Prostate Health Awareness
Risk factors, diagnosis and treatment of prostate
cancer, by Sanjeev Vohra, M.D.
September has been designated as national prostate health awareness month,
in an effort to increase public awareness about prostate screening exams and
the importance of annual physicals for men aged 50 and over.
Prostate cancer is the most commonly diagnosed malignancy in American men,
and is the second leading cause of death after lung cancer. In 1995, there were
244,000 new cases of prostate cancer diagnosed in the United States, and 44,000
men died from it that year.
Prostate cancer is unique, in that there are two distinct forms. One is
latent: a lot of men have it, but it grows so slowly, it will never become a
significant problem for the vast majority. Most of these men will die with
prostate cancer, not of it. However, one out of six men will be diagnosed with
the second form of prostate cancer, which is clinically detected and which
grows more quickly and is more likely to spread to other parts of the body if
left untreated. One of the major goals of prostate screening is the early
identification of this second type of cancer in younger men.
Risk factors for prostate cancer
There are three major risk factors for developing prostate cancer, the most
significant of which is age. After the age of 50, the
incidence and mortality of prostate cancer increase exponentially. The second
major risk factor is family history, which accounts for approximately 10
percent of all prostate cancer. If you have a first degree male relative
(father or brother) with prostate cancer, your own chances of developing it
increase several fold. The third risk factor is race. African-American men have
a higher incidence of clinically-detected prostate cancer than Caucasian or
Two remaining probable risk factors relate to diet and hormones. Research
indicates that men eating a diet high in fat content increase their chances of
developing prostate cancer. We know, for example, that American men eat much
more fat than Japanese men living in Japan, and the rate of prostate cancer in
Japan is significantly lower than it is in this country. However, when Japanese
families emigrate to the United States, within two
generations, their incidence of prostate cancer has risen to a level that more
closely resembles that of American men.
There also seems to be a correlation between individual hormone levels. Men
with higher testosterone levels have an increased likelihood of developing
prostate cancer. Testosterone is necessary for prostate cancer to grow, and
higher levels promote cancer growth and spread.
Diagnosing prostate cancer
Since most men experience no symptoms in the early stages of prostate
cancer, regular screening is critical for early detection. Fortunately, we have
one of the most accurate tumor markers on the market for diagnosing prostate
cancer. It is a simple, inexpensive blood test called PSA, which measures
levels of prostate specific antigen, a protein that is made by prostate cells.
This test enables us to diagnose the cancer at a far earlier stage than ever
before. PSAs are not perfect, however. Infections, benign tumors, and biopsies
can all cause elevated PSA levels, so these tests must be carefully
The PSA has made a significant difference in early detection and cure.
Today, in less than 5 percent of those having prostate surgery has the cancer
spread to other parts of the body. Prior to the availability of PSA, 40 percent
of men at the time of prostate cancer surgery were found to have disease that
had already spread.
The PSA should be administered in conjunction with a digital rectal exam
(DRE). This is a simple test in which the physician palpates the prostate gland
through the rectum, to detect hardening or nodules in the prostate. Each of
these exams is important in screening, and both can be performed by a primary
care physician. Because most men experience no symptoms in the early stages of
prostate cancer, regular screening by your primary care physician is critical
for early detection.
Should your primary care physician detect a potential problem, you will be
referred to a urologist for follow-up. After a
thorough medical history and physical examination, the urologist will examine
the prostate gland using ultrasound. At this time, the doctor will also collect
a sample of prostate cells for microscopic examination. This procedure, which
is mildly uncomfortable, is necessary to determine whether cancer is present in
the prostate. If cancer is discovered, imaging studies (CT scan or MRI) will
help the urologist determine if the malignancy is confined to the prostate
gland, or if it has spread to the lymph nodes in the pelvis. A bone scan will
identify any spread to the axial skeleton (the bones in the trunk of the body).
Approaches to treating prostate cancer
If the cancer is confined to the prostate gland and has not spread, the
recommended follow-up may vary, depending on the age and health of the
individual involved. For example, if the cancer is slow-growing and the
individual has an expected life span of less than ten years or he is in poor
general health, he and his doctor may decide to monitor his condition with
regular PSAs. This conservative approach to treatment is based, in part, on
patient outcome studies which concluded that invasive treatment for prostate
cancer does not necessarily improve or extend life for patients older than 70.
However, if the individual is healthy and has an expected life span of more
than ten years, it makes sense to consider definitive treatment. There are
currently three approaches to treating localized prostate cancer: radical
prostatectomy, in which all or part of the prostate gland is surgically
removed; external beam radiation therapy; and Brachy therapy, in which
radioactive seeds are implanted in the prostate, delivering a continual dose of
radiation directly to the cancer site.
Two articles in the most recent issue of the Journal of the American Medical
Association indicate that men with low-grade (slow-growing) prostate cancer
will do well with any of the three approaches to treatment. However, men who
are diagnosed with a more aggressive form of cancer have a higher failure rate
with either forms of radiation therapy. The studies cited in the articles
conclude that for these men, surgery is clearly the recommended form of
No approach to treatment is completely free of risk. A
small percentage of patients who undergo radiation therapy experience erectile
dysfunction. Similarly, in a small percentage of cases, surgical patients
experience erectile dysfunction or urinary incontinence as a result of the
procedure. However, if the surgery is performed by a specialist who is well
versed in the technique, the risk of incontinence is less than 5 percent.
Locally, the surgical results are even better than the national average, with
the incidence of urinary incontinence at less than 1-2 percent.
See your doctor
The message is clear: if you are a man over the age of 50, see your doctor
annually. If you have a family history of prostate cancer, begin your annual
exams when you turn 40. A recent long-term Canadian case study by one of the
most prominent researchers in the field, involving 45,000 men, showed that
annual screening resulted in a 69 percent reduction in mortality from prostate
cancer. This is because annual exams detect the presence of cancer at such an
early, treatable stage. These figures suggest that in the United States, we
have the potential to prevent almost 27,000 of the 44,000 annual deaths from
prostate cancer through early screening.
If you are diagnosed with prostate cancer, you have a very good chance of
beating this disease by working with your urologist to monitor the cancer and
to treat it any one of three different ways. Over the last few years, we have
refined treatment techniques and mortality results have improved dramatically.
And in Tompkins County, our surgical results compare very favorably with
national statistics. This means you can receive state-of-the-art care for
prostate cancer right here in your own community.
Dr. Vohra is a board-certified urologist affiliated with Cayuga
Medical Center. He trained in urological surgery at University Hospital in
Syracuse and Beth Israel Hospital in Boston. He is in practice at Ithaca
Urology and can be reached at (607) 273-8502.
Last update: August 2006