Prostate cancer: what every man should know
Prostate cancer is the most common type of cancer found in men, other than skin cancer. In fact, the American Cancer Society estimates that one of every six men in the United States will be diagnosed with the disease at some point in his life.
Fortunately, there are more and better treatment options today than ever before. With good screening and careful management, the vast majority of men with prostate cancer will survive the disease and enjoy a high quality of life after treatment.
Who should be screened -- and when
One of the best ways to beat prostate cancer is to get regular screenings using the widely available prostate-specific antigen (PSA) test. By measuring the amount of PSA in a man's bloodstream, the test helps physicians discover prostate cancer at earlier stages -- giving men a better chance for survival.
The test is not perfect. Some studies show that it misses up to 15 percent of cancer cases, while flagging some cancers so small and slow-growing that they pose no threat.
Still, the PSA test remains the best clinically available tool for predicting prostate cancer. PSA screening is especially important for men with a family history of prostate cancer and for African-American men, who have a 60 percent higher incidence of the disease than whites.
The American Urologic Association (AUA) recommends that all men obtain a baseline PSA test at age 40. This value can help doctors tailor future screening frequency. For example, men who have an initial PSA of less than 1.0 can generally be reassured and told to return at age 45. Many health care organizations, including Duke, offer free PSA screenings during September (National Prostate Cancer Awareness Month).
New treatment options
If a screening test and prostate biopsy does reveal prostate cancer, there are many potential treatment options. In fact, treatment may not even be necessary. If the disease is detected very late in life, or if the cancer is slow-growing, physicians may recommend active surveillance -- carefully monitoring the cancer's course with PSA tests, physical exams, and biopsies to determine whether and when treatment is needed.
Nutritional therapy may be recommended in conjunction with active surveillance. In a Duke study, men who ate low-fat diets supplemented with three tablespoons of ground flaxseed daily had lower levels of testosterone (which can “feed” prostate cancer), lower PSA levels, and tumors with lower proliferation rates.
Treatment for more aggressive cancers varies depending on individual medical needs and personal preferences. Since patients usually have tumors scattered throughout the prostate, most therapies focus on eliminating the entire gland. Duke researchers, headed by Thomas Polascik, MD, are studying focal therapies for prostate cancer, such as cryotherapy, at this time.
The most commonly used technique is nerve-sparing prostatectomy, in which surgeons remove the prostate while preserving the surrounding nerves that control erectile and urinary function. Up to 90 percent of men who are fully potent prior to the operation can regain erections sufficient for intercourse afterward.
Robotic prostatectomy, which uses a precision robotic system to help surgeons remove the prostate through very small incisions, is another option. Surgeons also can do the open operation through much smaller incisions and with many fewer side effects than in years past.
Radiation therapy is commonly used to treat cancer that has spread beyond the prostate, and it can also provide an alternative to surgery. One of the more recent options is brachytherapy, in which physicians insert radioactive pellets into the prostate via thin catheters. The pellets destroy the prostate, while minimizing the amount of radiation delivered to surrounding tissues.
Cryotherapy is another treatment option for localized prostate cancer. In this technique, fine needles are inserted into the prostate and frozen, forming ice bulbs that kill the prostate tissue. Cryosurgery is a minimally invasive, one-hour, outpatient treatment that maintains quality of life and can be repeated if necessary.
Chemotherapy may be used to treat advanced cancers and cancers that do not respond to hormonal therapy. Physician-scientists are continuing to discover more effective, less toxic chemotherapy regimens, many of which may be available to patients through clinical trials.
The importance of a second opinion
Despite the range of treatments, many men remain unaware of their options until they have late-stage disease, according to the Prostate Cancer Foundation. For optimal treatment, men with high PSA levels should seek out several opinions, and obtain care from a multidisciplinary team of providers, including surgeons, radiation oncologists, and medical oncologists.
By receiving information and advice from several perspectives, men and their families can get the support they need to make the best decisions for them.
Judd W. Moul, MD, FACS (Fellow of the American College of Surgeons), is director of the Duke Prostate Center. He is a noted authority on prostate cancer in African-American men, biochemical recurrence of prostate cancer, prostate biopsy technique, and nerve-sparing radical prostatectomy.