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"  Fun fact number one: Half of all men who die in this country this year will be killed by heart disease, stroke, or cancer. Fun fact number two: Half of all doctors seem to have different ideas about how to prevent the biggest killers of men. We spoke to the best of them, and we&amp;#039;ve simplified, clarified, and prioritized their advice on minimizing the risks of dying before your time. For more tips, click here. Plus:\u00A03\u00A0Things That Can Happen When You Live Without a Prostate Let us be lovers, let us be open to siren\u00A0songs of death cheated and lives prolonged. Two and a half years ago, a well-known woman published an essay in The New York Times, &amp;quot;My Medical Choice,&amp;quot; about how she decided at thirty-seven years of age to prophylactically, preventively surgically remove her healthy breasts in order to reduce her chances of dying from cancer.\u00A0 &amp;quot;My mother fought cancer for almost a decade and died at fifty-six,&amp;quot; the woman wrote. Ovarian cancer. The woman&amp;#039;s six children had asked her if the same might happen to her, and &amp;quot;I have always told them not to worry, but the truth is I carry a &amp;#039;faulty&amp;#039; gene, BRCA1, which sharply increases my risk of developing breast cancer and ovarian cancer.&amp;quot; Her particular genetic marker, BRCA1, and a related gene tied to sex glands, BRCA2, are extremely rare mutations , and her doctors determined she faced an 87 percent risk of developing breast cancer at some point in her life. Prophylactic surgery was a way out, and post-surgery, her doctors announced her\u00A0chances of developing breast cancer had dropped to below 5 percent. Not cured, exactly, but Angelina Jolie and her brood of Jolie-Pitts may well have felt 82 percent more relieved. (Two years later, to address the concerns about ovarian cancer, she would have two ovaries and two fallopian tubes removed prophylactically, and she would write an essay in the Times about that decision, too.)\u00A0 Within three weeks of Jolie&amp;#039;s double mastectomy, a fifty-three\u00A0year-old British businessman opted to have his healthy prostate removed. The man had enrolled in a clinical trial at the Institute of Cancer Research in London, and his doctors discovered that he carried the faulty BRCA2 gene and thus faced a heightened risk of prostate cancer. Rather than follow the standard of care for potentially high-risk patients\u2014regular blood tests looking for signs of prostate trouble, operating only if cancer is detected and deemed aggressive\u2014he and his doctors determined the most effective way to prevent any eventual onset of prostate cancer, a disease that kills close to thirty thousand men in the U. S. (and eleven thousand in\u00A0the UK) every year, was to remove the organ altogether before the cancer set in. The surgeon who performed the procedure told The Sunday Times: &amp;quot;This patient is now absolutely fine. A number of these BRCA families have now been identified, and knowing you are a carrier is like having the Sword of Damocles hanging over you. You are living in a state of constant fear. I am sure more male BRCA carriers will now follow suit.&amp;quot;\u00A0 The patient (who remains anonymous) was said at the time to have made medical history as the first man to undergo a preventive prostatectomy.\u00A0 This was not exactly true. Let us be frank, for when it comes to\u00A0matters below the belt, men have time and again taken matters into their own hands. Which is pretty much what John Yavornik decided to do fourteen years ago when the shaggy-haired Dallas dentist, then fifty-two, felt something wasn&amp;#039;t quite right with his prostate. Somehow he sensed trouble with the walnut-sized, hormone-fed sexual gland that wraps around a man&amp;#039;s urethra\u2014hard by the bladder and snugged up against the rectum\u2014and houses all manner of nerves that act to trigger erections from one&amp;#039;s teens to one&amp;#039;s seventies. No, Yavornik wasn&amp;#039;t up peeing four times a night, seven to ten times during the day, as countless men with swollen prostates do with life-altering urgency. This here was different. Probably nothing big, maybe BPH (benign prostatic hypertrophy, a condition that constricts urine flow when the gland grows over time), but something.