Prostate Cancer – an Overview
This is a long article – actually excerpts of a book that is not yet completed. So it is not meant to be exhaustive. But it can be provide a general introduction and overview for those interested in learning more about prostate cancer – from a survivor. It is “straight talk” – not very technical or medical.
INTRODUCTION
Prostate cancer (PCa) is the single most common form of non-skin cancer in men in the USA. It is estimated that there were over 200,000 new cases in 2010 and over 30,000 deaths due to prostate cancer in the USA alone (National Cancer Institute). PCa is the second leading cause of cancer death among men after lung cancer. This disease is receiving increasing attention as the discovery rate continues to rise and medical advances are being made - and many famous men are reported to have had it. With the increasing population of men over 50 from the "baby boomer generation", and the rapidly expanding use of detection methods, the number of cases of prostate cancer is expected to grow substantially. Approximately 25% of men discovered to have PCa are under 65 years of age.
Although prostate cancer is prevalent in other parts of the world, it has not received as much attention (or medical care) as in the USA. Most men over 50 years of age have been sensitized to the subject and those who have begun the process of routine testing and diagnostics develop an appetite for information to help them. Many of these men have found internet-based sources of information and communication on this subject, so hopefully this kind of article can be useful.
There are a lot of books about prostate cancer, but almost all of them have been written by physicians. They are a valuable source of medical information - and I would encourage men facing prostate cancer to research the available professional and technical resources. However, I found that the experiences of other men who have gone through the process(es) to also be very valuable. Their perspective and experience is different from that of the physician. Even the best physicians have a bias towards their specialty and methodology and most typically have all of their experience from the "operating" side of the medical instruments - not the receiving side that patients do.
Quality of life issues, such as urinary, sexual and bowel dysfunctions, can be significant factors in the decision making process. Many "guys" are reluctant to ask questions - or even take the tests that help them minimize risks. Guys like (and need) straight talk - uncomplicated, to the point, no surprises. Plain talk and non-technical language with real life examples may make it easier for some men to deal with the subject.
There is an enormous amount of information about prostate cancer available from a wide variety of sources. That is the good news. However, there is so much that it can be overwhelming. It is not possible for an individual to absorb it all. And since the field is changing rapidly, much of the information is out of date. Either each man will have to sort it out by himself, or rely on a few sources to do it for him. I feel that there is a need and value to sorting, summarizing, and organizing the wide variety and large volume of information available about prostate cancer in a logical and easy to read format. And, by providing the personal experience of a PCa patient, the reader can obtain an understanding of what to expect and how to be prepared. There is also a lot of confusing and conflicting information about prostate cancer. It may help to provide a balanced and objective view with awareness of the potential for confusion or conflicts.
The medical field involved in diagnosing and treating prostate cancer has experienced significant advances in the past 5-10 years. There are more options available today with better prospects for cures with minimized side effects and complications then there have been in the past. There continue to be developments in techniques, technologies, drugs, and methodologies that will hopefully bring even more improvements in the near future. It is a dynamic field, so a patient should try to stay informed of the latest developments.
IT CAN HAPPEN TO YOU
Prostate cancer does not discriminate. It can happen to any man – and has happened to many famous men. Some died of it – perhaps because they found out too late or were not aggressive enough in treating it. Others survived – by finding it early enough and pursuing aggressive treatment.
Some of those who died from PCa:
· Francois Mitterrand: President of France for 14 years. He had prostate cancer during both terms and eventually died a painful death from it.
· Telly Savalas - actor
· Frank Zappa - rock star/muscian
· Linus Pauling - Nobel prize winning medical researcher
· Pierre Trudeau - former Prime Minister of Canada
· "Happy" Hairston - You probably won't recognize this name unless you followed basketball. I watched this guy play in college in the mid-60s when he was a star at New York University. He went on to be a pro and wound up starting on the champion Los Angeles Lakers team that included Wilt Chamberlain, Jerry West and Pat Riley. He was diagnosed with inoperable prostate cancer, underwent chemotherapy and died within 2 years at the age of 58. So being a world class athlete doesn't matter if you don't find the cancer soon enough. What a tragedy!
