Why Zappa died so young

By Dr Thomas Stuttaford

The Times, December 7, 1993

The rock star’s death from prostate cancer should make others more alert to the disease’s dangers.

TWO years ago, Moon Unit, daughter of Frank Zappa, announced to the audience waiting for him that the show was off as her father had carcinoma of the prostate.

Zappa died on Saturday, aged 52, an example of how lethal this cancer can be if treatment is postponed, often unavoidably, until symptoms draw the attention of the patient and their doctors to the tumour.

Cancer of the prostate is hormone dependent, that is to say that if the level of the male hormones is reduced by surgical or medical castration – such as hormone treatment – the malignant tissue will shrink, and the patient will be trouble-free for a length of time.

Zappa was unfortunate that his tumour was fast-growing and soon slipped out of hormonal control. In another case involving a world-famous celebrity, Lord Olivier lived for about 20 years after he initially developed a cancer and had treatment at a London teaching hospital.

When Zappa first developed symptoms he was, certainly in medical terms, young. Roger Kirby, a consultant surgeon at St Bartholomew’s Hospital, London, who has a particular interest in prostate disease, said that prostate cancer in younger patients is attracting special interest at the moment as there seemed to be in many, but not all cases, a strong genetic link.

If a first-degree relative, whether brother or father, had the disease, a patient is more than twice as likely to develop it than is a man with no familial links: if a patient has two first-degree relatives who have been affected, the risk is quadrupled. The Americans are now carrying cut a trial with 7.000 high risk patients to see if routine prophylactic treatment with Proscar, a drug which shrinks the prostate, could do for men’s prostates what Tamoxifen can do to save women from breast cancer.

Benign enlargement of the prostate is an almost inevitable consequence of aging: it is as much part of an older man’s life as is grey hair or balding. But there is a difference. A few grey hairs do not affect the quality of life, but an enlarged prostate is both damaging to kidney function and can impair enjoyment of life and restrict employment. As Mr Kirby said, “Patients and their doctors need to be aware of prostate-related disease, not only for the early detection of cancer but for the better treatment of benign enlargement.

“Forty-three per cent or men over 60 have symptoms of prostatic enlargements, of whom half are so badly affected that their quality or life is impaired.” These men, he said, may have to get up several times a night and are unable to sit through a single act at the theatre, and have to excuse themselves from meetings, or stop every two hours on the motorway.

The same symptoms are a warning of prostatic enlargement, whether benign or malignant.

In Britain every year, 9,000 men die from cancer of the prostate. In America. the figure is 32.000. But hope has now been given to mankind by the discovery or a blood marker which helps to differentiate malignant enlargement of the prostate from benign hypertrophy. This tests the prostatic specific antigen (PSA), which usually rises in age as the prostate enlarges but rises particularly quickly if the enlargement is from malignant tissue.

If the PSA reading is under four, only a tiny proportion of the patients will be found to have a malignancy: between four and ten, a patient needs to have a specialist opinion, for the specialist is more expert in judging a prostate from rectal examination. If here is marked increase in the PSA after a year, the latest evidence suggests that a 20 per cent increase during this time carries a 17 per cent chance or cancer, and a biopsy of the gland can be organised. If the PSA is over ten, the chance of malignancy is one in two, and biopsy at the gland may almost certainly be recommended.

Some surgeons are now suggesting that older patients should initially be treated with Proscar and if the PSA falls by 50 per cent, the rumour is probably benign, if the level remains static, further immediate investigations are called for.

Cancer or the prostate is, in its earlier stages, a curable disease when treated by radical prostatectomy. The problem has been that, as the cases of Lord Olivier and Zappa illustrate, the natural outcome is variable and surgeons are reluctant to venture into radical treatments if the chance of survival without them might well be good. Older doctors, too, remember when radical prostatectomies were associated with a 25 per cent death rate for the unlucky, and weeks lingering in hospital for the more fortunate. Times have changed: in the last 56 radical prostatectomies performed by Mr Kirby at Barts, none died. Modem surgery is nerve and blood vessel sparing, so that in 50 per cent of cases the patients potency is preserved, and only 2 per cent later have incontinence.

ln America, the radical prostatectomy rate among patients covered by its largest insurance scheme has risen from 6,852 in 1986 to 39,157 in 1992, the period in which PSA has been available. In Britain, a similar trend will certainly be seen if improved PSA type tests from Abbott Laboratories and Hybritech come satisfactorily through their trials.

“Doctors when asked to carry out a medical must think beyond the heart and lungs, to the areas below the umbilicus which they might prefer to ignore.” Mr Kirby said. “They must ask about urinary stream as well as chest pain and be prepared to use their surgical gloves for a rectal examination, as well as a stethoscope and an ECG machine. The PSA needs to be measured as well as the serum cholesterol.” If doctors and patients are to take full advantage of these advances such as PSA, they must become more prostate conscious.