To treat or not to treat? And if the decision is to undergo treatment for prostate cancer, which of the half-dozen or so treatments to choose?

Those are the questions that face the nearly 200,000 American men the American Cancer Society says are diagnosed with the disease each year. The fact that all the treatments carry at least some risk of post-treatment incontinence and/or impotence makes the decision-making even tougher.

Here is how some area patients proceeded:

When he was diagnosed in 2002, Jerome Matthews, 64, a retired state police captain from Reserve, chose to have his tumor removed by open, or hands-on, surgery by Dr. Joel B. Nelson, head of the urology department at UPMC. So did Mark H., 44, a West Virginia restaurateur diagnosed this year who preferred not to be identified by his last name.

Both men underwent radical, nerve-sparing prostatectomies. A "radical" procedure means that there was removal of tissue adjacent to the prostate, a gland found below the bladder and in front of the rectum that produces a fluid that becomes part of semen. "Nerve-sparing" means the surgery is designed to avoid interfering with nerves that produce an erection, although it is not foolproof.

Alan Janus, 61, a project engineer from Bethel Park, also chose surgery, only he went for a robot-assisted laparoscopic procedure called a da Vinci prostatectomy. Relatively new to Pittsburgh hospitals, this da Vinci, which also can be nerve-sparing, was performed by Dr. Arthur Thomas at West Penn Hospital this past February.

James Gregg, 68, of Canonsburg and a retired operating engineer, had interstitial brachytherapy at Allegheny General Hospital after he was diagnosed in 2004. Dr. Russell Fuhrer did the brachytherapy, which involves implantation of dozens of tiny pieces of radioactive metal called seeds in the prostate and is one of two kinds of radiation used against prostate cancer. The other type is external beam radiation, of which there are several varieties.

Retired steelworker Richard Bryan, 68, of Bessemer, Lawrence County, underwent cryotherapy -- which means the tumor was frozen to death -- in May. The procedure was done at AGH by Dr. Ralph Miller, who helped to pioneer the therapy in Pittsburgh in 1990.

A more advanced or a recurrent cancer might be treated by chemotherapy or hormonal therapy. In the latter, drugs are used to trick the body into not producing any testosterone, which the cancer cells need to survive, a process sometimes called "chemical castration." Another option is to remove the testosterone-producing testicles.

And then there are those patients who choose to do nothing, a bona fide medical option known as "active surveillance," or "watchful waiting."

"One of the challenges we face is we don't know that everybody who has prostate cancer in fact needs to be treated," said UPMC's Dr. Nelson. "So that's one of the issues we're dealing with both locally in our own research laboratories and nationally, is what is the best way to manage prostate cancer.

"You're dealing often with really elderly men who have a lot of other medical problems and a tumor that we know is going to be very slow-growing. And so, increasingly, we have begun to note it's probably safe and appropriate to simply watch the tumor, where we carefully keep track of the progression of the tumor and only intervene if we feel it's going to be necessary to avoid symptoms or in the very rare case where somebody would actually die of the disease."

Active surveillance is one of the treatment options presented to patients at the Allegheny General Hospital Prostate Center, a sort of one-stop-shopping medical facility where patients can in one visit see both a urologist and a radiation oncologist specializing in the disease as well as a medical oncologist.

"If you have an expected life span of 10 years or less and the cancer is a small, slow-growing tumor, [active surveillance] might be a fair option," AGH's Dr. Miller said. "It's less good if the life span is greater than 10 years [and] if there is a large volume of cancer and a higher grade of cancer, there is less reason to hold it."

At the AGH center, he added, "we tracked that number [of those choosing active surveillance] and out of the newly diagnosed, 14 percent chose it. ... Across the nation it might be a lower percentage, but it's definitely a treatment option."

Prostate cancer generally afflicts men beginning in their 50s and is more common in African-Americans and men whose fathers and/or brothers and/or sons have had the disease. It is the second-most common cancer afflicting males after skin cancer and is also the second-leading cause of cancer death in American men behind lung cancer, accounting for about 10 percent of men's cancer deaths.

The American Cancer Society estimates that about one man in six will be diagnosed with prostate cancer but -- and here's some good news -- only one in 35 will die from it.

The ACS also reports that there are more than 2 million men in the United States who have been diagnosed with prostate cancer at some time in their lives who are still alive today.

It further says that according to the most recent data for all men with prostate cancer, the relative five-year survival rate is 100 percent; the relative 10-year survival rate 91 percent; and the 15-year relative survival rate 75 percent. Because of new methods of detection and treatment developed during those periods, the ACS added, men diagnosed this year have an outlook "likely to be better than the numbers reported above."

Another number likely to change is the 14 percent of patients at AGH who after initial diagnosis choose active surveillance over a proactive treatment.

"Some of those may change their minds as time goes on," Dr. Miller said, adding that the doctors at the prostate center tell every patient it is an option. "Even for good candidates, it can become a philosophical/psychological decision. ... Some just can't stand the idea of having cancer and not doing anything about it."

Jerome Matthews, an African American who religiously had annual screenings for several years before his diagnosis, did as much research as possible after his cancer was found. He contacted the ACS "and a couple other places across the country," talked to people with experience with the cancer and attended support group meetings. He would never even have considered active surveillance.

"My reason for choosing a radical prostatectomy was I wanted it out as quickly as possible," he said. "It's the quickest, and I thought it would be the most complete." He knew urinary incontinence and impotence were possible side effects even with the nerve-sparing procedure but gave them little consideration.

"Sure it's quality of life, but there is no quality of life without life," Mr. Matthews said. "Life is first." As it turns out, though, he has not suffered from either side effect.

Mark H.'s father had prostate cancer but died of heart problems before he could begin his radiation treatments. Mr. H. did the right thing and regularly had his primary care physician perform the two screening tests, which include a PSA, or prostate specific antigen, blood test and a DRE, or digital rectal exam, on a regular basis. But when she found a nodule and recommended he see a urologist, he backed out because he didn't want to undergo another DRE.

Finally, 10 months later, after his PCP found out he hadn't followed up on it and read him the riot act, he had a biopsy that confirmed the cancer.

He said he "reached out in any way I could," researching both treatment options and doctors. He rejected cryotherapy because impotence was a likely side effect and the da Vinci because local surgeons had only been doing the procedure for a few months. Finally, he said, "I chose Dr. Nelson because he still actually does surgery with his hands."

Alan Janus turned to the Internet to find out all he could about treatments. In the end, like Mark H. and Jerome Matthews, he decided "the most sure way [to cure it] is, of course. removal." Unlike the other two men, though, he was, because of his engineering background, attracted to the da Vinci prostatectomy. "Being a technical-oriented person, that's what I liked."

James Gregg, who was caring for his wife with Alzheimer's disease at the time of his diagnosis, listened to an explanation of the many options at the AGH Prostate Center before choosing the brachytherapy.

"For me, this was the easiest way out," he said. "To me it was less invasive than the others. You do it as an outpatient. My sister took me in in the morning and I went home at night. You go twice a year and get your PSA checked."

Richard Bryan's prostate was pushed up into his bladder, making him a poor candidate for the da Vinci laparoscopy, and because he had had numerous operations for a leg injury he was reluctant to have conventional surgery. "I didn't want to get cut again," he said. Nor did he like the idea of being irradiated.

"I said 'How about if we freeze it?' -- I'd seen it on TV," Mr. Bryan said. "[The doctor] said I was just as good a candidate for that as for the seeds. I said 'Give me the cryosurgery.'

"It looks like I'm heading in the right direction."