And some who survived PCa:
· Joe Torre: World Championship Manager of the New York Yankees (and more recently the Los Angeles Dodgers) and former star baseball player in his own right. Torre elected to have surgery at Johns Hopkins with Patrick Walsh - considered the leading surgeon for prostectomy, including the development of nerve- sparing techniques. After taking a leave of absence from his job as Manager of the Yankees, he came back to win another World Series Championship.
· Rudy Giuliani: mayor of New York City during 9/11. Giuliani chose combined radiation treatment at Mt. Sinai with Dr. Richard Stock - considered the leading seed implantation specialist in the New York area. Although Giuliani had to drop out of a race for the US Senate, PCa did not disrupt his term of service as Mayor of New York City.
· Bob Dole: former US Senator and candidate for President. Dole chose surgery – and became a spokesman for VIAGRA!
· Andy Grove: chairman of the board of INTEL Corporation. Grove chose a "fast track" radiation procedure to minimize the time to complete the process so he could continue his very busy career as Chairman of Intel.
· Norman Schwartzkopf - retired General of the US Army and commander of the forces in the first Gulf War.
And Others:
· Arnold Palmer - legendary golf champion
· Jerry Lewis - comedian
· Sean Connery - actor
· Sidney Poitier - actor
· Johnny Unitas – football star
So, it doesn’t matter if you are rich, famous, or a world-class athlete. You can get prostate cancer, and it can kill you.
BACKGROUND
WHAT IS THE PROSTATE - and what does it do?
Most men do not know what the prostate is, what is does and where it is. It’s a small gland surrounding the urethra located behind the bladder - the size and shape of a chestnut (about 1 1/2 inches in diameter). The prostate provides fluid and "nutrients" to the sperm that is secreted by the seminal vesicles, which surround the prostate gland. The prostate contributes between 15-30% of the semen and helps to propel the sperm through the urethra - "the prostate gland secretes the fluid that carries the sperm". It is surrounded by nerves and blood vessels - that are critical to urinary and sexual function. The prostate gland will often enlarge with age, which can, at some point, cause problems - such as difficulty urinating.
WHAT IS PROSTATE CANCER - and what can it do to you?
Cancer cells in the prostate gland lead to the formation of tumors which enlarge the size of the prostate. Prostate enlargement can also be caused by non-cancerous BPH (below)
Cancer cells can spread outside the prostate - to lymph nodes (that drain the prostate), bones (e.g., the bone marrow in the spine and ribs) or other organs - a situation called metastases.
Prostate cancer is often slow growing - in many cases it may go undetected while men die at old ages from other causes. The cause of PCa is not known. However, there is evidence that a predisposition to it can be inherited genetically. PCa may start with changes to a few cells which usually takes many years to grow into detectable levels of cancer. Testosterone can accelerate the growth of PCa. There is also some evidence that diet can influence the rate of growth of PCa (high saturated fat, in particular).
Benign Prostatic Hyperplasia (BPH) is the enlargement of the prostate that happens to many men as they age. Most men over 50 develop BPH eventually. BPH can cause difficulties urinating - which in some cases can be severe. It is not a cancerous condition and can be treated. BPH is often present when there is also PCa. BPH can be treated by heat (using microwave, radio-frequency or laser energy), surgery to remove excess tissue in the prostate or drugs - to shrink the prostate.
Prostatitis is a Bacterial infection of the prostate that is usually treated with anti-biotics.
Many men who have prostate cancer, especially those under 60, do not experience any noticeable symptoms. Since PCa is often a slow growing cancer, it may not be detected unless specifically tested. Symptoms of prostate cancer are similar to those of other prostate diseases - such as BPH, including:
- Difficulty urinating
- Frequent urination
- Pain or burning sensation during urination
- Blood in the urine
- Sometimes, prostate cancer can also cause pain in the areas of the back, pelvis or hips.
