The prostate gland sits in the body below the bladder, and urine flows through it on its way out of the body. The function of the prostate is to secrete fluids that nurture the sperm that come out with ejaculation.

Prostate cancer will strike nearly one in six men. If a man lives to the age of 80, his chances of prostate cancer rise to one in three. Sccording to the American Cancer Society, more than 230,000 men will be diagnosed with prostate cancer in 2006 and more than 27,000 will die. It is the second most common cancer, after skin cancer, and the leading cause of cancer death, after lung cancer, in American men. The disease primarily affects men over the age of 40.

Some of the symptoms of prostate cancer are also symptoms for a prostate infection or prostate enlargement, so it's important to see a physician if you experience any of these. Unfortunately, most cases of prostate cancer do not produce symptoms until it is too late. Symptoms that can be associated with prostate cancer include:

    * Difficulty with urination
    * Frequency of urination
    * Pain with ejaculation
    * Blood in the urine
    * Blood with ejaculation


Usually the cancer is discovered during an examination in which a finger is placed in the rectum and the prostate gland is felt. The American Cancer Society recommends that an annual rectal examination be done on all men over the age of 40. The normal prostate feels firm, while cancer will feel hard like a rock.

In addition to the rectal examination, a blood test called prostate-specific antigen (PSA) can help diagnose prostate cancer at an earlier stage. The American Cancer Society currently recommends that all men over the age of 50 have the PSA blood test done annually. Additionally, men with one immediate relative (father, brother or son) who has had prostate cancer before age 65 and black men should have the examination starting at age 45. Men with multiple immediate relatives who have had prostate cancer before age 65 should begin testing at 40.

One reason for starting early with PSA is to establish a baseline and monitor change. Any increase of greater than 1 points in a year is cause for concern, and an increase of more than 2 in a year is cause for big concern.

We can also measure the ratio of free (unbound) PSA to bound PSA. Free PSA is a much stronger indicator of cancer. When more than 25 percent of the PSA is bound, there’s only an 8 percent chance of positive biopsy.

Elevated prostate-specific antigen does not necessarily mean cancer, since the blood test may also be elevated in enlargement of the prostate, but it’s the best test we’ve got. Sound waves, or ultrasound, can also be used to visualize the internal parts of the prostate.

If a DRE or PSA test is suspicious, it should be followed up by a biopsy. Samples are taken from a number of different locations to be certain the cancer isn’t missed. Every biopsy should be done with a local anesthetic. Analysis of the biopsy can  confirm or deny the diagnosis.

My attitude about treating prostate cancer has changed a great deal over the years. So many men who get prostate cancer don’t die of it; they die with it. With early detection and improved treatments, the American Cancer Society says that only 1 man in 34 now dies from his prostate cancer.

Nonetheless, if prostate cancer is not diagnosed early, it can spread. In contrast to some forms of cancer, prostate cancer generally is an extremely slow-growing cancer, and men will frequently live with it for years.

Once diagnosed, tests including blood, bone scan and other diagnostic X-ray procedures are done to see if there is any evidence that it has spread. If not, treatment depends on a combination of the biopsy results, the PSA level and something called the Gleason grade, which is a score based on how the cancer looks under a microscope. It goes from 2 to 10, with 2-4 considered mild (low grade), 4-7 moderate and 8-10 high grade (aggressive).

When PSA is below 10, the Gleason grade is less than 7 and the percentage of biopsy samples with cancer is low, the cancer is considered low risk. Radiation (brachytherapy and external beam) and surgery are equally effective. Any of them will give a man an 85 percent probability of being cancer free 10 to 15 years down the road.

Radiation has advanced considerably over the years. In bracytherapy, 70 to 100 radioactive seeds are inserted into the prostate, and the technique is quite effective. Seeds pose a lower risk of causing erectile dysfunction that does surgery, but there is still some risk. They can also cause some urinary symptoms, such as urgency and frequency. Most men who have them also get Flomax to ease these problems. External beam radiation is also a good option. 3D conformational radiation focuses the beam and enables a higher dosage while sparing nearby tissue.

Surgery can be done using the traditional open approach or laparoscopically. With the latter, men can leave the hospital within 2-3 days. Some surgeons are now doing prostatectomy robotically. It takes up to five hours, but it does allow the surgeon to do maneuvers that are impossible using the hand alone. Results are similar to laparoscopic surgery. No matter the method, surgeons always try to spare the nerves that cause erection, but it isn’t always successful. Incontinence continues to be a problem with surgery.

When PSA is high, the Gleason score is 8 or more and a large percentage of the biopsy samples are positive, the man is at high risk and surgery is unlikely to be effective. Treatment should probably include radiation (either external beam and seeds) and a medication such as Lupron to reduce testosterone production (called hormonal ablation). The side effects of these medications include loss of energy, significant bone loss (osteoporosis frequently occurs within a year and a half), decreases in cognitive ability, loss of sex drive and erectile dysfunction.

For men with short life expectancy because of other health problems and for those whose cancer has metastasized (gone outside the prostate), hormone therapy is really the only choice. Besides the pills mentioned above, shots, combinations of shots and pills, and castration are also options.

Bear in mind, though, that although the last two paragraphs sound pretty dire, with early detection, few men should end up in such situations.

What can I do to prevent myself from developing prostate problems, such as enlargement and prostate cancer?

Your concern is well founded. Approximately a third of all men over 50 suffer from prostate enlargement, and prostate cancer is now the most common malignancy in America. Fortunately, there are important steps you can take to reduce your risk of developing prostate problems.

Perhaps most important, reduce the amount of dietary saturated fat (red meat, and full-fat dairy products) that you eat. It's no coincidence that American men eat more saturated fat and have higher rates of prostate cancer than men from any other nation or that foreign men who move here and adopt our diet soon have a higher incidence of prostate cancer. In fact, research at Sloan Kettering has shown that increased fat in the diet of rats not only increases the risk of prostate cancer, it also affects the rate at which the cancer grows.

Drink at least eight glasses of water per day. A thorough flushing helps keep your prostate, and your entire urinary tract, happy.

Be sure to get adequate zinc in your diet. Good sources include oysters and other seafood, whole grains, nuts and beans. Be careful with zinc supplements, though. More is not necessarily better.

Men who have borderline prostate problems usually find hot baths comforting, and avoiding caffeine, alcohol, and spicy foods is worthwhile. Evidence also continues to accumulate that saw palmetto is helpful to the prostate without causing significant side effects.

Discovering prostate cancer early, when it can be treated successfully, is second best to avoiding it in the first place. Be sure you have an annual digital rectal exam beginning at 40 and a yearly PSA blood test beginning at 50 (earlier if you have a family history of prostate cancer).

Finally, although I know this one will be tough to face, try to ejaculate regularly. Because the prostate provides some of the fluid in semen, ejaculation may help keep it well drained. You can consider that a prescription.


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