Prostate of the union

00:00
Speaker 1
You. Defense Secretary Lloyd J. Austin made a public appearance this week.

00:04
Speaker 2
Good day, everyone. Thanks for working across time zones, his.

00:09
Speaker 1
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.

00:23
Speaker 2
Can the ambulance not show up with lights and sirens? We're trying to remain a little subtle.

00:30
Speaker 1
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.

00:38
Speaker 2
Curious if we need them to take him to Walter Reed medical? Is that a possible.

00:43
Speaker 1
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.

01:00
Speaker 3
The Macintosh computer just turned 40, and longtime tech journalist Walt Mossberg, who has one, has some thoughts on why it stuck around. I don't know of another computer that's 40 years old. I mean, what Apple set down for the Mac is the way all computers, pcs work. This week on the Vergecast, we talk to Walt about the Mac's journey over four decades and where it might go from here. Listen anywhere you get podcasts. I'm Ethan Wu, host of unhedged the markets podcast from the Financial Times. On the show, we answer questions like, are we going to see another financial cris? So I guess where we land at the end of the day is there is a lot of scope for things to go bad here, but maybe not quite 2008 ugly, but smaller ugly. It's the worst way to describe your second child.

01:51
Speaker 3
At least he doesn't eat much. Listen to unhedged, wherever.

02:00
Speaker 4
This is today.

02:01
Speaker 1
Explained.

02:04
Speaker 2
Hi, my name is Tyler. I am calling in regards to the prostate.

02:08
Speaker 1
Tyler is calling in regards to the prostate because we asked you guys about something.

02:14
Speaker 2
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 with somebody bending over and then the doctor having to inspect from the dairy air, 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.

02:52
Speaker 1
Beyond some of this derriere discomfort, you had some big questions about a cancer that kills 3% of men.

03:01
Speaker 2
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.

03:31
Speaker 1
Okay. There is a lot here. And so we called up Howard Wolinsky, who is himself a lot.

03:39
Speaker 5
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. 13 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.

04:34
Speaker 1
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.

04:44
Speaker 5
The prostate itself is a gland. Often you'll hear it's the size of a walnut. But 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 pea from your bladder. 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.

05:35
Speaker 1
So you all need your prostates. Humanity needs your prostates.

05:39
Speaker 5
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.

06:01
Speaker 1
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?

06:16
Speaker 5
I understand why Austin would want to be quiet, but the sub headline was, to the effect, 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 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.

07:16
Speaker 6
Right?

07:16
Speaker 1
And you won the dollar.

07:18
Speaker 5
Well, I didn't even get the donut. Damn it.

07:21
Speaker 1
Why did he keep it secret?

07:22
Speaker 5
Well, of course, only he could answer that. But I can speculate that, 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.

08:15
Speaker 1
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.

08:26
Speaker 2
In general, I think the fear comes from how the exam is conducted. I've always been told, as well, that the pleasure from gasex comes from the prostate. And for some reason, there is a lot of stigma attached to being vulnerable enough, quote unquote, to have your anus inspected in that way.

08:51
Speaker 1
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?

09:02
Speaker 5
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 personally, 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.

09:40
Speaker 1
Dr. Michael Leapman, an oncologist at the Yale School of Medicine, is here to help us dig a little deeper.

09:46
Speaker 4
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 very experienced, and it turns out to be nothing. And so 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 erectile 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.

10:29
Speaker 4
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.

10:42
Speaker 5
Hi, my name is Keith.

10:43
Speaker 6
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 once, but not sure why those numbers go around.

11:07
Speaker 4
We just said that PSA is a great test, but it is prone to fluctuation. 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 we see this very commonly where there are these wide fluctuations.

11:31
Speaker 1
What is treatment for prostate cancer typically look like?

11:34
Speaker 5
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.

11:59
Speaker 4
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.

12:44
Speaker 4
We know that the cancers that are ultimately lethal and aggressive probably start at a younger age. They could be as early as most men are diagnosed with prostate cancer in their. 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.