Prostate cancer can progress from a slow growing cancer to a faster growing aggressive form that is life threatening. Symptoms of prostate cancer that has spread beyond the prostate gland may include pains (e.g., back, ribs or pelvis) and weakness or fatigue. Prostate cancer can spread to the bones and lymph system causing a long and painful death.
WHAT IS GOING ON?
Is this an epidemic or are we just discovering more prostate cancer? PCa is the second leading killer of men. It kills about the same number of men annually as breast cancer kills women. As the life expectancy of men increases, the risk of developing prostate cancer also increases (since it is usually a slow growing cancer). Many men are reluctant to talk about prostate problems and avoid routine screening. If they wait until they have serious symptoms, it may be too late to cure them. Prostate cancer, when discovered early, is curable. The field is developing rapidly in recent years. As the attention to PCa increases, it may lead to more research.
Some interesting statistics (FDA, ACS):
- 80% of prostate cancers occur in men over 65
- 89% of men diagnosed with prostate cancer will survive at least 5 years and 63% will survive at least 10 years.
- 50 % of men in their 60's who died from a variety of other causes were found to have prostate tumors.
- General Conclusion - 50% of men over 60 have PCa - whether they know it or not!
FACTORS THAT MAY AFFECT PROSTATE CANCER
Family History
There seems to be a strong genetic link to prostate cancer. Men whose father or close male relatives have prostate cancer have been found to have a higher risk of PCa. The younger the onset on PCa in the family history, the higher the risk of getting PCa at an earlier age. There is some evidence that there may be differences in the risk of PCa between certain ethnic groups – for example, higher risks for black and Hispanic men, lower risk for Asian men. For some reason, the mortality rates in African-American men are more than twice as high as in white men.
Personal Health
Prostate cancer can strike men who are in otherwise excellent health. However, there is some evidence that diet can have an influence on prostate cancer - perhaps not in terms of causing it, but maybe affecting its rate of growth. It is generally felt that high fat diets may increase your risk of prostate cancer, but of course, such diets can cause a variety of other health risks as well.
Age
Prostate cancer most often occurs in men over 60, but with the improvements in testing and diagnostic techniques, more men under 60 are being detected with at least low grades of PCa. It is still very unusual to find cases of prostate cancer in men under 50 - so that is when physicians will normally recommend starting routine testing as part of general physical examinations.
CHECK-UPS/PHYSICALS
For men over 50 or with a family history of prostate cancer, testing for PCa should be a routine part of annual physical examinations. There are a number of early warnings for prostate cancer:
· Urinary function:
If you find that you begin to have some noticeable and repetitive urinary symptoms, don't ignore them even if they are mild. Take note of them in case they continue or get worse. This may take the form of urinating more frequently or having difficulty urinating or perhaps even some leaking. I occasionally got kidded by my friends when I would seem to go to the bathroom more frequently than they did. But I knew that I really do drink a lot - not just alcohol - but coffee, tea, water and soda - all day and night - so I didn't let them bother me. Guys love to kid other guys! Then sometimes, I would leak a little bit after I urinated. But that was because I was always in a hurry! Well, in hind sight, they just may have been early warnings that I should have taken note of. Since now I know that I had BPH, my prostate was probably getting enlarged and effecting my urinary function even before there was any cancer. Listen to your body. It's like any other complicated machine. There are usually early warnings when something is going wrong. And it is always easier to take corrective action earlier rather than later.
· While I was growing up, I often heard the phrase "Use it or lose it". It was a common belief that if men didn't use their sexual function frequently they would lose the capability. In particular, guys were told that prostate "problems" were the result of a lack of use. Don't believe it! It's pure myth. I have firsthand knowledge (no pun intended) that there is no relation between my sexual function and the occurrence of prostate cancer or even BPH.
· Digital Rectal Exam (DRE):
The dreaded “DRE” rectal exam may be repulsive to men, but it may show an enlarged prostate or a hard, irregular surface. This can be an early warning and is often made part of a routine physical exam for men over 50. So just “grin and bear it”.