\u00A0 Over the previous six months, Yavornik&amp;#039;s PSA numbers, the best available gauge of prostate cancer, had shown a steady rise in prostate-specific antigen amounts in his blood, from 1.0 ng/mL to 3.0. All within healthy limits, but Yavornik and his then wife, a family practitioner, were concerned by the PSA&amp;#039;s relatively rapid rise. There was also his family history: His maternal and paternal grandfathers had both died of prostate cancer; his father had died of prostate cancer after eight years of prolonged treatment; and his uncle\u2014his dad&amp;#039;s brother\u2014had been killed by the disease. Plus, his sister had been diagnosed with breast cancer, another familial sexual-gland cancer, in middle age. Death by Cancer was rarely far from his mind, and he felt something was wrong deep inside him, a feeling that he still can&amp;#039;t explain to anyone&amp;#039;s (much less his own) satisfaction. &amp;quot;It was metaphysical,&amp;quot; he says on a recent summer day, seated in the living room of the New Mexico adobe ranch home he built with his hands from the red rock up over seven years. &amp;quot;I can&amp;#039;t describe it exactly, but I had a feeling that my prostate should be looked at.&amp;quot;\u00A0 Yavornik&amp;#039;s first stop was a local urologist in Dallas. After performing a PSA test and a digital rectal exam, and after taking six coreneedle biopsies with a staple-gun-like needle-coring device, the doctor found nothing. Biopsy came back clean; PSA results were by-the-book normal. (Anything above 4.0 would have been suspicious, although readings of PSA can often spike into the teens or\u00A0twenties or higher and are still not necessarily, or reliably, a signal of &amp;quot;cancer.&amp;quot; The blood test measures a level of prostate antigen\u2014 a protein\u2014after all, not a concentration of cancer cells.) All fine.\u00A0 Still, Yavornik didn&amp;#039;t feel fine, and he sought a second opinion. Dallas Doc No. 2 took his history and then retreated to the exam table to examine him more carefully. He felt around, finding unremarkable prostate sponginess via a rectal wall. But because Yavornik seemed more anxious than most patients, this urologist decided to go the extra millimeter and take not six or twelve but at least twenty core-needle biopsies of Yavornik&amp;#039;s prostate gland. &amp;quot;If I don&amp;#039;t find it, you don&amp;#039;t have it,&amp;quot; Doc No. 2 told him. The pathology results came back negative\u2014no cancer was evident. Yet this round of biopsy showed atypia, or unnaturally shaped cells, and studies have shown that about 40 percent of prostate patients diagnosed with atypia in biopsy number one would, within six months, have a cancer diagnosis in biopsy two. The rising PSA count, a harrowing family medical history, the troubling atypia: Yavornik didn&amp;#039;t feel much like watching and waiting. &amp;quot;I felt, with my dad&amp;#039;s and uncle&amp;#039;s death, and my sister&amp;#039;s diagnosis of breast cancer, that I had all these bullets coming at me,&amp;quot; he says. &amp;quot;I felt like if I waited five years, with my prostate left in my body like my dad did, it would be too late. It could have metastasized.&amp;quot; He wanted his prostate gone, and when the first two urologists he contacted refused to perform prophylactic surgery, citing the potential for lifelong surgical complications (see below) when there may not even be cancer, he did what any reasonable person in search of something extreme and unusual would do. He went to Florida.\u00A0 Let us fly to Miami if we must, to find\u00A0the best doctors for our bodies as men, when the best biomarker evidence of its time is simply confusing or comes up wanting. This is where Yavornik found Doctor No. 3, Arnon Krongrad, a Miami-area urologic surgeon who was an early developer of laparoscopic (i.e., less invasive) prostate surgery. Krongrad welcomed Yavornik and his wife to his urology practice with a mix of warmth and healthy skepticism, taking it all in: Two licensed practicing urologists already had examined this patient thoroughly; the two together had tested his blood with the best available test at the time and had taken at least twenty-six different samples of his prostate gland and put them under a microscope; and neither doctor, nor any pathologist, had found any evidence of cancer. Yet the patient wanted him to remove his seemingly healthy prostate. &amp;quot;I refused at first,&amp;quot; says Krongrad, who wondered whether Yavornik was, perhaps, just a little bit nuts.  &amp;quot;For all I knew, the guy was waking up at night afraid his prostate was going to eat him,&amp;quot; says Krongrad. &amp;quot;But a psychiatrist I sent him to said he was &amp;#039;anxious&amp;#039; but rational.&amp;quot; Krongrad consulted with other urologists and a medical ethicist, and &amp;quot;the doctors I consulted didn&amp;#039;t have a problem with the surgery. They wanted to know: &amp;#039;What did the lawyers say?&amp;#039; So I had lawyers look at it, and they asked, How would Yavornik&amp;#039;s case be different from a woman having her breasts removed to prevent breast cancer, or a man or woman having their colon removed to try and prevent colorectal cancer? Legally, there wouldn&amp;#039;t be much difference at all.