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UNDERSTANDING PROSTATE CANCER

Prostate cancer is a group of cancerous cells (a malignant tumor) that begins most often in the outer part of the prostate. It is the most common type of cancer (excluding skin cancer) diagnosed in American men. In 2003, an estimated 220,900 new cases of prostate cancer will be diagnosed in the U.S.

Early prostate cancer usually does not cause any symptoms. However, as the tumor grows, it may spread from the prostate to surrounding areas. Change in urination, including increased frequency, hesitancy or dribbling of urine may be experienced.

Prostate cancer can spread from the prostate to nearby lymph nodes, bones or other organs. This spread is called metastasis. For example, as a result of metastasis to the spine, some men experience back pain.

THE VALUE OF EARLY DETECTION

The overall prognosis for prostate cancer patients has dramatically improved compared with years ago. Over the past 20 years, the overall survival rates for all stages of prostate cancer combined have increased from 67% to 97%. This means more men are living longer after diagnosis.

Some of the possible reasons for this increase in survival rates include public awareness and early detection.

WHAT CAUSES PROSTATE CANCER?

While researchers still do not know the exact answer to this question, they have identified some risk factors.

Age

Family history

Generally speaking, men with a father or brother diagnosed with prostate cancer at a relatively young age are at a greater risk of getting the disease themselves, compared to the average man.  Having an elderly relative with prostate cancer is not uncommon and doesn't increase risk. 

The risk appears to be higher if you have a brother with prostate cancer than it is if you have a father with prostate cancer.  The risk is higher still if you have more than one relative diagnosed with prostate cancer.  

It is important to remember that statistics are always a generalization.  There are likely to be specific factors at work for some men, which increase their risk.  Others not affected by these factors may not have an increased risk, despite having a relative with prostate cancer. 

The reason risk is greater if your family member was young when diagnosed or if you have several relatives with prostate cancer is that these are signs that there could be a faulty gene running in the family.  The younger the age at diagnosis, the more likely it is that a faulty gene is at work.  Remember - for there to be a gene at work, the affected relatives have to come from the same side of your family (your mother's side or your father's side).  There is no gene test because specific faulty genes for prostate cancer haven't been clearly identified yet.

Families that carry the breast cancer genes BRCA1 and BRCA2 also have an increased risk of prostate cancer.  We now know that men who carry the BRCA1 gene have almost twice the risk of getting prostate cancer before the age of 65, when compared with the average man under 65.  This sounds dramatic, but the risk of prostate cancer under 65 years is relatively low.  Once you are over 65, the risk of prostate cancer is the same as any man over 65.

For the BRCA2 gene, the risks are higher.  If you carry this gene, you have 7 times the risk of getting prostate cancer before you are 65, when compared with the average man under 65.  Once you are over 65, you have 4.5 times the risk of prostate cancer if you carry this gene, when compared to the average man over 65.

Race

Prostate cancer is much more common in some races than in others. For example, Japanese men living in Japan have an extremely low incidence of prostate cancer. By comparison African American men are at very high risk of this disease. The death rate for prostate cancer is more than 2 times higher in African-American men than in Caucasian/Asian men. Why is this? We don't know. What we do know is that it isn't just about their genetics and heritage, because men of Japanese origin living in America have a similar risk of prostate cancer as any other average American man living in the same area! However, race can be an important factor in determining when a man should have a prostate-specific antigen (PSA) blood test and digital rectal exam (DRE) once every year for signs of prostate cancer.

Environment

The cleaner your environment the less likely you are to be at risk of prostate cancer. But then that is true for nearly all cancers, and explains why smoking is such a particularly foolish thing to do if you want to avoid cancer. Smoking introduces pollutants directly into your lungs, and from there to almost every other organ of the body. You might as well go and stand beside the nearest major freeway and inhale car and truck exhaust fumes all day! Once again, however, there is no perfectly clean environment that will allow you to live without the risk of prostate cancer!

Diet

There is a lot of talk about diet and prostate cancer risk.  But we all eat such a variety of different things that any association between diet and illness is very difficult to prove.  Two new studies, both in the February 2004 Journal of Clinical Oncology, examine this relationship between obesity and prostate cancer recurrence. A very large Europe wide research study is looking into diet and several different types of cancer, including prostate cancer.  Thousands of people are taking part and recording what they eat and drink.  The researchers will follow their progress for more than 10 years and see who gets what. 