· Prostate Specific Antigen (PSA) test:
The advent of the PSA blood test has had a significant impact on the rate of detection of prostate cancer. It is the single most effective indicator and method of tracking the disease. Since it is simple, widely available and relatively inexpensive, all men over 50 should take advantage of it - just as they would a blood cholesterol test. Although there is a threshold level of PSA that normally triggers a concern – and further diagnostics (typically around 4.0) – the key indicator is actually the rate of change of the PSA number (the so-called “doubling rate”). So regular testing (annually for those over 60) is important for tracking to detect changes before it is too late.
· Biopsy – from the National Institute of Health:
If the results of a rectal exam or PSA test indicate the possibility of prostate cancer, a prostate biopsy is then the only test that can confirm the diagnosis. Tissue from the prostate is viewed underneath a microscope. Biopsy results are reported using something called a Gleason grade and a Gleason score. The Gleason grade is how aggressive the prostate cancer might be. It grades tumors on a scale of 1 - 5, based on how different from normal tissue the cells are. Often, more than one Gleason grade is present within the same tissue sample. The Gleason grade is therefore used to create a Gleason score by adding the two most predominant grades together (a scale of 2 - 10). The higher the Gleason score, the more likely the cancer is to have spread beyond the prostate gland:
Once prostate cancer is detected, additional tests may be conducted to determine whether the cancer has spread – including CT and Bone scans.
MEN YOU KNOW
I never heard much about prostate cancer - only occasionally - and generally referred to as an "old man's disease". But when I first started to be considered by some to be an old man (in my late fifties - which didn’t seem old to me!), I heard a lot more about it. There seemed to be a surprisingly large number of men that I knew around my age that had prostate cancer. It may have just been my new sensitivity to the subject, but there were a lot! Most of these men were older than me at the time, but I considered them contemporaries because they were friends, acquaintances or colleagues from work. Fortunately, most of them have had successful treatments and are now leading a normal life - which is very encouraging. This personal network is a valuable source of information and support if you use it. First hand information, especially from someone you know and trust, can be very important to your decision process.
TREATMENT ALTERNATIVES
There are a wide variety of alternatives available to treat prostate cancer. Depending on the stage of the cancer, some are more appropriate than others. If you are in the relatively early stages of prostate cancer, the focus of treatment will be on curing it, by one or more of these techniques. When the cancer has spread beyond the prostate, the treatment will focus on controlling the cancer to prevent it from spreading further. Following are the most common alternatives:
· Surgery: the traditional treatment for prostate cancer by surgically removing the cancer cells. Radical prostatectomy removes the entire prostate and is still considered the "gold standard" of treatment for prostate cancer - when the tumor is completely contained within the gland.
· Radiation
Radiation, in various forms, has been used for many years in the treatment of a wide variety of cancers. High energy radiation can kill cancer cells, which have been found to be more susceptible than healthy cells. However, high energy radiation can damage healthy cells, so radiation treatments have been developed to avoid or minimize the exposure to other tissues and organs. The advances in this field have been rapid in recent years, so radiation therapy is gaining more support and popularity - and favored by some over surgery.
There are several types of radiation therapy used for the treatment of prostate cancer.
- External X-ray Beam Radiation (EXBR): Daily treatment with controlled doses of high energy X-rays. The current technology uses computer-controlled "3D conformal" machines.
- Intensity Modulated Radiation Therapy (IMRT): A newer enhancement to EXBR to more precisely control the radiation dosage and target area.
- Radioactive Seed Implantation (Brachytherapy): Small pellets containing radioactive isotopes are surgically implanted in the prostate to provide localized high energy radiation. This treatment is often used in conjunction with EXBR.