&amp;quot; Krongrad took the case and performed a laparoscopic radical prostatectomy on Yavornik, slicing his prostate into sections, almost like quartering a citrus fruit. Krongrad pulled the sections out of Yavornik&amp;#039;s abdomen and navel area, and when the pathology results came back from the lab, the slides showed something unexpected: Not only was there evidence of cancerous cells in Yavornik&amp;#039;s tissue, but the organ was &amp;quot;loaded with cancer that the biopsies missed,&amp;quot; says Krongrad. &amp;quot;It was wall-to-wall cancer.&amp;quot; Luckily, the cancer had been encapsulated within the prostate gland, meaning the cells had yet to spread to surrounding organs. The cancer had been caught and contained. Yavornik woke from surgery, took in the news, and felt relief. His greatest fear, of early death from prostate cancer, could now be filed and stashed away. He no longer had a prostate, and he was finally at peace. Let us honor the blood and lives lost\u00A0by our prostate-patient brethren\u2014220,000 men receive a diagnosis of prostate cancer each year in the U.S., and more than 27,000 die annually from it. Let us acknowledge also that while millions of lives have been saved by PSAs, needle biopsies, rectal exams, surgery, radiation, radioactive seed therapy, cryotherapy, and chemotherapy\u2014plus new targeted prostate-cancer therapy\u2014millions of men have been overtreated (sometimes when no treatment was required) and left incontinent, impotent, and generally numb where they once felt alive. And let us ask a question of Yavornik&amp;#039;s case that must be asked: Does the fact that he was right about the cancer in his prostate mean the doctors who wouldn&amp;#039;t operate on him were wrong?\u00A0 The answer, according to the overwhelming majority of oncologists and surgeons, is no\u2014at least for now. &amp;quot;If you are scared out of your mind that you are going to die of prostate or breast cancer, and the chances would go way down if you had the [organ] removed, well, we don&amp;#039;t yet know enough to say that that strategy would work for everybody,&amp;quot; says Anna Barker, former deputy director of the National Cancer Institute and now professor of transformative health-care networks at Arizona State University in Tempe. &amp;quot;I am not convinced that removing tissue, removing that organ, is the entire answer.&amp;quot;\u00A0 Consider a living-room lamp in your home that flickers, then goes dark, dies out. Removing and replacing a bulb or even the\u00A0entire lamp may indeed fix the problem for six months or a year, but maybe that&amp;#039;s all. What if the problem didn&amp;#039;t begin inside the glowing bulbs or the lamp fixture housing them? What if the problem started in the wall, in contacts back inside the light switch fully twenty feet across the room? In that case, removing the entire light may not fix the problem at all. Same with preemptively removing, say, a prostate: What if the cancer process began with a confluence of events at a totally different site from the prostate and removing the seemingly healthy organ wouldn&amp;#039;t impact the eventual outcome? Fact is, fact was, scientists still don&amp;#039;t know enough about most forms of cancer to understand its exact origins, including prostate cancer, which is aggressive in only 15 percent of those diagnosed with it.\u00A0 What&amp;#039;s more, the various prostate-cancer screening tests in use today, many of them the very same ones that failed to pick up Yavornik&amp;#039;s cancer, are all lacking in their own troubling way. &amp;quot;The more screening we do, the more indolent [slowly progressing, probably nonlethal] disease we&amp;#039;re picking up among patients,&amp;quot; says Peter Carroll, professor and chair of the urology department at the University of California, San Francisco and a leading researcher in the field\u2014and that&amp;#039;s when the diseases are picked up at all. According to a recent report from the prestigious American Society of Clinical Oncology (ASCO), &amp;quot;ASCO, the American Urological Association, the American College of Physicians, and the U.S. Preventive Services Task Force have released revised prostate cancer screening guidelines that recommend reducing or completely eliminating the use of PSA screening for prostate cancer&amp;quot; due to its unreliability. (Some studies estimate the rate of false negatives, i.e., a low PSA score when cancer is present, at 20 percent, and the rate of false positives, i.e., a high PSA score when there is no cancer, at 75 percent.) The core-needle biopsies, with their thin needles, aren&amp;#039;t always able to distinguish fast-growing cancers from slower-growing ones. And the technology to isolate predictive genes for prostate cancer, which wasn&amp;#039;t available for Yavornik in 2001, remains controversial, with gene tests failing to account for the lifestyle and environmental factors that can lead to cancer. To take an extreme action in the face of such uncertainties\u2014and there are few actions more extreme than healthy organ removal\u2014requires a leap of faith that most doctors are not ready to make. To clear up those uncertainties, says Carroll, &amp;quot;the idea is to use modern technology to find who is more at risk and to then screen these people more carefully.