As with many other cancers, we think that a diet high in animal fat and low in fresh fruit and vegetables may increase your risk.  Tomatoes and tomato products in particular may help protect against prostate cancer.  Tomatoes contain something called 'lycopene'.   This is a carotenoid, meaning that it is similar to vitamin A.  Lycopene has now been associated with blood levels of a chemical called IGF-1 and prostate cancer risk.

IGF-1

Insulin-like growth factor is a normal chemical that we all make.  It is involved in the regulation of normal cell life, growth and death.  There is a strong link between levels of this chemical in the blood and prostate cancer risk. 

This research is still in the early stages and it is still a bit 'chicken and egg' at the moment.  Some researchers think that IGF-1 might help to cause prostate cancer.  Others think it might be made by prostate cancer cells, higher levels meaning you already have the disease - so they think it is a marker for cancer, like PSA.

What we do know is that several things affect the level of IGF-1 in your blood.  Low fat diet, eating fewer calories, lycopene, eating tomatoes and strenuous exercise can all lower IGG-1 levels.   A lot of milk, dairy products, calcium and polyunsaturated fat in your diet all increase IGF-1 levels. 

Hormones

The prostate gland is a sex organ. It produces a liquid which is mixed with sperm to form semen.

Testosterone is a sex hormone produced by the testicles. The prostate gland needs testosterone to work, but testosterone may help to cause prostate cancer. Men who lose both testicles early in life, and who don't have testosterone replacement do not get prostate cancer.

Prostate cancer cells need testosterone to grow. If testosterone is prevented from getting to the prostate cancer cells, then they can often shrink the cancer.

Vasectomy

One question that crops up over and over again is whether having a vasectomy (the procedure that stops a man from making a woman pregnant) can lead to a later diagnosis of prostate cancer.

First of all, it has to be said that men who have vasectomies do appear to be more likely to have a diagnosis of prostate cancer 20 years later than men who do not have vasectomies. However, it also has to be said that there is absolutely no evidence whatsoever of a cause and effect relationship. Indeed, there is good reason to believe that this is a statistical coincidence that has to do with the attitudes to health of men most likely to have vasectomies.

Basically, men who have vasectomies exhibit what is widely described as "health-seeking" behavior. In other words, they are the type of men who look after their health, tend to go for regular check-ups, and generally have a lifestyle which could be considered as "healthy." They are presumed to be more likely to have vasectomies because they have considered that the risks associated with a vasectomy are far lower than the risks associated with their wife/partner having a late or unwanted pregnancy.

Now it is also reasonable to suppose that men who exhibit health-seeking behavior are more likely to seek regular prostate examinations as part of that behavior. This immediately implies that the same men who seek vasectomies are more likely to have a prostate examination than the men who do not have vasectomies. Therefore these men are more likely to be diagnosed with prostate cancer!

The bottom line is that men who have vasectomies are somewhere between 1.5 and 2.0 times more likely to have a later diagnosis of prostate cancer than men who have not had a vasectomy ... but that we have no reason to believe that there is any connection between the two.

ARE ALL CASES OF PROSTATE CANCER EQUAL IN RISK?

Bluntly, no they aren't. One of the most infuriating problems is that for many men a diagnosis of prostate cancer is not significant! If you look at the prostates taken from 100 American men over 50 years old who die in car crashes and similar accidents, that is men who never showed any clinical sign of prostate cancer while they were alive, you can, in fact, find small areas of cancer in the prostates of about 30 of those men (30%). Those men could have lived for years with those small areas (foci) of prostate cancer -- or some of them could have been diagnosed with clinically significant prostate cancer just a few months later if they had lived. If you do the same thing with American men over 90 years old, you find that 90% of them have microscopic evidence of prostate cancer.

These small areas of prostate cancer tissue that do not develop into clinically important disease are often called "latent" prostate cancer. For an average American man of 50 years of age, with a reasonable life expectancy of another 25 years, the chance that he will develop a microscopic focus of so-called "latent" prostate cancer tissue is estimated to be 42% (that is, 42 of 100 such men will get such a microscopic focus). However, the chance that the same man will get clinically significant prostate cancer (that is, prostate cancer that is associated with clear signs or symptoms of the disease) is only 9.5%. Finally, of the same 100 men, only about three will actually die of prostate cancer. So you can clearly see that while many men may get prostate cancer, it will actually affect relatively few of them very seriously. It is often said that most men are much more likely to die with prostate cancer than because of this disease.