Cancer is the uncontrolled growth of cells that impair normal body functions, leading to disability or death. Most people, including doctors, believe that cancers should be cut out if possible. Some surgeries, such as removal of the breasts or ovaries, are performed even prior to a cancer diagnosis, with the assumption that cancer will otherwise occur.
Certain cancers, however, may linger in the body for years, never causing disability or death. Prostate cancer is one of these.
The chance of having cancer cells in the prostate increases with age. Put a percentage sign next to your age and you know the chance of having cancer within your prostate. So, a 70 year-old man has a 70% chance of cancer residing within his prostate. Most of these cancers are going nowhere. Prostate cancer is diagnosed in 200,000 men every year. Twenty-seven thousand men die yearly from prostate cancer, usually after at least 10 years of involvement. Thus, 90% of men with prostate cancer do not die from it.
PSA (prostate specific antigen) is a good screening blood test for prostate cancer. A level over 4 is abnormal, but does not mean cancer is present. PSA is also related to the size of the prostate, so a prostate gland that is twice normal in size, or more, will often cause the PSA to rise above normal. Inflammation of the prostate, usually from infection, may also raise the PSA. I have seen the PSA rise to 100 from infection alone, then fall to normal when the infection was treated.
Physical exam of the prostate via rectal exam is also informative. Prostate cancer may be felt as a nodule in the gland, or as hardening of the gland in one area.
Finding prostate cancer does not indicate surgery is necessary. Many of these cancers are indolent. They are slow-growing or not growing at all. Following the PSA sequentially helps determine what course the cancer is taking. If the PSA does not increase, the cancer most likely is stable. Prostate cancer does not metastasize, and does not endanger life, until the PSA rises above 10, and usually much higher than that.
Prostate cancer can also be monitored with an imaging technique called color Doppler-assisted ultrasound. Areas of increased blood circulation within the prostate suggest malignancy, and this study can be repeated over time to follow the course of a malignancy. Magnetic resonance imaging (MRI) provides similar information.
Prostate biopsy usually determines if cancer is present. It is not always necessary. A seventy year-old man with a PSA of 6 can simply be followed. If the PSA goes up very slowly, and stays below 10, he can continue to be followed with what is called “active surveillance.” This means that no surgery, radiation or drug therapy is being given.
In younger men, below 65, an elevated PSA, or PSA that is rising even within the normal range, biopsy is often warranted. Ultrasound-guided biopsy is useful, as it directs the biopsy needle toward the more suspicious areas, those with higher blood flow. Ultrasound also avoids unnecessary needle placements.
Microscopic examination of the biopsy tissue reveals how aggressive the cancer is. A Gleason score of 6 or below indicates low-risk disease. A score of 7 indicates intermediate risk. A score of 8-10 means high-risk. Lower-risk disease often means the PSA will not be increasing rapidly, if at all. A Gleason score is a rating of cancer aggressiveness based on cellular appearance under a microscope.
Several life-style approaches support active surveillance. Food choices should be primarily vegetarian, and always organic. High intake of animal protein supports prostate cancer. Cruciferous vegetables are recommended, like cabbage, kale, Brussels sprouts, and broccoli, as they contain nutrients like sulforaphane that suppress cancer growth. Non-GMO soy products are also recommended. Exercise supports immune function, and helps the body contain and eliminate cancer cells. Helpful supplements are lycopene, vitamin C, vitamin D, indole 3- carbinol, and plant sterols. I recommend Prostate Formula, two a day. Certain herbs, such as Artemisia, may also enhance immune function.
Surgery to remove the prostate is often not useful and may be harmful. Men over 65 years of age have not shown improved survival compared with men treated with other methods. Surgery also causes a high rate of impotence and temporary if not permanent urinary incontinence. Often the surgical margins are not clear of cancer, leaving behind malignant cells that will continue to grow.
Radiation therapy is an improved modality for treating prostate cancer. Techniques have advanced so that damage to surrounding structures like the bladder and rectum is uncommon. Treatment can be with tiny seeds implanted within the prostate tissue, or with external beam radiation to include area just outside the prostate itself. If treatment is successful, the PSA will decline within a few months to very low levels, and stay there.
Another method is hormone suppression therapy. Testosterone does not cause prostate cancer, but does support its growth. Suppressing testosterone removes the fuel for prostate cancer growth. Lupron is given by injection, and blocks the pituitary from stimulating the testes to make testosterone. Casodex blocks testosterone receptors, so the hormone is no longer effective. Proscar prevents the conversion of testosterone to dihydrotestosterone, a more potent byproduct that directly stimulates prostate cancer growth.
These medications can be given separately or together to manage prostate cancer. They are especially useful when the cancer has spread beyond the gland, when surgery or radiation will no longer be effective. They can also be used intermittently, when the cancer shows signs of growing via a rising PSA. Sometimes a limited period of treatment, for several months or one year, can have prolonged effects on the cancer.
The loss of testosterone causes weight gain, loss of muscle mass, lower bone density, impotence and loss of libido, and sometimes depression. Improved nutrition and vigorous exercise, especially with weights, helps to minimize these changes.
Exercise can be aerobic- endurance type, such as walking, jogging, swimming, and bicycling, or anaerobic, such as weight-training. Aerobic activities assist weight loss and cardiovascular fitness. Weight-training builds muscle mass and raises bone density. A combination of aerobic and anaerobic activities is ideal. You should always pursue gradual changes to increase speed, distance or amount of weight. Pushing yourself too hard is likely to cause injury. Exercising 30 minutes a day is sufficient. If you are physically active, the overall risk of getting cancer is lower, and the chance of surviving it is greater.
The main point is that most men with prostate cancer do not require surgery, and can often be managed with active surveillance and beneficial lifestyle changes. Most prostate cancer is not aggressive, and tends to smolder along, often slowly enough to never require potent intervention.
I recommend reading a book called Invasion of the Prostate Snatchers, by Mark Scholz, MD, and Ralph Blum. It explores these ideas in detail, and helps alleviate the fear that men with newly diagnosed prostate cancer may experience.
Allan Sosin, MD