By, Dr. Brett Parkinson
Mountain Medical
Every year more than two hundred thousand men are diagnosed with prostate cancer; approximately thirty thousand of those individuals die of the disease.
Many used to consider prostate cancer a death sentence,
but thanks to improved detection and better treatment that is no longer the case.
When questioned, almost all women can locate and identify cancer-prone body parts, such as breasts and the cervix. Most men, however, are clueless when it comes to prostate geography.
The prostate is a small glad about the size and shape of a walnut. It produces a clear, thick fluid that mixes with sperm to form semen. The gland is located just below the bladder, surrounding the upper part of the urethra—the tube that carries urine and semen outside the body through the penis.
SYMPTOMS OF PROSTATE CANCER:
• Difficulty starting or stopping the urinary stream
• Increased urinary frequency, especially at night
• Difficulty or pain with urination or ejaculation
• Feeling of not being able to completely empty bladder
• Blood in urine or semen
• Impotence
PROSTATE CANCER SCREENING:
There are two ways to screen for prostate cancer: a digital rectal examination and a PSA blood test.
1. Digital rectal exam
Because of the prostate’s proximity to the rectum, it is easily accessible on physical exam. The doctor, or other health care provider, is able to feel the gland by inserting a gloved, lubricated finger into the anus. It is uncomfortable, but not painful. Since the examining finger can only perceive tumors on the bottom and sides of the gland, not all cancers can be detected in this way.
2. PSA test
This is a blood test which looks for the PSA protein, which is produced by the prostate gland. Although the normal gland makes some PSA, increased amounts are produced by malignant tumors. However, other conditions–such as benign prostatic hypertrophy (enlargement of the prostate) and prostatitis (infection of the prostate) can cause an elevation in PSA. Therefore, the test is not foolproof and false positives can be a problem.
There is no data to suggest that screening actually reduces death from prostate cancer. (However, screening for breast and colon cancer has been shown to reduce the death rate.) Nevertheless, both the American Cancer Society (ACS) and the American Urological Society (AUS) recommend regular prostate cancer screening.
ACS and AUS Screening Guidelines: Annual rectal exam and PSA test for all men, beginning at age 50.
African-American men and those with family history (father or brother) should begin at age 40.
There are new, more sensitive screening tests on the horizon. Recently published research from Johns Hopkins University looks promising. A new blood test which looks for a different protein, called EPCA-2, is being developed. Unlike PSA, this protein is not found in normal prostate tissue. Rather, it occurs in relatively large amounts only in prostate cancer cells. Preliminary data suggests that this new test may identify men with prostate cancer, rather than those with just enlarged or inflamed glands. The chief investigator, Robert H. Getzenberg, PhD, reports
that the new test is “97% specific, meaning that if you test positive there’s only a 3% you don’t have prostate cancer.” Since the test has been tried on so few people, more research is needed for validation.
If a man has an elevated PSA or a suspicious finding on digital rectal examination, the next step is a biopsy. The biopsy is performed using a transrectal ultrasound. An ultrasound probe is inserted into the rectum, allowing the doctor to see the prostate gland and decide which tissue to sample. Any suspicious areas are biopsied with a needle. In addition, random samples are taken from different parts of the gland to make sure no small cancers go undetected. The test is performed while the patient is awake. If a biopsy is positive, there are several treatment options:
TREATMENT OPTIONS:
• Surgery
• Radiation Therapy
• External Beam Radiation (comes from an external source)
• Radioactive seeds (comes from an internal source; radioactive seeds are placed in the prostate)
• Hormonal Therapy
• Since male sex hormones promote tumor growth, agents that block the effect of testosterone can impede tumor growth. Removal of the testicles can also have this effect.
• When the cancer is advanced, or has spread to other parts of the body, chemotherapy is then considered.
Most early prostate cancers can be effectively treated with surgery or radiation therapy.
Survival rates are equal for the tow methods of treatment
COMPLICATIONS OF TREATMENT:
• Impotence
• Incontinence
• Bladder irritation, rectal bleeding and diarrhea can occur from radiation therapy
For men with early prostate cancer, a nerve-sparing prostatectomy can be performed which increases the likelihood of preserving sexual function. However, this is a technically demanding surgical procedure, requiring a well-trained and highly-skilled urologist. Any man contemplating prostate surgery should ask his prospective urological surgeon about his/her complication rates.
OTHER OPTIONS
• Watchful Waiting
May be appropriate for older men with small, low-grade tumors, and slowly rising PSAs; or in those who have medical problems that would make them ineligible for surgery or radiation; or since prostate cancer is usually slow-growing, in men whose life expectancy is less than 10 years.
• Cryosurgery: Essentially freezes the tissue. Not currently recommended as is has not been shown to be more effective than radiation or surgery.
FOLLOW UP
Even though a patient has been treated, he should be followed for possible recurrence. This usually includes a PSA test, digital rectal exam and sometimes X-rays.
PROSTATE FACTS
• 232,000 men diagnosed with prostate cancer every year; approximately 30,000 will die of the disease
• After lung cancer, the leading cause of cancer related deaths in men
• African-American men are 65% more likely to be diagnosed than Caucasian-Americans, and twice as likely to die
• Early prostate cancer usually has no symptoms; can be picked up only with screening
• Five-year survival rate for prostate cancer is 98%; 84% at 10 years.
• Risk of dying of prostate cancer increases with obesity
• A high fat diet appears to be a risk factor
The challenge in the diagnosis and treatment of prostate cancer lies in the decision of whom to screen and how aggressively to treat. The experts continue to struggle with these issues. Even if the EPCA-2 test eliminates false positives, and the unnecessary worry and medical procedures generated from an elevated PSA in a patient without cancer; we are still left with the problem of how to treat those who are actually diagnosed with the disease. And do as little harm as possible. After all, the side effects of treatment–impotence and incontinence–pose significant problems for affected men.
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