 Here's a good article about two of the most common prostate problems: prostate cancer and benign prostatic hypertrophy (BPH). If you are hesitant to see your doctor about prostate problems, don't be. A medical check-up can ease your mind as well as your symptoms and head off more serious trouble later on. Many men are barely aware they have a prostate gland until it starts causing them
problems. What every man should know is that the prostate gland is an essential part of their reproductive organs. It collects and produces a clear fluid that is part of a man's semen. About the size of a walnut, the prostate gland is located below the bladder and surrounds the upper part of the urethra (the tube that carries urine and semen out of the penis). As a man ages, the prostate gland may gradually enlarge and cause urinary difficulties -- a condition called benign prostatic hypertrophy (BPH). By age 50, up to one-half of all men have this condition.
Prostate cancer -- which is totally unrelated to BPH -- is a much more serious health problem than BPH. It is the most common cancer (excluding skin cancer) of American men and the second leading cause of cancer death in men (exceeded only by lung cancer). Here is how you can help protect yourself against these two common prostate problems. What Are the Signs of BPH? BPH affects 10 million American men. It is not life-threatening but can cause symptoms ranging from mild to
severe. BPH usually occurs around middle-age, when an enlarged prostate puts pressure on the urethra and blocks the normal flow of urine. The signs of this condition include:
Difficulty starting the urine stream A need to urinate frequently, especially at night A feeling of incomplete bladder emptying
In a small percentage of cases, BPH completely blocks urination or causes bladder or kidney damage. If you're experiencing any of the symptoms listed, see your physician to rule out other conditions and find out about treatment possibilities. What Are the Treatment Options for BPH?
Watchful Waiting. In many instances, BPH does not cause medical complications and no treatment is necessary. You and your doctor may simply monitor the condition by getting regular checkups. Sometimes symptoms disappear on their own. Men who have had bladder or kidney damage, repeated urinary tract infections or episodes of acute urinary retention may require surgery. But for the majority of men, the risks associated with surgery, which increase with age, must be weighed against the benefits. Drug Therapy. Men with moderate symptoms may be given a drug that shrinks the prostate by blocking production of testosterone, the hormone that stimulates prostate growth. One study found that about 70 percent of men who took the drug experienced relief. Some drawbacks: the medication takes four to six months to take effect, and it interferes with a test used to screen for prostate cancer. Other drugs that relax certain prostate muscles or reduce blood vessel wall expansion can also be used to relieve pressure. Surgery. The most common surgical treatment for BPH is transurethral resection of the prostate (TURP), in which excess prostate tissue that blocks the flow of urine is removed using a tiny instrument inserted through the penis. A hospital stay of two to three days is usually required.
The success rate of TURP is high -- about 85 percent -- with only 15 percent of men needing a repeat TURP within 8 years. An estimated 400,000 TURPs are performed each year, and it is the second most common procedure paid for by Medicare. But TURP is not without side effects: Many men experience retrograde ejaculation in which semen travels backward into the bladder rather than out through the penis. This is not medically harmful and doesn't affect sexual pleasure, but it does render a man infertile. About four to eight percent of patients become impotent due to TURP.
Another form of surgery is transurethal incision of the prostate (TUIP). In this procedure, the urologist passes a thin tube, or catheter, through the urethra into the center of the gland and then scrapes away prostate tissue with an instrument inserted through the tube. This can cause incontinence and impotence in rare cases. Electrovaporization. In this modification of TURP, a device is inserted into the urethra with a catheter and electronic waves are used to vaporize prostate tissue. Needle Ablation. Transurethral needle ablation or TUNA was approved by the FDA in September 1996 for the treatment of BPH. In TUNA, doctors heat and destroy enlarged prostate tissue by sending radio waves through needles positioned in the prostate gland. TUNA poses less of a risk of incontinence and sexual dysfunction than traditional surgery and can be performed as an out patient procedure. However, it doesn't reduce symptoms and increase urine flow as much as surgery does. Laser Therapy. A urologist inserts a laser into the urethra via a catheter. The laser heats and destroys extra prostate tissue. It may take several weeks to notice results. Balloon Dilation. Similar to balloon angioplasty, which is used to open up clogged heart arteries, a balloon inserted through the urethra is expanded to push back prostate tissue and widen the urinary path. Improvement often lasts only one or two years, so balloon dilation use has declined. Stents. A tiny metal coil is inserted into the urethra to widen it and keep it open. Tissue grows over the stent to hold it in place. Stents may be recommended for patients with heart conditions or other illnesses that prevent surgery. Experimental Treatment. The use of high-frequency, high-intensity ultrasound to destroy prostate tissue is being tested. The procedure is performed in much the same way as laser or microwave therapy.
