Prostate Cancer
The most common cancer in men
Prostate cancer sneaks up on most men as they age. With silent symptoms, it slowly grows in the prostate (a gland that surrounds the neck of the bladder and urethra), gradually spreading throughout the body.
Found in about half of men over age 70, and in almost all men over age 90, prostate cancer is the most common noncutaneous (non-skin) cancer in men. The cause isn't known, but treatment can be effective if the cancer is diagnosed in its early stages. Early discovery of prostate cancer is dependent on yearly digital rectal examinations, which should be routine for all men over age 40.
Pronunciation
PROS-tate KAN-sur
Synonyms
- Adenocarcinoma of the prostate
- Carcinoma of the prostate
Detailed Description
Though quiet and slow-growing, cancer of the prostate gland is the most common malignant disease found in American men. Usually prostate cancer is recognized when men are in their 70s and older, and can exist for years without producing symptoms. Prostate cancer is found in 50% of all men over age 70, and in virtually all men over age 90, but often the symptoms for this slow-developing cancer are difficult to detect. If the disease becomes apparent at an earlier age (50 or 60), it tends to grow faster and exhibit a higher grade of malignancy.
The prostate gland is a walnut-size organ that helps the body form semen. The prostate gland is located at the base of the urinary bladder where the urethra joins the bladder neck. The urethra is the outflow channel for urine, and it passes through the body of the prostate when it drains urine from the bladder. Prostate cancer is a growth of malignant cells in the prostate gland. Male hormones (androgens) promote this cancer growth. This is typically a very gradual disease, but can be in advanced stages before detected. What starts out being localized in the prostate gland usually expands to adjacent tissue and lymph glands before detection. Bones, lungs, liver, and other vital organs can become cancerous as the disease progresses.
Treatment of prostate cancer varies greatly, depending on the stage of detection and development of the cancer cells. Surgery, radiation, hormone treatment and anticancer drugs can stop or slow the cancer growth in many cases.
How Common Is Prostate Cancer?
As the most common noncutaneous (non-skin) cancer among American men, prostate cancer strikes approximately 69 out of 100,000 men. The incidence as shown by autopsy is actually higher because many men die before detection of the cancer. Autopsy shows that approximately 67% of men over age 80 have prostate cancer. Although it is the second most common type of cancer, only 3% of men with prostate cancer die from it. The incidence of prostate cancer increases with age. Men under age 50 rarely get it -- 95% of all reported cases are found in men between age 45 and 89. Prostate cancer only effects men.
Causes
The cause of prostate cancer is unknown, but the following risk factors may increase a man's chances of getting prostate cancer:
- Family history of prostate cancer
- Exposure to cancer-causing chemicals
- High-fat diet
- Sexually transmitted diseases
- Being 60 or older
- Being African-American
Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily "causes" of the condition.
Symptoms
The best way to detect prostate cancer early is for all men over age 50 to go through routine screening, such as an annual digital rectal exam and PSA (prostate specific antigen) blood test, because the disease often shows no symptoms in its early stages. Men with risk factors, such as being African-American or having a family history of prostate cancer, should talk to their doctors about starting screening at a younger age.
By checking your prostate gland, your doctor may be able to feel a lump before you notice any changes. If the cancer progresses, you may have some of these warning signs. See your doctor if you have any of the following:
- Weaker urine stream
- Frequent or urgent urination
- Trouble with starting to urinate or sudden blockage of urine
- Waking often at night to urinate
- Urinary tract infections
In later stages:
- Blood in urine
- Impotence
- Swollen lymph nodes in groin area
- Weight loss
- Pain, most often in the spine, hip, pelvis, or ribs
- Bone fractures
- Kidney failure
- Anemia
Conditions That May Be Mistaken for Prostate Cancer
Other prostate conditions may be confused with prostate cancer, among them:
- Benign prostatic hyperplasia (BPH) also called "enlarged prostate"; this noncancerous enlargement of the prostate gland is a common problem among men in their 40s and older
- Prostate infection
- Seminal vesicle enlargement (uncommon)
How Prostate Cancer Is Diagnosed
Prostate cancer is most often diagnosed during routine screening that includes an annual digital rectal exam (DRE) and a PSA (prostate-specific antigen) blood test. If screening causes your doctor to suspect prostate cancer, you may need more tests, such as ultrasound and biopsy.