From Cancer medical journal (August 1, 2007) “Dual therapy can control high-risk prostate cancer … High rates of tumor control over the long term are possible with combination treatment using external beam radiation followed by brachytherapy in high-risk prostate cancer patients, according to researchers. "These patients have been followed longer than any other treatment group reported in the prostate specific antigen era," (Dr. Michael Dattoli – a leading prostate cancer researcher and physician). Prostate specific antigen (PSA) has become a standard tumor marker for prostate cancer, with high levels correlating with an increased risk of cancer. "Moreover," said Datoli, "the vast majority of the patients in this study group had extreme adverse features so that surgery would not have even been a treatment option -- certainly not a good option." The Dattoli Cancer Center followed 119 intermediate-risk and 124 high-risk patients who had been treated by Dattoli between 1996 and 1998. All but 39 of the patients had at least one risk factor for cancer progression.
· Hormone Treatment
The male hormone testosterone can stimulate the growth of prostate cancer. A variety of forms of hormone treatment have been developed to reduce or eliminate this stimulation by blocking the testosterone. Hormone therapy may be used as a complementary or standalone treatment.
· "Watchful Waiting" – monitoring
For some men, it may be appropriate not to obtain treatment at this time. This could be because of advanced age or other illness where the necessary treatment for their prostate cancer may be a significant risk - or a lower priority to other medical treatment that they need or are undergoing. The physician may believe that the cancer is of such a low grade and the patient is at an age where he is not likely to die from the disease. This is often recommended to men over 65 - those in their late 70s or 80s in particular. In any case, watchful waiting does not mean doing nothing! It means monitoring the situation by periodic exams and tests to make sure that the cancer is not growing and spreading. Depending on the stage of the cancer, most men are at risk if they live more than 10 years without some form of treatment for it. There is an unfortunate dichotomy that relates to the "watchful waiting" category. Those men with very early stage, low grade cancer may not need treatment, but are usually the best candidates for it. And those with advanced stages of cancer will probably not be cured with the conventional treatments available today. Since the field of prostate cancer treatment has been advancing rapidly, it may lead some men to think that they can wait until new improvements are available. This can prove to be a fatal mistake if the cancer has already reached a moderate stage.
Each of these alternatives has some risk associated with it. Not only the chances of successfully treating the cancer, but differences in possible side effects – which can include: urinary dysfunction (incontinence), sexual dysfunction (impotence), bowel dysfunction (diarrhea & urgency). Recent developments in both surgery and radiation treatment have been able to minimize the risk of these side effects (but not eliminate them). So, be prepared to live with some problems as part of the cure.
Other Alternatives: There have been and continue to be developments for alternative treatments and cures for prostate cancer. Among those that have been around for a while are:
· Cryosurgery (freezing the prostate gland to kill the cancer)
· Chemotherapy - drugs to slow the growth of the cancer and ease pain and other symptoms - but not to cure. Chemotherapy often comes with severe side effects. There continues to be research in this area.
· Immunology/Biological Therapy - "using the body's immune system to fight the cancer"
· Proton beam - a relatively new technique with limited facilities, experience and data - but some consider having promise for effective treatment of prostate cancer.
· Herbs - a number of herbal preparations have shown some evidence of symptomatic relief and possibly even reduction in the growth of cancer.
· Microwave treatments/Prostaton - to shrink the prostate (BPH)
· Diet – e.g., low fat, soy-based products, antioxidants either as a preventative or complementary measure. Johns Hopkins reports that “Experts now estimate that up to 90 percent of cancers of the prostate may have a dietary link. New evidence that the progression of prostate cancer may actually be slowed by dietary changes.”
New Developments
Perhaps the most promising at this time are:
· Robotic-assisted and laparoscopic radical prostatectomy, which is being successfully used for more precise, minimally invasive surgery.
· Johns Hopkins reports that there is “a new use of an oral hormonal medication may represent an important breakthrough in prostate cancer treatment. And, how a team of scientists and physicians is zeroing in on an improved Prostate Specific Antigen (PSA) test -- one which will reduce false positive readings and provide greater accuracy in predicting which men have PSA elevations due to benign prostate enlargement and which are due to prostate cancer.”
