Thursday, December 13, 2007

Prostate Cancer

I've known several people who have been diagnosed with prostate cancer, which is not surprising given that this is a common cancer among men, and I am now at that age that my male friends are in the likely age range to develop it.

Luckily, prostate cancer, when found early, is highly curable and in most cases not that aggressive. It is said more men die with prostate cancer than of it.

What is Prostate Cancer?

As it is described in nearly every website on the subject, the prostate is a "walnut-sized gland" located under the bladder and in front of the rectum.

Helpfully, the American Cancer Society also explains that only men have one, which, if you didn't already know this, is good information to have if you're a woman - this means if you are a female hypochondriac it's one cancer you don't have to worry about. (Don't worry, you have several other female-only cancers to choose from that men don't have to worry about, so don't get too smug).

According to the American Cancer Society, over 99% of prostate cancers develop from the "gland cells," which make the fluid that is added to the semen. The cancer arising from this type of cell is called "adenocarcinoma."

Other types of cancer that can start in the prostate gland include sarcomas, small cell carcinomas, and transitional cell carcinomas. Because these other types of prostate cancer are so rare, this post will just focus on adenocarcinoma.

Overall, prostate cancer tends to be slow-growing, and autopsy studies show that many older men who died of other diseases also had prostate cancer. The studies indicate that 70% to 90% of the men had cancer in their prostate by age 80, but in many cases neither they nor their doctors even knew they had it.

How Is It Diagnosed?

In the past, men frequently didn't receive a diagnosis until symptoms showed up, by which time it often was too late. Now there are methods available that can diagnose prostate cancer at a much earlier stage. From the Mayo Clinic website: the following screening tests are used today:

Digital rectal exam (DRE). During a DRE, your doctor inserts a gloved, lubricated finger into your rectum to examine your prostate, which is adjacent to the rectum. If your doctor finds any abnormalities in the texture, shape or size of your gland, you may need more tests.

Prostate-specific antigen (PSA) test. A blood sample is drawn from a vein and analyzed for PSA, a substance that's naturally produced by your prostate gland to help liquefy semen. It's normal for a small amount of PSA to enter your bloodstream. However, if a higher than normal level is found, it may be an indication of prostate infection, inflammation, enlargement or cancer.

Memorial Sloan Kettering recommends the following criteria in interpreting PSA tests:

"To balance the influence of age on PSA levels, the following age-specific PSA level cut-offs should be considered:

Greater than or equal to 2.5 ng/mL for men up to age 49
Greater than or equal to 3.5 ng/mL for men aged 50 to 59
Greater than or equal to 4.0 ng/mL for men aged 60 and older.

Men with values outside their age-allowed targets should be considered as candidates for prostate biopsy.

For those men being screened for PSA velocity, a PSA velocity of greater than or equal to 0.75 ng/mL per year should necessitate a prostate biopsy -- even if the PSA level is in the normal range."

There are differences of opinion among experts about PSA testing. The American Cancer Society recommends that both the PSA and DRE should be offered annually, beginning at age 50, to men who have at least a 10-year life expectancy. However, men at high risk, which includes African American men and men with a strong family history of close relatives diagnosed at an early age, should begin testing at age 45.

Experts in favor of regular screening believe that finding and treating prostate cancer early offers men more treatment options with potentially fewer side effects. Those who recommend against regular screening feel that because most prostate cancers grow so slowly, the side effects of treatment would likely outweigh any benefit that might be derived from detecting the cancer at a stage when it is unlikely to cause problems. Although the jury is out on this one, given that two of my friends discovered their cancers solely through an abnormal PSA test, I tend to believe in testing.

The following tests are used to diagnose prostate cancer if the initial DRE and PSA tests raise a red flag. (From the Mayo Clinic site):

"Transrectal ultrasound. If other tests raise concerns, your doctor may use transrectal ultrasound to further evaluate your prostate. A small probe, about the size and shape of a cigar, is inserted into your rectum. The probe uses sound waves to get a picture of your prostate gland.

Prostate biopsy. If initial test results suggest prostate cancer, your doctor may recommend a prostate biopsy. During a biopsy, small tissue samples are taken and analyzed to determine if cancer cells are present.