Digital rectal exam
Your doctor will insert a gloved finger into the rectum to check for lumps on the prostate gland.
PSA (prostate-specific antigen) test
This blood test checks the level of a substance called prostate-specific antigen. In men with prostate cancer, the PSA level is often higher than normal, although other conditions, such as a noncancerous enlarged prostate, can raise PSA levels, too.
A normal PSA level is lower than 4 nanograms per milliliter (ng/ml). Roughly 20% to 25% of men with borderline PSA elevation (4.1 to 10.0 ng/ml) are found to have prostate cancer. Almost two-thirds of those with PSA levels of 10 ng/ml or higher are found to have prostate cancer. Very high PSA levels may indicate that the cancer is advanced. PSA levels rise naturally as men age -- even in the absence of prostate cancer -- so doctors may also take into account how a man's PSA levels compare with those of other men the same age.
Interpreting PSA results is controversial because the test isn't highly accurate. It misses one-third of prostate cancers (false-negative), and about 60% of the time, it indicates cancer when none exists (false-positive). The medical community is divided over its usefulness. For these reasons, PSA levels should be only one of several tests for diagnosing prostate cancer. You may want to ask your doctor whether he or she feels this test is useful to you.
Besides the conventional use of PSA testing, some doctors have experimented with new approaches, such as serial PSA testing. With this method, a baseline PSA level is taken. Then the test is done annually and checked for changes. For instance, a rise of 0.75 ng/ml or more in a single year may point to prostate cancer. Doctors can also calculate "PSA density" (the PSA level is divided by the volume of the prostate, as measured by ultrasound). Some experts believe men with high PSA densities may be more likely to have prostate cancer, even if they have normal digital exam and ultrasound results.
Ultrasound
If your doctor finds a lump or your PSA level is high, the next step is an ultrasound test. A machine bounces high-frequency sound waves off your prostate gland to create pictures of it on a video monitor. These pictures can be recorded so that your doctor can check the images for tumors.
Biopsy
Sometimes a biopsy, in which prostate tissue samples are removed for lab study, is done during ultrasound. As your doctor inserts a needle through the rectum and into the prostate to gather the cells, you may feel brief pain. The biopsy is done on an outpatient basis with local anesthesia. Afte the sample is removed, a pathologist checks the cells under a microscope and runs tests on them to check for cancer. A biopsy is the only sure way to diagnose prostate cancer.
Grading and Staging Prostate Cancer
If you're diagnosed with prostate cancer, you'll need more tests to find out whether the tumor is an aggressive one that can spread quickly, or a more typical, slower-growing form. This process is called "grading" the tumor. A number from 2 to 10 is assigned to the cancer. The higher the number, the more likely the tumor is to grow fast.
Your doctor will also order "staging" tests to check the location and extent of your cancer -- for instance, whether it remains confined to the prostate, has spread to nearby seminal vesicles, or has spread to distant parts of the body. These staging tests are crucial in helping your doctor to assess your chances for a cure and to plan your treatment. You may have several imaging tests, among them, more ultrasound, a CT scan (computed tomography), and an MRI (magnetic resonance imaging). To check whether the cancer has spread to lymph nodes near the prostate, a surgeon may perform a laparoscopy. A long thin tube (laparoscope) inserted into a small incision in your body allows the surgeon to remove lymph nodes near the prostate for lab studies. You may also need other tests to see if the cancer has spread to other parts of the body. For instance, a bone scan can check for cancer in the bones, a common site for prostate cancer to spread.
Doctors classify prostate cancer into four stages:
- Stage A: In this early stage, the tumor remains confined to the prostate gland, but it's too small to be found by digital rectal exam. It may be detected during prostate surgery for benign problems, or through ultrasound.
- Stage B: The tumor still remains confined to the prostate, but now a tumor may be able to be felt through digital rectal exam. The PSA level may be elevated as well.
- Stage C: The cancer has spread through the prostatic capsule and may involve nearby tissue and seminal vesicles.
