky: Well, I mentioned Bob Dole, Harry Belafonte.
--:-- Howard Walensky: I'm going to add two more, two people that Secretary Austin can identify with, Colin Powell and his fellow General Storm and Norman Schwartz Club.
--:-- Howard Walensky: All four of these people that I mentioned were open about having prostate cancer.
--:-- Howard Walensky: Arnold Palmer, the golfer, Warren Buffett, the zillionaire, Elton John.
--:-- Howard Walensky: I mean, it's like an honor roll of people in sports, in entertainment, politics to some degree, you know, are open about it.
--:-- Howard Walensky: And so I wrote an open letter that I published in a newsletter I do called The Active Surveiller.
--:-- Howard Walensky: And a lot of people, you know, prominent people in the prostate community signed it.
--:-- Howard Walensky: Basically, we wrote to Secretary Austin that we hit his back.
--:-- Howard Walensky: 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.
--:-- Howard Walensky: And, you know, in a lot of ways, you know, he blew it.
--:-- Howard Walensky: But maybe there's time for him to redeem.
--:-- Noel King: That was Howard Walensky, author of the Active Surveiller Substack.
--:-- Noel King: Thanks to him and to all from the prostate community who called in, we really did love hearing from you.
--:-- Noel King: Thanks also to Dr. Michael Liepman of the Yale School of Medicine.
--:-- Noel King: Victoria Chamberlain produced today's episode.
--:-- Noel King: Matthew Collette edited.
--:-- Noel King: David Herman engineered.
--:-- Noel King: Laura Bullard fact-checked.
--:-- Noel King: Noelle King, that's me, explained today.
--:-- Noel King: Thank you.