To do a biopsy, your doctor inserts an ultrasound probe into your rectum. Guided by images from the probe, your doctor identifies any suspicious areas. Then a fine, hollow needle is aimed at these areas of your prostate. A spring propels the needle into your prostate gland and retrieves a very thin section of tissue."

The biopsy could show either no cancer, precancerous or cancerous cells.

It is believed that prostate cancer begins with a pre-cancerous condition called "prostatic intraepithelial neoplasia" or PIN. Almost half of all men have this condition by the time they reach 50. Under a microscope, the gland cells with PIN appear changed, but not invasive. They can be low-grade (almost normal) or high-grade (more abnormal).

Doctors recommend that men with high-grade PIN be watched carefully and a repeat biopsy may be necessary.

Another type of precancerous condition that may be found is "atypical small acinar proliferation," or ASAP, sometimes known as "atypia." It just means there are some possibly cancerous cells showing up in the biopsy, but not enough to be sure. If ASAP is found, there's about a 40% to 50% chance that cancer is also present in the prostate, which means it's best to get a repeat biopsy within a few months. You might think of "ASAP" as meaning "get another biopsy ASAP!"

If the cells that are evaluated turn out to be cancer, then there may be more tests ordered to understand how advanced the cancer is, if there is a possibility cancer may have spread (from the Mayo Clinic website):

"Bone scan. A bone scan takes a picture of your skeleton in order to determine whether cancer has spread to the bone. Prostate cancer can spread to any bones in your body, not just those closest to your prostate, such as your pelvis or lower spine.

Ultrasound. Ultrasound not only can help indicate if cancer is present, but also may reveal whether the disease has spread to nearby tissues.

Computerized tomography (CT) scan. A CT scan produces cross-sectional images of your body. CT scans can identify enlarged lymph nodes or abnormalities in other organs, but they can't determine whether these problems are due to cancer. Therefore, CT scans are most useful when combined with other tests.

Magnetic resonance imaging (MRI). This type of imaging produces detailed, cross-sectional images of your body using magnets and radio waves. An MRI can help detect evidence of the possible spread of cancer to lymph nodes and bones.

Lymph node biopsy. If enlarged lymph nodes are found by a CT scan or an MRI, a lymph node biopsy can determine whether cancer has spread to nearby lymph nodes. During the procedure, some of the nodes near your prostate are removed and examined under a microscope to determine if cancerous cells are present."

Once a cancer is identified and necessary tests are done, Grading and Staging can be performed. These evaluations help you and the doctor decide on your treatment.


Grading is the process by which cancer cells are evaluated in terms of how aggressive they may be. The most common cancer grading scale runs from 1 to 5, with 1 being the least aggressive form of cancer.

The pathologist then assigns scores to the cancer, called Gleason scores. The Gleason score adds the grades of the two most aggressive types of cancer cells found in the tissue, so scoring may range from 2 (non-aggressive cancer) to 10 (very aggressive cancer).


The next step is called staging, which determines if or how far the cancer has spread:

Stage I. Signifies very early cancer that's confined to a microscopic area; it cannot be felt by the doctor.

Stage II. The cancer can be felt, but it remains confined to your prostate gland.

Stage III. Cancer has spread beyond the prostate to the seminal vesicles or other nearby tissues.

Stage IV. The cancer has spread to lymph nodes, bones, lungs or other organs.

What Symptoms Can Prostate Cancer Cause?

Although early prostate cancer doesn't cause any noticeable symptoms, eventually it can cause the following:

-Dull pain in your lower pelvic area
-Urgency of urination
-Difficulty starting urination
-Painful urination
-Weak or intermittent urine flow;dribbling
-A feeling that your bladder doesn't empty
-Frequent urination, especially at night
-Blood in the urine
-Painful ejaculation
-General pain in the lower back, hips or upper thighs
-Loss of appetite and weight
-Bone pain

Please don't panic if you do have some of these symptoms, as there are other conditions that can cause them. One of the most common is BPH, or benign prostatic hyperplasia. This is a harmless enlargement of the prostate caused by changes in the body's hormone levels. In older men, the inner part of the prostate around the urethra may continue to grow, and eventually cause problems leading to symptoms such as frequent urination, difficulty urinating, urination during the night, etc. Although this is a benign condition, it is important to get symptoms checked out and make sure that they aren't caused by cancer. BPH can be treated with medications, or if it is more severe, a surgical procedure called a TURP can solve the problem.

