by John Leifer & Dr. C.H. Weaver M.D. updated 7/2019
If you are like most American women, chances are you serve as the key decision-maker when it comes to the health of your family— whether it’s selecting a physician, deciding on treatment options, or taking steps to prevent the onset of illness. It’s a role that carries with it the awesome responsibility for making effective, informed decisions that give your loved ones the best chance of a good outcome and enduring health. This is particularly true when confronting the issue of cancer. And the cancer that is most likely to strike the men in your family, as they age, is prostate cancer.
What Exactly Is the Prostate?
The prostate is a walnut-size gland located between the bladder and the penis. It surrounds the urethra, the tube that carries urine from the bladder to the penis. When it becomes enlarged, a common condition with age, the urethra is squeezed and urinary problems can result. The prostate plays an important role in reproduction, being responsible for much of the seminal fluid produced by a man.
What Is Prostate Cancer?
When cellular growth goes awry in any organ, cancer is often the result. When this happens in the prostate, it is referred to as prostate cancer. Doctors refer to the most common type of prostate cancer as adenocarcinoma of the prostate, based on the particular type of cancer cells that have developed.
How Common Is Prostate Cancer?
With the exception of skin cancer, prostate is the most common cancer occurring in men. According to the National Cancer Institute (NCI), there are close to 3 million men living with prostate cancer in the United States. An additional 180,000 new cases of prostate cancer will be identified in 2016, and approximately 26,000 deaths will be associated with the disease.1
The good news is that most forms of prostate cancer are relatively indolent, or slow growing. As a result, the five-year survival rate following a diagnosis of prostate cancer is 98.9 percent. The NCI further states that while “an estimated 16 percent of men will be diagnosed with prostate cancer in their lifetime…only 3 percent will die of it.”1
Are There Clear Symptoms Associated with Prostate Cancer?
Prostate problems are relatively common in men over the age of 55, and these issues may be mistaken for cancer in some cases. An enlarged prostate, known as benign prostate hyperplasia (BPH), can be particularly troublesome, causing problems with urination, sexual function, and other symptoms. And while problematic, BPH is far more of a nuisance than a serious threat to a man’s health.
Though prostate cancer can mimic the symptoms of BPH, it can also be present without the appearance of symptoms, particularly in its early stages. When prostate cancer becomes advanced, other symptoms may be present, including bone pain (frequently occurring in the lower back) and unexplained weight loss.
How Is Prostate Cancer Diagnosed?
Preliminary diagnosis generally relies on screening, which consists of a blood test, known as a PSA (prostate specific antigen), accompanied by a digital rectal exam. Because the prostate is located directly in front of the rectum, a physician is able to palpate the gland with his or her finger to see if there are any obvious abnormalities. Neither test is definitive, which means that suspected cases of cancer must be biopsied.
When a man’s PSA reaches a certain threshold or there is perceived abnormality upon physical examination, the physician may recommend a biopsy. It should be noted that some physicians also recommend biopsies based on the rate of change in PSA levels, referred to as PSA velocity. Recent research suggests, however, that PSA velocity, by itself, is not a reliable measure on which to recommend biopsies.2
When performing a biopsy, a surgeon—most frequently a urologist—relies on ultrasound-guided imaging to insert needles into various sites on the prostate. The hollow needles extract tissue cores that can then be examined to determine the extent of the disease. Twelve samples are most commonly collected.
The cores are then examined by a pathologist, who rates them based on what is known as the Gleason score,3 which ranges from 2 to 10; higher numbers signify a more serious expression of the disease.
If more-advanced disease is suspected, additional imaging studies may be performed to determine if the cancer has metastasized, or spread to bones or other organs. Based on the sum of the evidence collected through these various tests, patients are assigned a stage that indicates the extent of the disease. The earliest-stage cancers are described at Stage I; cancer that has spread to other portions of the body are Stage IV.
What Types of Treatment Are Recommended?
The stage of the tumor and one’s age at diagnosis may significantly guide treatment options. Because many forms of prostate cancer are slow growing, very early-stage tumors may warrant careful observation, known as active surveillance, rather than aggressive treatment.
When treatment is required, the urologist may recommend either radiation therapy or the surgical removal of the prostate, known as a radical prostatectomy. Radiation therapy can take several forms, with the most common being an external beam of radiation to target the prostate and kill cancer cells. The most common form of external radiation is image modulated radiation therapy (IMRT). IMRT generally involves five treatments per week for eight weeks.
A small number of cancer centers offer another form of external radiation known as proton therapy. Proton therapy is controversial4 because its cost greatly exceeds that of IMRT, and numerous experts have argued that there is insufficient data to prove that it is more effective or less toxic.