- Stage D: In this advanced stage, prostate cancer has spread to distant sites in the body, such as lymph nodes, bones or other organs, such as the lungs and liver.
Goals of Treatment
Prostate cancer can be cured if it's detected in the earlier stages, before it has a chance to spread to other parts of the body. Many effective treatments are used. For early-stage cases in which the cancer has not spread beyond the prostate, surgery, radiation therapy, and hormonal therapy often work well. For later cases in which a cure isn't possible, hormonal therapy and chemotherapy can relieve symptoms and prolong life.
The type of treatment you'll receive depends not just on the type and extent of cancer you have, but also your age and your general health. Men in their 50s and 60s with faster-growing cancers may desire aggressive treatment and be in better health to handle rigorous therapy. But for men over age 70, treatment offers fewer advantages. First, they may not be able to withstand major surgery and other treatments that can have serious side effects, and second, prostate cancer is usually such a slow-growing disease that many older men are more likely to die from other causes. For men with slow-growing, asymptomatic cancers that are confined to the prostate, a "watchful waiting" approach may be the best route. If the cancer begins to cause problems, you can switch to an active form of treatment.
Treatment Overview
For men who choose active treatment over watchful waiting, prostate cancer therapy includes the following:
- Aminoglutethiamide
- Casodex (bicalutamide)
- Cyproterone
- DES (diethylstilbestrol)
- Megace (megestrol acetate)
- Eulexin (flutamide)
- Luteinizing hormone-releasing hormones (LHRH), including Lupron (leuprolide) and Zoladex (goserelin)
- Nizoral (ketoconazole)
Chemotherapy
Chemotherapy is used only in advanced cases of prostate cancer to relieve pain and slow the spread of the disease. These cancer-killing drugs can be given by pill or by shot. Some chemotherapy drugs for prostate cancer include:
- Doxorubicin
- Estramustine phosphate
- Mitoxantrone
- Paclitaxel
- Vinblastine
Considerations When Selecting Treatment
Treatment of prostate cancer may have serious consequences. Impotence, infertility, incontinence, and depression may result after surgery, radiation therapy, and drug therapy. For men over age 70 with slow-growing prostate cancer, watchful waiting may be a better approach because active treatment may provide few advantages and many drawbacks. For men in their 50s and 60s with fast-growing tumors, a more aggressive approach may be appropriate. If you're concerned about impotence or incontinence after therapy, talk to your doctor about which treatments, such as nerve-sparing surgery, will give you the best chance of retaining erections and bladder control.
People with metastatic disease may also want to look into clinical trials. There are exciting projects involving vaccines, growth factor inhibitors, and gene therapy.
Appropriate Healthcare Setting
Surgery requires hospitalization, but all other treatments can be done on an outpatient basis.
Healthcare Professionals Who May Be Involved
- Family physicians
- Internists
- Getriatricians
- Urologists
- Medical oncologists (chemotherapists)
- Radiation oncologists (radiotherapists)
- Surgical oncologists
Activity & Diet Recommendations
There is no special diet for prostate cancer. But it is important for people with cancer to eat enough calories and protein to prevent weight loss, rebuild tissues, and grow strong again. It's normal to lose your appetite during treatment, but doctors, nurses, and dietitians may be able to give you tips on how to keep eating healthy.
After surgery, go back to your normal activities gradually. When you're physically able, it's fine to resume sexual relations.
Monitoring Prostate Cancer
After you've been treated for prostate cancer, you will still need follow-up appointments with your doctor for several years to monitor your overall health and to check for any recurrences of cancer. Your doctor will recommend a schedule of visits. During these checkups, you may have X-rays, scans and lab tests, including the PSA test, to detect if cancer has returned.