13:30
Speaker 1
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 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.

13:58
Speaker 5
Noel, I have to tell you, could it be any worse than what the doctors do to women with vaginal exams?

14:05
Speaker 1
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 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 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 if.

14:41
Speaker 5
I can disagree with you a little bit.

14:43
Speaker 1
Sure, you've earned it.

14:46
Speaker 5
Okay, 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 when you're getting into this, 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. There's a huge difference. But you are where you're at, and so you're going to take that seriously.

15:30
Speaker 4
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 ten year life expectancy because finding cancers and treating them might not improve their life, might not improve their longevity.

16:01
Speaker 1
That was howard wolinski. Howard's going to be back with us, and we're going to say goodbye to Dr. Michael leapman of the Yale School of Medicine. Stick around. Hi, everyone.

16:23
Speaker 7
This is kara swisher, host of the podcast on with kara swisher from New York magazine and the Vox Media podcast network. This week on the show, I talked to professor and historian Heather Cox Richardson about how we got here being the age of Donald Trump and the rise of authoritarianism in America.

16:40
Speaker 8
We tend to think about the idea of dictatorships coming in, tanks, for example, or with people goosestepping. And the reality is in this moment that more often people vote down a democracy, that is, they vote into power, people who are pushing toward authoritarianism.

16:57
Speaker 7
It's a great interview, but it's not also despairing. I promise. Professor Richardson still has hope for american democracy. You can listen to our conversation now. Wherever you get your podcast, just search for on with kara swisher.

17:18
Speaker 1
It's today. Explain. Prostate of the union. Today's guest is howard wolinski. He's a medical writer from Chicago. He writes the active surveillor substac. Howard, you were diagnosed with prostate cancer. Tell me about how that went.

17:32
Speaker 5
I've told it a hundred times. I'm happy to tell it 101. I drag my wife along with me and we meet with a doctor, and he says 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 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. You know, if they found something, I was going to get a second opinion. And so I got turned away.

18:28
Speaker 5
Well, I pushed away this doctor, and the first doctor and I went to see the second, 1 second one said, you're the poster child for active surveillance. Said, I predict in ten years your cancer will not have grown. Well, it was even better than that. Ten 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 it still has implications because you're suddenly a cancer patient.

19:13
Speaker 1
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're a health reporter. How comfortable were you telling people?

19:31
Speaker 5
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 so, you know, not a doctor, but I can share with them my experience. And 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 state of Michigan, it's 90%, which is where it should be. We're still lagging behind Sweden and UK.

20:27
Speaker 1
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 know, it's interesting.

21:01
Speaker 5
I don't know. You probably remember Senator Bob Dole.

21:04
Speaker 9
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.

21:16
Speaker 5
He kind of made it okay for men to talk about prostate cancer.

21:21
Speaker 9
I'm asking all men to see their doctor for annual checkup, not only for prostate cancer, but for all problems such as heart disease and colon cancer that hit men especially hard.

21:32
Speaker 5
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 Schwartz Club. 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 are open about it. And so I wrote an open letter that I published in a newsletter I do called the active surveillor, and a lot of know, prominent people in the prostate community signed it.

22:44
Speaker 5
Basically, we wrote to the 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. In a lot of ways, he blew it. But maybe there's time for him to redeem.

23:23
Speaker 1
That was Howard Wolinsky, author of the active surveillor Substac. 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 Leapman of the Yale School of Medicine. Victoria Chamberlain produced today's episode. Matthew Collete edited. David Herman engineered. Laura Bullard, fact checked. Noel King. That's be explained today. All right, we've reached the end of the show. You're still here. We put jokes in the credits just for people like you. Now, all year we're going to continue to bring clear and fact checked reporting to this election, to the stakes, and we would welcome your support. By giving a monthly or annual contribution, you're going to gain access to expressions of our gratitude.

24:27
Speaker 1
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