When Richard Wassersug gives a lecture, he likes to begin with a provocative question: Who in our modern society is castrated?
The answer invariably comes back loud and clear: sex offenders. Someone may venture another guess: transsexuals? Or maybe men with testicular cancer?
Wrong, wrong and wrong.
In reality, castration is almost exclusively the lot of men with advanced prostate cancer.
An estimated 500,000 men in North America have been surgically or chemically castrated, the latter with a treatment known as androgen deprivation therapy, and their ranks are swelling by 40,000 a year. Yet the practice and the devastating side effects that can result are virtually never discussed publicly, and most patients suffer alone in silence.
“Right now, it's such a humiliation to be androgen-deprived that patients barely even talk to other patients,” said Dr. Wassersug, a professor of anatomy at Dalhousie University in Halifax, and a prostate cancer survivor. “To admit that you've been castrated is shameful.”
But Dr. Wassersug and a growing number of activists have no such shame. They are aiming not only to break the silence but to end the emasculation – sexual, social and medical – that castration can bring about.
Dr. Wassersug was diagnosed with prostate cancer in 1998, at age 52. He underwent surgical removal of his prostate – a walnut-sized gland located between the bladder and the rectum – as well as radiation.
The treatments failed to eliminate all the cancerous cells, so he was prescribed androgen-deprivation therapy.
Prostate cancer is a hormonally fuelled cancer. Cancerous cells feed on testosterone – the principal male sex hormone – and the way to snuff out their spread is cut off the fuel supply.
Most testosterone (also known as an androgen) is produced in the testicles. So men are left with an agonizing choice: Accept castration – surgical or chemical – or risk cancer running rampant in the body. “There are hundreds of thousands of men who are faced with this difficult decision,” said Andrew Loblaw, a radiation oncologist at Sunnybrook Regional Cancer Centre in Toronto.
Worse yet, the decision is not nearly as clear cut as it seems, because of the potentially devastating side effects and the fact that while ADT may prolong lives, it doesn't save them.
While stopping the production of testosterone slows cancer growth, researchers don't know exactly who benefits most from ADT, when it is best to begin treatment and, more important, whether castration improves quality of life in the long run.
“We really don't have good answers for those questions,” Dr. Loblaw said. He is currently recruiting prostate cancer patients for a study that should provide answers, but it will take at least a decade.
In the meantime, Dr. Loblaw said, it is important for patients to discuss the issue more openly and make decisions based on the best available evidence. “In my experience,” he said, “people want to choose their poison.”
Most treated successfully
This year in Canada, 223,000 men will be diagnosed with prostate cancer, according to the Canadian Cancer Society. Most of them will be treated successfully and eventually die of another cause. But 4,300 men will die of prostate cancer. All of them, and many others, will have been offered castration as a means of prolonging their lives.
ADT aims to shut down production either through orchiectomy (surgical removal of the testicles) or using drugs called luteinizing hormone releasing hormone (LHRH) agonists.
In 1941, Charles Huggins, a Canadian-born researcher, showed that removing the testicles dramatically improved the fate of men with prostate cancer, a discovery that earned him a Nobel Prize. Then, in the early 1980s, French scientist Ferdinand Labrie showed the same effects could be achieved with drugs, and LHRH agonists have been the standard treatment since.