Possible Complications
Possible complications and side effects from prostate cancer treatment include:
Surgery
- Urinary incontinence
- Impotence
- Infertility (without a prostate gland, no semen can be made)
Radiation therapy
- Frequent urination
- Blood in the urine
- Burning sensation while urinating
- Bowel problems
- Impotence
- Incontinence
- Fatigue
Hormonal therapy
- Reduced sex drive
- Impotence
- Hot flashes
- Tender breasts
- Breast growth (gynecomastia)
Chemotherapy
- Nausea and vomiting
- Loss of appetite
- Hair loss
- Increased risk of infection
Quality of Life
Impotence, discomfort, trauma, depression and incontinence may result from major surgery, radiation therapy and drugs used to treat prostate cancer. You and your partner may wonder how your sex lives will be affected. Consider these possible consequences thoroughly before starting treatment, especially if the watchful waiting approach is an option for you. It's important that you and your doctor work together to decide when to start treatment, as well as decide which therapy works best for your particular situation.
Being diagnosed with cancer can make a man fearful and depressed. Men with prostate cancer may find it helpful to speak with a friend, religious leader, or counselor or to join a support group. If you're so inclined, your doctor or hospital may be able to point you toward sources of help. Support groups can also be a good way to learn more about the disease.
Considerations for Older Men
Prostate cancer is extremely common among older men. If the tumor is slow-growing, an older man may decide to take the watchful waiting approach and forego treatment rather than deal with the side effects of surgery, radiation, hormonal therapy or chemotherapy. Older men, especially those in frail health, may find it harder to tolerate these therapies, and their adverse effects may be worse than allowing the disease to take its gradual course.
Alternative Therapies
Though conventional medical care has been shown to be helpful in treating prostate cancer (particularly in the early stages), there are still many recognized side effects to treatment. Because of this, it is important to be aware of the alternative therapies that may be helpful to use in conjunction with traditional treatment. Alternative therapies have had varying degrees of success (largely determined on an individual basis) in controlling pain, maintaining good nutrition, and alleviating anxiety.
Acupuncture and Acupressure
Useful for controlling pain, these techniques can also be helpful in relieving anxiety and encouraging relaxation.
Hydrotherapy
Sitting in a hot tub is sometimes recommended to increase circulation in the prostate region, as well as to relieve pain. One specific technique is to sit in hot water while immersing the feet in cold water for three minutes, then to reverse the process for three more minutes.
Imagery or visualization
Whether done with a guide or in silent meditation, you picture your body fighting and overcoming the disease.
Preventing Prostate Cancer
Though prostate cancer cannot be prevented, it can be detected early enough to limit its effects. All men over age 50 should undergo annual screening for prostate cancer. A digital rectal examination is typically the first step in screening. The earlier the cancer can be detected, the better the possibility for curative treatment, so regular checkups are imperative as men age.
Self-Care Measures
An environment that is not stressful and allows for support and rest during recovery will be helpful in healing from prostate cancer. In addition, the following changes in diet can help keep you healthy and speed your recovery:
- A low-fat, primarily vegetarian diet may help prevent the risk of cancer. Fruits, vegetables, nuts and seeds, dried beans, peas, brown rice, and fruit juices may be regularly included as part of your diet. Reduction of coffee, black tea, and alcohol, while not directly associated with prostate cancer, is recommended by some nutritionists.
- Zinc deficiency has been linked to prostate inflammation. About one handful of pumpkin seeds, which are high in zinc, may be eaten daily. Or, if you prefer, take pumpkin seed oil capsules.
Feelings of fear and anxiety are natural for someone with prostate cancer. Allowing friends and family to provide support during treatment may ease the emotional burden and speed your healing. Counseling can also be a very useful tool for some.
Websites & Organizations
American Cancer Society
625 North Court
Palatine, IL 60067
Phone: 800-ACS-2345 (800-227-2345)
American Foundation for Urologic Disease
300 West Pratt Street, Suite 401
Baltimore, MD 21201
Phone: 410-727-2908 or 800-242-2383
Fax: 410-783-1566
Cancer AnswerLine
800-865-1125
Cancer Care Inc.
intelliHealth
Man to Man
Prostate Cancer Patient Education and Support
National Kidney and Urologic Diseases Information Clearinghouse
3 Information Way
Bethesda, MD 20892-3580
Email: nkudic@info.niddk.nih.gov
Office of Cancer Communications
National Cancer Institute (NCI)
Building 31, Room 101-18
9000 Rockville Pike
Bethesda, MD 20205
Phone: 800-638-6694 or 800-4-CANCER (800-422-6237)
Prostate Health Council
American Foundation for Urologic Disease, Inc.