For patients who do not want to undergo repeated treatments, referred to as fractions, brachytherapy provides a highly effective option. Brachytherapy involves a single, surgical insertion of radioactive seeds into the cancerous portions of the prostate.
Before deciding on a treatment option, it is vitally important that you and your loved one understand the nature of each, as well as its potential short- and long-term side effects. It is advisable to get more than one opinion. Consider scheduling a consultation with both a urologist and a radiation oncologist. You may also find it helpful to do some research into the disease and your treatment options. The National Comprehensive Cancer Network at nccn.org provides excellent treatment guides based on disease and stage.
Are There Significant Side Effects of Treatment?
Prostate cancer treatment, whether involving surgery or radiation, can cause a host of short- and long-term side effects. Transient side effects are generally tolerated well. Long-term problems with incontinence and or erectile dysfunction, however, can have a major impact on a man’s quality of life. Though estimates vary widely, it is reasonable to assume that such long-term or permanent side effects may occur in significant percentage5 of all patients.
When surgery is performed, a nerve associated with sexual function can be severed. A skilled surgeon may be able to spare the nerve, but there are no assurances. Radiation often damages the nerve, though the onset of symptoms may be delayed by as much as one to two years. You should actively question your physicians about their outcomes—specifically the frequency with which their patients experience long-term problems with incontinence and/or impotency.
What Is the Most Important Thing You Can Do to Help Your Partner When He Is Diagnosed with Prostate Cancer?
First, encourage your loved one to slow down, despite the anxiety generated by a potential diagnosis of cancer, and gather the information needed to make truly informed decisions before proceeding with a biopsy or treatment. A great deal has been written about the overdiagnosis and over treatment of prostate cancer in recent years—with much of the controversy centering on the appropriateness of PSA testing among relatively young patients. Before undergoing a biopsy, talk to your doctor(s) about their confidence in the PSA scores and whether it may be wise to repeat the test in three to six months before proceeding to a biopsy.
This is your first step as you seek to become an expert on the disease, its presentation, and treatment. Once you have availed yourself of the best available information and medical opinions, you are ready to serve as an advocate who ensures that your loved one receives the most appropriate treatment based on the particular stage of disease. Remember, that may mean active surveillance rather than active treatment. You want him neither over treated nor under treated, both of which are real possibilities with prostate cancer.
Finally, be sure you tune in to the potential impact of the disease and its treatment on your loved one’s quality of life, as well as his self-esteem. Issues of sexual function affect both of you, and being able to engage in open and effective dialogue is important to the health of the relationship. You may wish to seek help from a counselor trained to address such issues.
Though prostate cancer is often cured, it may nonetheless take a toll on the family. The more empowered you and your loved one are with information, the greater your probability of limiting this toll and ensuring the best possible outcome from treatment.
Ladies: Check Your Prostates
Okay…you may not have one physically, but if you are married to a man or care about other males in your life, you might as well resign yourself to becoming an advocate for this small and mysterious part of the male anatomy. Men are often their own worst enemy when it comes to their healthcare, making a strong dose of feminine persistence just what the doctor ordered. Here’s an introduction to the number one men’s health issue that might be affecting someone you love.
Prostate cancer affects one of every six American men. For those who are African American or have a family history of the disease, the odds are one in three. As the second most prevalent form of cancer for men after skin cancer, prostate cancer is projected to claim more than 27,000 lives in the United States this year, with an additional 192,000 new cases diagnosed.
In light of these figures and the fact that nearly 2.5 million American men and their families are facing the disease, it is baffling—perhaps unconscionable—that this disease is among the most misunderstood and least talked about types of cancer.
The Paradox of Being Male
Throughout the ages men have been taught that they must be strong, virile hunters, gatherers, and defenders of their families. Over time this societal mandate has ingrained a false sense of invincibility—one that seemingly exempts men from having to pay attention to their physical ills or see their doctors for annual checkups. The same pressure often leads them to feel extremely vulnerable and reluctant to discuss their self-perceived weaknesses when diagnosed with health problems—especially those that lie below the belt.
“When women are diagnosed with breast cancer, they go on the offensive,” explains Jonathan Simons, MD, president and CEO of the Prostate Cancer Foundation (PCF), the world’s leading philanthropic supporter of advanced research for finding a cure. “They open lines of communication with family and friends, they conduct extensive research, and they mobilize with pink ribbons and races. In contrast, too many men shut down and shut up. They are convinced that they can fight the battle alone. It’s ironic. By doing so they are actually shirking their roles as protectors and contributing providers for their families and partners.”