What If It's Cancer? The number of men diagnosed with prostate cancer has increased dramatically: Between 1973 and 1993 new cases of prostate cancer rose by 173 percent. The good news is that this increase is largely chalked up to improved detection methods rather than an epidemic of the disease. Most prostate cancers develop in older men and grow very slowly; but there are some prostate cancers that grow and spread quickly. It's estimated that in 1999 about 179,300 new cases of prostate cancer will be diagnosed in the United
States and about 37,000 men will die of the disease. The bad news about prostate cancer is that treatment for it is far from straightforward. There is controversy over how -- or even if -- it should be treated at all. Since nine out of ten cases of prostate cancer are silent and grow slowly, it is said that more men die with prostate cancer than from it. Autopsy studies of men in their fifties who died of unrelated causes showed that one third had prostate cancer that was unrecognized during their lives. By the time men reach their eighties, it is believed 75 percent have some
cancerous prostate cells. Who Gets Prostate Cancer? The causes of prostate cancer are not known, but certain factors, such as age, race, genetic predisposition and hormones, are linked to an increased risk of getting it. Most prostate cancers occur in men over age 50. More than 80% of all prostate cancers are diagnosed in men over the age of 65. The disease is most common in North America and northwestern Europe and is about twice as common among African-American men as it is among white American
men. Prostate cancer seems to run in some families, so having a father or brother with the disease may double a man's risk of developing it. High levels of hormones, such as androgens (male hormones) and insulin-like growth factor-1 (IGF1), may also promote prostate cancer in some men. Other risk factors may include lifestyle habits. Research, including a recent Harvard study, suggests that a diet high in animal and dairy fat increases the risk of developing prostate cancer. Some scientists speculate that a lack of fruits and vegetables in the diet is another contributing factor.
Men who have had a vasectomy may have a slightly increased risk for prostate cancer. Two studies, largely financed by the National Cancer Institute, showed a small statistical relationship between vasectomy and the development of the disease. But the data is far too preliminary, and more studies are needed to confirm any association. Can Prostate Cancer Be Prevented? Since so little is understood about what causes cancer of the prostate gland, there is no sure-fire prescription for prevention.
However, men can try changing some of the controllable risk factors such as poor eating habits. A diet low in fat and plentiful in vegetables, fruits, and grains is associated with a reduced risk of prostate cancer. And some studies suggest that taking 50 milligrams of vitamin E daily can lower risk of the disease by 32 percent. What Is the Debate Over the Detection and Treatment of Prostate Cancer? Prostate cancer often grows very slowly. For men whose cancer has not spread beyond the prostate gland,
the five-year survival rate is almost 100%, whether or not they are treated. The crux of the debate over prostate cancer centers around the fact that although early diagnosis and treatment of the disease may help some men live longer, it will have no impact on the life span of other men. Some experts argue that the main prostate cancer test is often inaccurate and leads to more expensive and invasive tests. Further, they say prostate cancer treatment can be more destructive than the tumors themselves due to possible side effects, including impotence and incontinence. On the other hand, other experts point out that before early detection tests were widely
used, most men were diagnosed when their disease was in an advanced -- often lethal -- stage. So it's better to over-diagnose than under-diagnose because the sooner a man finds out he has prostate cancer, he can evaluate his options and do something before the cancer spreads. Most major health organizations do not endorse mass, routine screening for prostate cancer. But the American Cancer Society (ACS), the American Urological Association, and the National Comprehensive Cancer Network (NCCN) believe that prostate cancer screening can save lives and recommend that doctors offer
men 50 years or older the option of testing for early detection of prostate cancer and discuss the risks and benefits of early detection and treatment of the disease. Signs and Symptoms of Prostate Cancer Most often, early prostate cancer causes no symptoms, but in certain cases men notice a weakening of the urinary stream or the need to urinate more often than usual. Symptoms of advanced prostate cancer include blood in the urine, impotence, and pain in the pelvis, spine, hips, or ribs.
Detecting Prostate Cancer
Digital rectal examination (DRE). In this exam, the physician inserts a gloved, lubricated finger into the rectum to feel the prostate gland for any irregular or abnormally firm area. Drawbacks to DRE: A tumor may lurk in an area a doctor can't reach or may be too small to be detected by hand. DRE is uncomfortable, but it is painless and brief. Prostate-Specific Antigen Blood Test (PSA). This simple test measures levels of PSA (a protein which is made by prostate cells) in the blood. High PSA levels can indicate BPH or cancer of the prostate. Although studies have shown the PSA test to be the most accurate detection method, it misses up to 40 percent of prostate cancer cases. The test also indicates cancer in up to 30 percent of patients who are cancer-free, which leads to costly follow-up tests. For improved screening results, the ACS and the NCCN recommend doing the PSA blood test and the DRE at the same time. A man
can be reassured that he is unlikely to have prostate cancer if both exams are negative. Transrectal Ultrasound (TRUS). This test uses sound waves sent out by a probe inserted into the rectum to form a picture of the prostate on a video screen. When the PSA or DRE indicates an abnormality, TRUS is useful to guide a biopsy needle into exactly the right area of the prostate. But test is not recommended as a routine test for early detection of prostate cancer.
