Prostate cancer is very common, although its exact cause is unknown. Each year more than 150,000 new cases of prostate cancer are diagnosed in the United States, and more than 30,000 deaths are caused by this disease. It is third after lung cancer and colon cancer as a cause of cancer death in men.
Your risk of getting prostate cancer escalates after age 50, and having a father or a brother with the disease triples your risk. You are also at increased risk if you are African American. Prostate cancer can grow slowly—so slowly that years can pass before the disease becomes evident. Most cancer of the prostate never becomes life-threatening because men tend to develop it later in life and often die of another cause. However, some cancers of the prostate may be more aggressive and shorten the person’s life. In some men the cancer grows so grad- ually that it never produces any symptoms. In others, prostate cancer causes a weak or interrupted ﬂow of urine, inability to urinate, difﬁculty in starting or stopping the ﬂow of urine, frequent urination (especially at night), blood in the
urine, pain or burning during urination, or persistent pain in the lower back, pelvis, or upper thighs.
Prostate cancer usually is discovered in one of three ways: as the result of a prostate-speciﬁc antigen (PSA) blood test (see box below); during a digital rec- tal examination; or during an operation called a transurethral resection of the prostate, done to treat an enlarged prostate. To promote early detection, every white male over age 50 with no family history of prostate cancer should have a digital rectal examination performed by his doctor. Every African American male over age 45 and every white male over 45 with a family history of prostate cancer also should have a digital rectal examination. See your doctor immedi- ately if you experience any of the symptoms of prostate cancer. When discussing prostate problems with the doctor, men of any age should mention if they are sexually active.
The PSA Test
Ablood test called the prostate-speciﬁc antigen (PSA) test has been developed to diag- nose prostate disease, including cancer, enlargement, and inﬂammation. The PSA test measures the blood level of a protein called prostate-speciﬁc antigen that is produced only by the prostate gland and is normally not found in the blood. High levels of this pro- tein in a man’s blood suggest the possibility of prostate cancer but also may indicate less serious prostate problems, such as an enlarged prostate or inﬂammation. Because of this, the test results need to be conﬁrmed by removing a tiny portion of the prostate gland and examining it under a microscope, a procedure known as a biopsy.
A considerable amount of controversy exists about whether the PSA test should become an annual part of the health checkup for men over age 40. The test is useful for detecting tumors that cannot be found during a digital rectal examination. On the other hand, the test results can be uncertain, resulting in unnecessary follow-up procedures that may include a biopsy or even surgery. Still, the PSA test is the best technique doctors cur- rently have to discover tumors in the prostate gland while they remain small and are poten- tially curable.
If you are over 50 years of age (45 if you are African American), discuss with your doctor the pros and cons of having an annual PSA test and the possibility of follow-up procedures if elevated levels are found. Only by talking with your doctor about the test can you come to the decision that is best for you.
Various treatments for prostate cancer are available, including surgery, radia- tion therapy, hormone therapy, chemotherapy, and combinations of these. When determining a treatment plan for you, you and your doctor will evaluate the ben- eﬁts and possible side effects or risks of the available therapies, taking into account your age, your feelings and preferences, any other health conditions you
may have, and the stage of your cancer. If you are an older man and your cancer is at an early stage, your doctor may recommend nothing more than “watchful waiting.” Watchful waiting means that you would have regular digital rectal examinations to monitor your prostate, PSA blood tests every 3 to 6 months, and, perhaps, a yearly biopsy of your prostate.
The most common surgical procedure for prostate cancer is a radical prosta- tectomy. Radical prostatectomies are performed when the cancer does not appear to have spread beyond the prostate. In a radical prostatectomy, the whole prostate gland and the seminal vesicles are removed, along with surrounding tissue and, often, pelvic lymph nodes. In some cases, a procedure called transurethral resec- tion of the prostate (TURP) is used to relieve symptoms before other treatments are used. TURP is most often used to treat noncancerous enlargement of the prostate (see page 170). Cryosurgery (also known as cryotherapy) is occasion- ally used to treat prostate cancer that has not spread beyond the prostate. In cryosurgery, a surgeon destroys cancerous cells by freezing them with a metal probe. Cryosurgery is generally not used as a ﬁrst-line therapy.
One of two types of radiation therapy may be used to treat prostate cancer: external radiation therapy and internal radiation therapy (also called brachyther- apy). In external radiation therapy, the physician uses a machine to aim high- power rays (gamma rays or X rays) or particles (electrons, protons, or neutrons) from outside the body directly at the tumor and, in some cases, the surrounding lymph nodes. In brachytherapy, tiny (about the size of a grain of rice), low-level radioactive pellets are inserted (permanently or temporarily) into the prostate gland. The doctor uses an imaging method such as ultrasound or CT scanning to guide the placement of the pellets. The permanent pellets, which give off radia- tion for a period of weeks or months, are left in place. In some cases, pellets con- taining high doses of radiation are inserted for less than a day and removed. Brachytherapy and external radiation therapy are frequently used together.
Hormone therapy is usually used for men whose prostate cancer has spread to other parts of the body or whose cancer has returned after treatment. The goal of hormone therapy, which is not a cure, is to lower the levels of androgens (male hormones such as testosterone, which can stimulate the growth of cancer cells in the prostate), thereby shrinking the cancer or slowing its growth. The two most effective ways to lower androgen levels are to surgically remove the source of androgens, the testicles (in a procedure called orchiectomy), or to give injections of medications that block the production of testosterone. The injections are usu- ally given monthly, every 3 months, or every 4 months at the doctor’s ofﬁce or at a cancer center. Hormone therapy probably works best if it is started as soon as possible after the cancer has reached an advanced stage.
Because the adrenal glands produce a small amount of androgens, drugs called antiandrogens are sometimes used in addition to orchiectomy and testos- terone-lowering drugs to inhibit the body’s ability to produce the hormones.
These medications are usually taken as pills one to three times a day. This treatment does not appear to be as effective as the other treatments for prostate cancer.
Chemotherapy is used for men whose prostate cancer has spread beyond the prostate gland and for whom hormone treatment has not been successful. Chemotherapy uses high doses of drugs, given intravenously or by mouth, to kill cancer cells. The treatment may help slow tumor growth and reduce pain. Because chemotherapy does not kill all the cancer cells, it is not recommended for treating early stages of the disease.
The side effects of the various cancer treatments include:
• problems with sexual function such as erectile dysfunction (inability to achieve or maintain an erection) or loss of sex drive
• problems with urination such as frequent urination, incontinence (leakage or dribbling of urine), blockage of urine ﬂow, blood in the urine, or a burning sensation while urinating
• problems with bowel function such as diarrhea, blood in the stool, or irritation
• swelling of the penis, scrotum, or prostate
• bruising of, pain in, or damage to the treatment area or nearby tissues
• nausea, vomiting, or loss of appetite
• breast enlargement or tenderness, hot ﬂashes, or osteoporosis (weakening of the bones)
• fatigue, infection, heart disease, hair loss, or sores in the mouth