Many men refuse to submit to annual physical exams and screenings. Yes, it’s woefully hypocritical considering the myriad tests, exams, and procedures they expect women to endure to remain healthy moms, sexual mates, and partners. Moreover, the very patients who are afflicted with prostate cancer often prefer not to talk about it, making questions about the prostate and the cancers that can affect it plentiful.
Everything You Should Know but Wouldn’t Ask
Men and their families should not be embarrassed if they do not know what the prostate is, where it is located, or what it does. I cannot remember my high school biology teacher, Brother Patrick—or anyone else—ever discussing the prostate and its function, so I wasn’t too astounded when I learned that in a poll conducted by the PCF a few years ago 60 percent of women responded by saying they knew they had a prostate but couldn’t identify its location. Ding! Wrong answer.
The prostate is an important part of the male reproductive and sexual anatomy. The small gland, about the size and the shape of a walnut, is tucked deep inside the lower extremities beneath the bladder, above the testicles, and in front of the rectum—where it is clearly out of site and out of mind. Its role in life is to create protective seminal fluids that mix with sperm cells and help them along their way. It’s elegantly small, simple, and unobtrusive—until something goes wrong.
Battling Prostate Cancers—Yes, Cancers with an*s*
Prostate cancer is not one disease. It’s a problem that fuels misconceptions about this cancer and creates understandable confusion when it comes to screening, diagnosis, and treatment. One treatment option doesn’t serve all patients.
“We fund research on more than six molecular and clinical subtypes of prostate cancer,” explains Dr. Simons. “Some are lethal, while others do not require treatment. We do not yet have genomics- and epigenomics-based tests that can distinguish between the two, thus overtreatment often occurs to ensure that a patient’s cancer doesn’t progress into advanced, metastatic disease. Many of our funded research projects are focused on identifying cancer-specific biomarkers that will deliver better diagnostics, treatment decision tools, and progression and response measurements.”
To Screen or Not to Screen
Due to concerns about overtreatment and raising unnecessary anxiety, there has been increased debate over the importance of annual screenings for prostate cancer using the prostate-specific antigen (PSA) test and a digital rectal exam (DRE). This past March the New England Journal of Medicinepublished two conflicting papers on the value of screening, based on studies conducted in North America and England. Following much analysis, many medical experts agree that the larger (U.K.) study, conducted over a much longer time span supports the idea that early detection and treatment does indeed save lives. The PSA test, even with its limitations, remains an important tool in the diagnosis and the treatment of prostate cancer.
In a follow-up commentary, Patrick C. Walsh, MD, of Johns Hopkins Medical Institutions wrote: “What is the take-home message? If you are the kind of person who doesn’t wear a seatbelt nor goes regularly to the dentist or your family doctor for a
checkup and are not worried about dying from prostate cancer, do not undergo PSA testing. On the other hand, if you are a healthy man age 55 to 69 who does not want to die from prostate cancer, the European trial provides conclusive evidence that PSA testing can save your life.”
More recently, the American Urological Association revised its screening guidelines to recommend that all men receive a baseline screening at age 40 and then determine with their physician how often subsequent screening should occur, based on family history and individual health factors.
As for the issue of undue anxiety, there is a stronger argument that a vial of blood and a few seconds of swallowed pride during the DRE exam can provide more peace of mind by eliminating the question Could I have cancer? and the consequence of catching it after it has progressed to an advanced, more life-threatening stage. Personally, I like knowing that early detection and treatment provide a five-year survival rate greater than 95 percent. If I hadn’t already started my own schedule of annual screenings, I’d be calling my doctor today.
PSA Testing: One Step at a Time
The PSA test is a diagnostic beginning, not an end. Its biggest limitation is that it is not cancer-specific. I have heard it best explained as a smoke alarm that can alert us to potential problems in the prostate, but it cannot distinguish between a full-blown fire fueled by cancer or one of several other medical conditions, such as an enlarged prostate or prostatitis, that can be creating smoke. This data, combined with the DRE that provides a tactile assessment for the presence of tumor growth, gives physicians information that may lead them to recommend a needle biopsy to determine if cancer cells are present in the prostate.
Becoming Number Six
Patients whose biopsies come back positive for prostate cancer join the one in six American men who will be diagnosed with prostate cancer each year. But it isn’t a foregone conclusion that they need to join the 27,000 men who die annually from the disease. It is prudent at this stage to remember that some prostate cancers are lethal and require aggressive treatment, whereas others most likely do not require treatment. Patients with the second classification of cancer will die with, not from, prostate cancer. But, as referenced earlier, we cannot yet differentiate between the two.
At the point of diagnosis, men (and their partners) need to be active participants in the treatment plan. Personal research is needed along with in-depth consultation with a known and trusted physician. Together, the pros and cons of various treatment options can be thoroughly weighed and selected based on each individual’s medical status. Depending on the specific treatment selected, a detailed follow-up plan will also be outlined (see “Common Treatment Options for Prostate Cancer”).