How is Prostate Cancer Diagnosed? If your doctor suspects cancer, you will probably be referred to a urologist, a physician who specializes in diseases of the urinary tract and male reproductive system. This specialist will perform a biopsy by inserting a needle through the wall of the rectum into the prostate gland. The needle then removes some prostate tissue which is sent to a lab to check for cancer. When prostate cancer is found, the
tissue is analyzed to estimate how fast it is likely to grow and spread (called grading the cancer). Other tests, such as the DRE and CAT scan, are done to find out how far the cancer has spread (called "staging the cancer"). Guidelines for Watchful Waiting A recent Johns Hopkins study found that a combination of these two detection methods can reveal whether or not prostate surgery is necessary: 1. Calculation of PSA
density.The amount of PSA in the bloodstream is divided by the size of the prostate (gauged by transrectal ultrasound) to determine how much PSA per gram of prostate tissue is produced. Based on this calculation, doctors can tell if high PSA levels result from a large prostate or a tumor that needs to be removed. 2. Evaluation of prostate tissue. In an outpatient procedure (sextant biopsy), six tissue samples from various sections of the prostate are analyzed. A man is a candidate for watchful waiting
if: his PSA density is less than 15 percent of the total weight of his prostate gland; no more than two samples of tissue show any evidence of cancer; less than 50 percent of any single sample contains cancer cells; and the cancer cells are deemed to be slow-moving. How is Prostate Cancer Treated? The challenge with prostate cancer lies in identifying and treating men at risk of dying from it, while not treating those who may lead normal lives with the disease. Trouble is, it can be difficult to
distinguish who will benefit from treatment from who will suffer unnecessarily from the side effects of treatment. Sometimes, no therapy is the best option. The stage and grade of the cancer is one consideration in deciding on the best treatment. But other important factors to be considered include the man's age, life expectancy, medical history, and his personal preferences and feelings about the side effects associated with each treatment. It is important that men be well-informed about the disease, ask questions, and get a second or third opinion on a treatment plan.
Many men with early prostate cancer or who are elderly and/or have other serious health problems decide to do nothing -- the "watchful waiting" approach. A study by the Prostate Patient Outcomes Research Team of the Agency for Health Care Policy and Research found no clear benefit for aggressive therapy in many cases because prostate cancer may stay confined to the gland for years or even decades, making the severe side effects associated with treatment unnecessary. But not all experts agree on this course of action. Doctors often advise younger men who are in otherwise good health to consider radical prostatectomy or radiation
therapy. If you and your doctor decide intervention is necessary, radical prostatectomy, the surgical removal of the prostate, is one option. About 90 percent of these operations remove the cancer entirely. To determine if all of the cancer was removed, doctors monitor PSA levels after surgery. As for the side effects that can occur after prostate surgery: 40 percent of patients become impotent and five to 15 percent of cases develop significant incontinence. In addition, men who have radical prostatectomy no longer produce semen, so they have dry orgasms which, though upsetting
to some, need not affect sexual pleasure. Fortunately, recent refinements to the procedure, including nerve-sparing techniques, may lower the incidence of such side effects.
Radiation therapy uses high-energy rays to kill cancer cells. This therapy is sometimes used to treat cancer that is still confined to the prostate gland or has spread to nearby tissue. In more advanced cases, radiation may be used to reduce the size of the tumor and provide relief of symptoms. When radiation therapy is not successful, a patient can still have surgery. As for side effects -- 50 percent of men experience impotence and about three percent incontinence. Seed implantation, also called prostate cancer brachytherapy is an internal form of radiation therapy. With this minimally invasive procedure, small radioactive capsules -- or seeds -- are implanted into the prostate with thin needles. Imaging tests, such as CT scans or MRI, are used to guide placement of the radioactive material. The seeds give off radiation for weeks or months. Internal radiation therapy may be an effective way to treat prostate cancer that has not spread beyond the prostate gland and spare the normal tissue of the bladder and rectum from high doses of
radiation. However, long-term statistics on this approach are not yet available. Cryosurgery is used to treat localized prostate cancer by freezing its cells with a metal probe. It is not yet known whether the long-term survival rates are as high as with prostatectomy or radiation. This procedure is currently used for men who are unable to tolerate surgery or radiation therapy.