What are the Risk Factors for Prostate Cancer?


Age is the strongest risk factor for prostate cancer; the chance of getting it rises quickly over the age of 50. Two-thirds of prostate cancers are found in men over 65.


Prostate cancer occurs more often in African-American men than in men of other races. African-American men are also more likely to be diagnosed at an advanced stage, and are more than twice as likely to die of prostate cancer as white men.

Conversely, prostate cancer occurs less often in Hispanic, American Indian, and Asian/Pacific Island men than in non-Hispanic whites. It is not known why these differences occur. (See chart below from the CDC for a comparison).

Prostate Cancer Death Rates by Race/Ethnicity in Men Aged 45 and Above


Prostate cancer is most common in North America, northwestern Europe, Australia, and on Caribbean islands. It is less common in Asia, Africa, Central America, and South America. Intensive screening in the more developed countries may account for some of this difference, but other factors, such as lifestyle differences (diet, etc.) may be important as well.

Family History

Prostate cancer seems to run in some families, so there may be a genetic factor. Having a father or brother with prostate cancer more than doubles a man's risk of developing this disease. (The risk is higher for men with an affected brother than for those with an affected father.) The risk is much higher for men with several affected relatives, especially if their relatives were young at the time the cancer was found.

Scientists have found several genes that seem to raise prostate cancer risk, but they probably account for only a small number of cases overall. Genetic testing for these genes is not yet available.

(One of my friends, who was diagnosed with prostate cancer through a routine PSA test, immediately called his brothers and told them to be checked - and a good thing, too. One of his brothers was also diagnosed with prostate cancer as a result of his warning.)

Some inherited genes raise the risk for more than one type of cancer. For example, inherited mutations of the BRCA1 or BRCA2 genes, which lead to breast and ovarian cancers, may also increase prostate cancer risk in some men. So if there seems to be a pattern of women in a family with breast or ovarian cancer, the men in the family may be at a higher risk of prostate cancer and should be checked.


A number of dietary factors may raise risk of prostate cancer. Men who eat a lot of red meat or high-fat dairy products appear to have a slightly higher chance of getting prostate cancer. These men also tend to eat fewer fruits and vegetables, so it is not clear whether it is the presence of the red meat and dairy or the absence of fruits and vegetables that is to blame. A diet high in fat also seems to be a risk factor.

Some studies have suggested that men who consume a lot of calcium may also have a slightly higher risk; this may be why dairy products are associated with a higher risk as well.


Although being obese does not seem to be linked with a higher risk of getting prostate cancer, several studies have found that obese men may be at greater risk for having more advanced prostate cancer and of dying from prostate cancer. The reasons for this are not clear, although it may be the connection with higher fat diets and higher fat levels in the body that does it.

Infection and Inflammation of the Prostate

Some studies have suggested that prostatitis (inflammation of the prostate gland) may be linked to an increased risk of prostate cancer. Inflammation is often seen in samples of prostate tissue that also contain cancer.

Can Prostate Cancer be prevented?

Eating more fruits and vegetables, particularly tomatoes, may confer some protection. Lycopene, a substance found in tomatoes, which is also available as a supplement, may help as well. One study has shown that pomegranate juice may be protective. Several other agents, including difluoromethylornithine (DFMO), isoflavonoids, selenium, and vitamins D and E have shown potential benefits in studies. Further studies are needed to confirm this.

A drug calle finasteride is being studied as a possible preventive agent, as it lowers testosterone levels, as this hormone is another factor in developing prostate cancer.

How is Prostate Cancer Treated?

Treatments options vary depending on the grade and stage of the cancer, the patient's age and overall life expectancy. Many factors must be taken into account, including the patient's own attitude toward the cancer. Some people just want to have the cancer removed, and are not as concernd with side effects, while others are more focused on their quality of life afterward. These concerns may result in different treatment choices even within the same stage of cancer. Following are some options recommended by the American Cancer Society.

Stage I

Since these prostate cancers are small and not aggressive, for elderly patients "watchful waiting" (by following PSA numbers) may be preferred. Other choices may be radiation therapy (either external beam therapy or the implantation of radioactive seeds (called brachytherapy).

Men who are younger and healthy may consider watchful waiting, radical prostatectomy (complete surgical removal of the prostate), or radiation therapy (external beam or brachytherapy).