It’s Time for Men to Step Up
In a recent campaign, Kaiser Permanente ran a series of print and broadcast ads proclaiming, “I have cancer. It doesn’t have me.”There is both wisdom and inspiration in the statement. While there is still much progress to be made in eliminating prostate cancer, we now know that early detection and treatment can drastically improve outcomes—in fact the death rate from prostate cancer is now nearly 40 percent lower than what was once predicted. Moreover, scientific studies are beginning to underscore the importance of nutrition and exercise in preventing certain cancers and improving survivorship. Treatments are now less invasive and better tolerated by patients, and new therapies are close at hand.
The time is long overdue for men (prompted by the women who love them, if needed) to move beyond their traditional behaviors, make prostate cancer something to talk about, and proactively develop their personal programs for protecting their prostate health.
A Woman’s Guide to Prostate Cancer
- Understand and make prostate cancer something to talk about; share what you know with your partner, family, and friends.
- Know your partner’s family history and share it with sons and relatives.
- Recommend diets low in fat, carbohydrates, and processed sugars in combination with regular exercise.
- Be sure your partner talks to his doctor about a baseline screening (PSA and DRE) at age 40 and develops a schedule of subsequent screening based on his medical history.
Common Treatment Options for Prostate Cancer
- Active surveillance. For those men diagnosed with slow-growing cancers, immediate treatment might not be recommended because of the possible side effects of other treatments. Recent studies have shown that men over 65 with low-grade cancers can do well with this approach.
- Surgery. Because prostate cancer grows through a number of small tumors scattered throughout the prostate, the entire prostate plus some surrounding tissue must be removed. Depending on how much tissue outside the prostate must be removed, side effects can include incontinence and erectile dysfunction. Fortunately, improvements made in nerve-sparing technologies are lessening the impact of these side effects.
- Radiation therapy. Oncologists can kill prostate cancer cells by delivering high doses of X-rays to the prostate via external beam radiation or intensity-modulated radiation therapy. Or, in a treatment called brachytherapy, small radioactive pellets can be injected into the prostate. Over the course of a year, the radioactive matter degrades, leaving harness pellets inside the prostate.
- Proton therapy. For many patients proton therapy offers a new treatment option without the side effects of radiation. This treatment is relatively new and costly, however, limiting patient access.
- Hormonal therapy. In advanced, metastatic cases of prostate cancer, testosterone can actually fuel the growth of cancer cells. With hormonal therapy patients are treated with drugs to block the effects of testosterone.
- Chemotherapy. Also utilized in advanced, metastatic cases of prostate cancer, chemotherapy floods a patient’s system with cytotoxic drugs that kill fixed and circulating tumor cells.
- SEER Cancer Statistics Fact Sheets: Prostate Cancer. National Cancer Institute website. Available at: http://seer.cancer.gov/statfacts/html/ prost.html. Accessed July 25, 2016.
- PSA Velocity Does Not Improve Prostate Cancer Detection. National Cancer Institute website. Available at: <a href="http://www.cancer.gov/types/prostate/research/psa-velocity-detection.">http://www.cancer.gov/types/prostate/research/psa-velocity-detection.</a> Accessed July 25, 2016.
- Understanding Your Pathology Report: Prostate Cancer. American Cancer Society website. Available at: http://www.cancer.org/treatment/ understandingyourdiagnosis/understandingyourpathologyreport/prostatepathology/prostate-cancer-pathology. Accessed July 25, 2016.
- Wisenbaugh ES, Andrews PE, Ferrigni RG et al. Proton beam therapy for localized prostate cancer 101: Basics, controversies, and facts. Reviews in Urology. 2014;16(2):67-75. doi: PMC4080851.
- Pardo Y, Guedea F, Aguiló F et al. Quality-of-life impact of primary treatments for localized prostate cancer in patients without hormonal treatment. Journal of Clinical Oncology. 2010;28(31):4687-96. doi: 10.1200/ JCO.2009.25.3245.
John Leifer has spent more than 30 years immersed in the healthcare industry as a senior healthcare executive, consultant, academician, and writer. An outspoken advocate for patients’ rights, he has published widely on the need for patients to receive appropriate, safe, effective care, including two, recent books: The Myths of Modern Medicine: The Alarming Truth about American Health Care and After You Hear It’s Cancer: A Guide to Surviving the Difficult Journey Ahead. Leifer is the founder and chief executive officer of My Cancer Advocate, a not-for-profit organization committed to empowering patients with the right information and resources needed to participate actively in their cancer care. Copyright © 2018 CancerConnect. All Rights Reserved.