What If the Cancer Has Spread Beyond the Prostate? Once cancer has spread beyond the prostate, it usually can't be cured, but its growth can be slowed and some of the discomfort it causes relieved. Doctors may recommend radiation or decreasing the body's production of testosterone, the male hormone that stimulate's the cancer's growth. One way to do this is through orchiectomy (surgical removal of the testicles) which are the main source of testosterone. The side effects of this procedure include sterility and loss
of sexual drive, usually accompanied by an inability to have an erection and hot flashes. An alternative to surgery is hormone therapy, which involves taking medication that counters the production of testosterone. Hormone therapy can cause loss of sex drive., erection problems, hot flashes, nausea or diarrhea. If hormone therapy fails, chemotherapy (treatment with anticancer drugs) can slow down tumor growth and reduce pain. Finally, even when cancer has spread, "watchful waiting" (doing nothing) may be recommended for elderly men with slow-growing cancer, no symptoms and other
serious health problems. For this population of men, the side effects of aggressive treatment outweigh their benefits. Should I Get a Second Opinion? Decisions about prostate caner treatment are very complex and sometimes it's helpful to have the advice of more than one doctor. In fact, many insurance companies require a second opinion before they will pay for the costs. If the second opinion contradicts the first, you may need a third opinion. A short delay in starting treatment will not reduce the
chances of treatment success. What Are Some Recent Research Developments? In 1999, doctors announced that checking for an abnormal growth called prostatic intraepithelial neoplasia (PIN) could warn that prostate cells might turn cancerous. In military vets treated in Boston, it was found that those with the most abnormal stage of the growths had double the usual risk of developing prostate cancer. Though the procedure involves having a costly biopsy, doctors may recommend that men with PIN undergo
biopsies every three to six months to monitor the possible development of cancer. In the same year, researchers reported that they found a way to estimate the risk that prostate cancer would recur and turn deadly in men who had already had cancerous prostates removed. Men with the highest risk are those whose with high Gleason scores (a rating of the tumor's aggressiveness), a rise in PSA within two years after surgery and a doubling of it in less than 10 months. Prior to knowledge of these three telltale characteristics, many men who had had surgery for prostate cancer and
needed no further treatment received it anyway, suffering side effects needlessly. Now doctors can identify those men who should be treated. Talking to Your Doctor Patients should learn all they can about their condition and treatment choices in order to take a more active part in decisions about their medical care. Since treatment for prostate cancer sometimes affects sexual activity and bodily functions, such as urination, it is especially important to weigh the risks and benefits of different
therapies. Although written material is a good start toward informing yourself, it cannot take the place of a discussion with a qualified professional. Your doctor can answer questions about the extent of the cancer, how it can be treated, how successful the treatment is expected to be and how much it is likely to cost. It is helpful to make a list of questions before you see your physician. Here are some issues you may want to discuss:
What are my treatment choices? What are the benefits of each treatment? What are the risks and possible side effects of each treatment? How will the treatment affect my sex life? If I have pain, how will the treatment help me? Will I need to change my normal activities? For how long? How often will I need to have follow-up exams?
Taking notes can make it easier to remember what the doctor says. Some patients find it also helps to have a family member or friend along to take part in the discussion, to take notes or just to listen. There's a lot to learn about prostate cancer and its treatment. Don't feel as if you need to understand everything the first time you hear it. There will be many opportunities to ask your doctor to explain things that are not clear. Use them.
For More Information Prostate Cancer Treatment Guidelines For Patients
800-227-2345 or 888-909-6226
The American Cancer Society and the National Comprehensive Cancer Network have published a free brochure with guidelines based on how prostate cancer is most commonly diagnosed and treated. The material is designed to explain options and help patients understand what each choice means.
Agency for Health Care Policy and Research
800-358-9295
AHCPR offers a free copy of their guidelines on treating your enlarged prostate and managing cancer pain.
Cancer Information Service
CancerNet
800-4-CANCER
A National Cancer Institute provides a website and toll-free number set up to answer questions from the public nationwide. NCI also offers two free booklets online or in print (call the number above): Chemotherapy and You and Radiation and You.
Us Too
800-80-USTOO
The Foundation for Informed Medical Decision Making
603-650-1180
A nonprofit medical education and research foundation based in Hanover, New Hampshire, which has produced videos on a variety of health topics including prostate disease. The videos are $49.95 plus $6.05 shipping and handling.
American Foundation for Urologic Disease
P.O. Box 630605
Baltimore, MD 21263-0605
410-468-1808
Offers the Prostate Cancer Resource Guide, which provides extensive information about the disease and its treatment options, along with a listing of patient-support organizations. For a copy, send $5 to address above.
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