300 West Pratt Street
Baltimore, MD 21201
Phone: 800-242-2383
Prostate Pointers
US TOO International, Inc.
930 N. York Road, Suite 50
Hinsdale, IL 60521
Phone: 630-323-1002 or 800-808-7866
Fax: 630-323-1003
Sources for This Article
Books
Balch, James F. and Balch, Phyllis A. Prescription for Nutritional Healing. Garden City Park, NY: Avery Publishing, 1997.
Bennett, J. Claude and Plum, Fred. Cecil Textbook of Medicine, eds. Philadelphia: W. B. Saunders, 1996.
Fauci, Anthony J., et. al. Harrison's Principles of Internal Medicine, eds. New York: McGraw-Hill, 1998.
Hardman, Joel G. and Limbird, Lee E. Goodman and Gilman's The Pharmacological Basis of Therapeutics eds. New York: McGraw-Hill, 1996.
Hurst, J. Willis. Medicine for the Practicing Physician eds. Stamford, CT: Appleton & Lange 1996.
Murray, Michael T. Encyclopedia of Natural Medicine. Prima, 1998.
Noble, John. Primary Care Medicine ed. St. Louis: Mosby, 1996.
Physicians' Desk Reference. Montvale, NJ: Medical Economics Co., 1998.
Rakel, Robert E. Conn's Current Therapy eds. Philadelphia: W.B. Saunders, 1998.
Segen, JC, Stauffer, J. The Patient's Guide to Medical Tests. New York, NY: Facts on File, 1998.
Taylor, Robert B. Family Medicine: Principles and Practice. New York: Springer-Verlag, 1998.
Tierney, LM, McPhee, SJ, and Papadakis, MA. Current Medical Diagnosis and Treatment eds. Stamford, CT: Appleton & Lange, 1998.
Articles
Bagshaw, MA, Cox, RS, Hancock, SL. "Control of Prostate Cancer with Radiotherapy: Long-term Results." J Urol. 1781-5. Nov 1994.
De Stefani, E, Fierro, L, Barrios, E, Ronco, A. "Tobacco, Alcohol, Diet and Risk of Prostate Cancer." Tumori. 315-20. Sep-Oct.
Eeles, RA, Dearnaley, DP, Ardern-Jones, A, Shearer, RJ, Easton, DF, Ford, D, Edwards, S, Dowe, A. "Familial Prostate Cancer: The Evidence and the Cancer Research Campaign/British Prostate Group (CRC/BPG) UK Familial Prostate Cancer Study." British Journal of Urology.
8-14. Mar 1997.
Garnick, MB, Fair, WR. "Combating Prostate Cancer." Scientific American. 279(6):74-83. 1998 Dec.
Hiatt, RA, Armstrong, MA, Klatsky, AL, Sidney, S. "Alcohol Consumption, Smoking, and Other Risk Factors and Prostate Cancer in a Large Health Plan Cohort in California." Cancer Causes Control. 66-72. Jan 1994.
Keetch, DW, Rice, JP, Suarez, BK, Catalona, WJ. "Familial Aspects of Prostate Cancer: A Case Control Study." J Urol. 2100-2. Dec 1995.
Mebane, C, Gibbs, T, Horm, J. "Current Status of Prostate Cancer in North American Black Males." J Natl Med Assoc. 782-8. Nov 1990.
Meikle, AW, Smith, JA Jr. "Epidemiology of Prostate Cancer." Urol Clin North Am. 709-18. Nov 1990.
Merrill, RM, Weed, DL, Feuer, EJ. "The Lifetime Risk of Developing Prostate Cancer in White and Black Men." Cancer Epidemiol Biomarkers Prev. 763-8. Oct 1997.
Naitoh, J, Zeiner, RL, Dekernion, JB. "Diagnosis and Treatment of Prostate Cancer." Am Fam Physician.
1531-9, 41-2, 45-7. Apr 1, 1998.
Smart, CR. "Prostate Cancer Facts and Fiction. J Surg Oncol. 223-9. Dec 1997.