· The New York Times reported (11/18/10) “An experimental drug is showing what some experts say is intriguing effectiveness in treating a major cause of death and disability for men with prostate cancer - tumors that have spread to the bone.”
· And, from WebMD (Feb. 17, 2011) – “Researchers are a step closer to developing a genetic test that could help men with newly diagnosed prostate cancer decide whether they are good candidates for active surveillance or whether they need treatment right away.”
GENERAL CONSIDERATIONS
Aggressive treatment (either surgery or radiation) is usually recommended if you are relatively young and healthy. For early stage cancers, where the tumor is very small and contained within the prostate gland, physicians will generally recommend either:
· Radical prostatectomy - if you are relatively young (e.g., under 60), since you will probably live long enough that the cancer could eventually be life threatening.
· Watchful waiting - if you are relatively old (e.g., over 70) since you may not live long enough for the cancer to be life threatening.
Most common treatments (surgery & radiation) work best with early stage tumors (and low PSA levels). Radiation treatments are often proposed as an alternative to avoid the trauma and potential risks of surgery. For larger tumors and where there is the potential that the cancer has spread beyond the prostate gland, surgery may not be an effective cure. For advanced stages of prostate cancer, where the cancer may have spread beyond the prostate to other body parts, physicians usually recommend therapies that control rather than cure.
PERSONAL OPINIONS AND CONSIDERATIONS
· Choice of physician and facility is probably more important than the choice of the treatment.
· You run the risk of "information overload". There is so much information out there from so many sources (much of which is biased or conflicting), that you may reach a point when you become overwhelmed and confused. I recommend being selective in your research and seeking the opinions of others. Hopefully this article will also help.
· Your values in relation to quality of life factors will (and should) influence your choice for treatment.
· Think of this situation as your job. It is important to focus on it and do it well.
· Prostate cancer is serious business. Be aggressive and act as soon as possible to give yourself the best chance for an effective treatment before the cancer grows even more. Take charge of your prostate cancer!
· Don't be surprised if you are not told everything about the treatments in advance - even if you ask.
GENERAL ADVICE
· Men over 50 should insist on a PSA test
· Be: persistent, inquisitive, patient
· Have a positive, objective and aggressive attitude
· Find out about all treatment options and prepare yourself to make an informed decision. Research the subject like it was your job - because it is! But you must also beware of information overload and questionable sources of information. You will need to use your judgment on what information is important to you and what to believe.
· There is no one "right treatment" for everyone or even any one individual who has prostate cancer. There are alternatives with trade-offs.
· If you don't like to be poked or probed or "zapped" - get used to it! The alternatives are a lot worse. And if you are modest and get embarrassed easily - learn to live with it (or get over it). The people you will be "exposed" to (frequently) are professionals and see lots of bodies every day - no big deal!
· Most people think sports are a "guy thing". Well prostate cancer is the "ultimate guy thing". It can only be experienced by guys and can affect their "guyhood" as well as their lives. It should be taken more seriously and aggressively than a sports enthusiast would his favorite sport and team.
· Focus on PCa, but keep occupied/living.
· "Leave Of Absence" - Be prepared to disrupt your life for several months - depending on the course of treatment and facility you choose. You may even have to take a leave of absence if you work daily. Think of it as a very important temporary assignment.
AFTERWORD
The process for treating prostate cancer will change your life – at least for a while. It will probably cause discomfort and maybe even pain. You will not function normally for probably a few months, and possibly in some cases permanently.
But consider yourself LUCKY! The alternative is much worse. Prostate cancer can kill you. You are fortunate enough to have a variety of effective treatment options. Other cancers are not so forgiving.
You have an opportunity for a second chance at life. Take advantage of it and focus on getting through a few months of disruption and inconvenience. It will be over soon and you can go back to being "a guy" again.
It may be the most important thing you are going to do for yourself - and your family. This is a big deal!
GOOD LUCK - and HAVE A GOOD LIFE!
All Rights Reserved © 2011 Henry P. Mitchell