Stage II

Stage II cancers that are not treated with surgery or radiation are more likely to eventually spread and cause symptoms. However, for elderly men who have other health problems, watchful waiting may still be the best option if the cancer isn't causing symptoms. These men are still more likely to die of something else rather than prostate cancer. However, surgery or radiation therapy may also be options for them.

For younger men who are healthy overall, radical prostatectomy (often with removal of the pelvic lymph nodes) may be the preferred choice. This may be followed by external beam radiation if the cancer is found to have spread beyond the prostate at the time of surgery, or if the PSA level is still detectable several weeks after surgery. This may be either external beam radiation, brachytherapy, or a combination of both. Participation in a clinical trial may be considered in order to take advantage of newer treatments. For aggressive cancers (as measured by Gleason score and PSA level), hormone therapy (to block the production of testosterone) may be added.

Stage III

Stage III cancers have spread beyond the prostate gland but have not reached the bladder, rectum, lymph nodes, or distant organs.

Treatment options at this stage may include:

-external beam radiation plus hormone therapy
-hormone therapy only
-radical prostatectomy in selected cases (often with removal of the pelvic lymph nodes). This may be followed by radiation therapy.
-watchful waiting for older men whose cancer is causing no symptoms or for those who have another more serious illness
-taking part in a clinical trial of newer treatments

Stage IV

Stage IV cancers have already spread to the bladder, rectum, lymph nodes, or distant organs such as the bones. These cancers are not considered to be curable, but treatment can be palliative and prolong life.

Treatment options may include:
-hormone therapy
-external beam radiation plus hormone therapy (in selected cases)
-surgery (TURP) to relieve symptoms such as bleeding or urinary obstruction
-watchful waiting for older men whose cancer is causing no symptoms or for those who have another serious illness
-taking part in a clinical trial of newer treatments

If symptoms are not relieved by standard treatments and the cancer continues to grow and spread, chemotherapy may be considered.

Treatment of stage IV prostate cancer may also include treatments for relief of symptoms such as pain.

One of the people I knew who had prostate cancer was a friend's father, who was diagnosed when he was nearly 80. Given his age and other health problems, and the stage of his cancer (which must have been III or IV), he was treated with hormones only. He lived about 18 months after his diagnosis.

For more details on all of the types of treatments, please see the Mayo Clinic website.

What Happens Next?

After prostatectomy, PSA levels are monitored to ensure the cancer is not returning. Since surgery removes the entire prostate, PSA levels should be undetectable afterward.

After radiation therapy, PSA is also monitored, but since the prostate has not been removed, the levels are not expected to be undetectable. A PSA that is rising on consecutive tests after treatment might indicate that cancer is still present.

For recurrent prostate cancer, the same treatments are available, depending on what has already been tried. If a patient has already had radiation treatment, for instance, then radiation treatment would not be an option if the cancer recurs. Surgery may still be an option, as is hormone therapy. For those whose cancer does not respond to hormone therapy, chemotherapy can extend life and reduce pain.

All treatments have side effects, varying from discomfort to impotence. It is important to understand the risks of these side effects before starting any treatment; be sure to discuss them with your doctor and make sure the doctor understands what your priorities are.

As with all cancers, when you are diagnosed, be sure to consult with various experts, including an oncologist and a radiation oncologist, as well as a surgeon, to truly understand your options. In addition be sure to consult with a major cancer center such as M.D. Anderson, Memorial Sloan Kettering, the Mayo Clinic, Johns Hopkins, or Dana Farber.

Will You Get It?

According to the American Cancer Society, about 1 man in 6 will be diagnosed with prostate cancer during his lifetime, but the good news is, only 1 man in 35 will die of it. If you have some of the risk factors mentioned above, then just make sure to get regular checkups and even if you do get it, you will likely catch it early and be cured.

Over 90% of these cancers are now found while they are still confined to the prostate gland, making them highly curable. Five-year survival rates are now at 99% for these men; for those whose cancer has spread to distant parts of their body, only 1/3 survive 5 years.

Sources used for this article: (American Cancer Society) (Memorial Sloan Kettering) (Mayo Clinic)

Other excellent sources of detailed information, including the latest news and other resources on Prostate Cancer: (Medline Plus) (National Cancer Institute) (Prostate Cancer Foundation) (Web MD)