&amp;quot; And that change is coming. According to Jonathan Simons, president and CEO of the Prostate Cancer Foundation, &amp;quot;There will be additional tests beyond PSA in the next three years to [diagnose and] treat prostate cancer earlier.&amp;quot; Enhanced genomic tests, urine tests, and other biomarker tests will help men like Yavornik and their doctors make the best decision for when and how to monitor and treat their disease through surveillance, radiation, chemotherapy, precision-medicine therapy\u2014or surgery. And as many new targeted, precision-medicine cancer drugs enter the picture, patients will need to take new measures to learn about and prepare for side effects and expected outcomes. The notion of &amp;quot;informed consent&amp;quot; when treatment or surgery begins will become far more important and wide-ranging in oncology than in years past.\u00A0 What Yavornik did right when he felt medically wronged was go further than most. He went out and got a far-flung third opinion from a doc who went out and got at least five other opinions. His case was decidedly unconventional, but not otherworldly. And perhaps most important, he knew all his options before taking the most extreme route, even though he wasn&amp;#039;t always sure of his decision.\u00A0A few days post-op, with his then-wife by his side and his temporary catheter attached to his penis, he visited the beach by the hotel near the hospital. All around, he saw here and there other middle-aged men, newly released from the urologic-surgery wing, also sporting catheters and toting urine bags, and he let his mind wander. How many of them had made the right decision for their treatment? How many of them were the 15 percent with the life-threatening form of prostate cancer, and how many had acted unnecessarily, or foolishly? How many had caught their cancer in time, and how many of them, if any of them, would still be around in ten years&amp;#039; time? And really: Would he ever have an erection again? Let us look into the future,\u00A0ever mindful and wary of the past. Although instances of women electing to undergo prophylactic mastectomies have increased steadily over the past twenty years, and preemptive surgeries tied to colon and thyroid cancers are relatively noncontroversial, prophylactic prostatectomies are virtually nonexistent in the United States. Their potential side effects are considered more complex than those of some of the other surgeries, and the special place that prostate cancer occupies in the medical universe\u2014as something that one dies with rather than from\u2014leaves most doctors firmly against preemptive surgical intervention. Things could change. Per the British surgeon who performed the not-first-ever prophylactic prostatectomy back in 2013, it stands to reason that more men, particularly those who are found to carry the problematic BRCA2 gene, will pursue preventative surgeries in the coming years. &amp;quot;I think men will be slower to adopt the process than women,&amp;quot; Barker predicts. &amp;quot;It will take enough patients to actually determine how effective this procedure is, and that is going to take some time.&amp;quot; There are many good reasons right now for them to avoid such a course, starting with shaky diagnostic tools, risky surgeries, unpredictable side effects, and the fact that most of them, even if they do develop prostate cancer, would never require the surgery anyway. But there is one good reason for them to consider it, and that is John Yavornik.\u00A0 Now sixty-six, divorced, and retired, Yavornik lives with his girlfriend in New Mexico and restores old cars in his free time, of which there is a lot. He has experienced no long-term side effects from his surgery; his urinary function returned to normal within a few weeks of his surgery, though he had to wait a full 365 days after his prostatectomy to detect the stirrings of his first post-surgical erection. He thought about calling Krongrad but refrained, and then he thought about putting that and future erections to good use. This article originally appeared in\u00A0Esquire&amp;#039;s November issue. "^^<http://www.w3.org/2001/XMLSchema#string>
<http://www.esquire.com/lifestyle/health/a39025/why-man-removed-his-healthy-prostate/>