Prostate Cancer

Current Recommendations on Testing

According to the American Cancer Society 2001 guidelines for early cancer screening detection, DRE and PSA testing should be offered annually to men over the age of 50 who have a life expectancy of more than 10 years. Although today there is little strong evidence that these tests lower the death rate from prostate cancer, one recent survey showed that overall mortality in white men younger than 85 has declined compared to the years before PSA tests were routinely given.

Another group, the American College of Physicians/American Society of Internal Medicine (ACP-ASIM), recommends that doctor and patient share the decision whether or not to screen.

The U.S. Preventive Task Force, citing the lack of evidence for improved survival, has recommended against prostate cancer screening.

Biopsy

Depending on the results of the DRE and PSA test, the next step is a biopsy, which means taking a small sample of tissue from the prostate for examination. Possible side effects from this prodedure include infection, bloody urine and blood in the stool.(8)

The Prognosis and Spread of Prostate Cancer

Prostate cancer can be extremely slow developing.(9) Statistics from autopsies show that 30% of men in their 70s, 40% in their 80s and 50% in their 90s had prostate cancer. Most, of course, died from something else.

The disease metastisizes (spreads) in three ways. The first is by moving directly into the tissues around the prostate; the second is via the lymph system to the lymph nodes; and the third is through the bloodstream into the bones. Only rarely does prostate cancer spread to the liver or lungs.

Age, overall health and above all how far the disease has progressed are the most important factors in determining life expectancy and likelihood of survival.

Treatment

In January 2001, NCCN (The National Comprehensive Cancer Network) issued a set of treatment guidelines. The NCCN recommended starting by determining the risk that the disease will recur. This is done by dividing prostate cancer cases into low, intermediate and high likelihood groupings. In the low group, the recommended treatment is observation and careful follow-up. In patients with a life expectancy of more than 20 years, either radical prostatectomy (removal of the entire prostate gland) or external radiation seem to be the options with the highest chance of complete cure. No difference in later quality of life has been observed between the two.(10)

In the intermediate risk group, the recommended choice is between radical prostatectomy and external radiation. If the patient's life expectancy is less than 10 years, then observation alone may be the best option.

When the risk of recurrence is deemed high, then hormone therapy, hormone therapy plus radiation or, in selected patients, radical prostatectomy are the best treatment options. If life expectancy is 10 years or less, observation alone may be the appropriate choice.

In cases of metastatic disease, hormone therapy is advised.(11)

Life expectancy needs to be considered when determining treatment because, as discussed above, there is always the chance — even the likelihood — that the patient will ultimately die from something else. Another important consideration is the possibility that treatment will cause impotence or other unpleasant problems. In treating prostate cancer, the goal is to be realistic. Adding life to years may be a better strategy than adding years to life.

Radical Prostatectomy (RP)

Studies have found no evidence that, for most people, RP improves survival in comparison with less radical treatment (such as radiation) and careful follow-up. While there is limited evidence that surgery does reduce the risk of metastasis compared to radiation,(12) RP carries the same health risks as other major surgeries. There are also some problems specific to RP, including sexual dysfunction (occurring in over 80% of patients), urinary incontinence (30%), urethral stricture (18%), fecal incontinence (5%) and others.

External Beam Radiation (EBR)

For most people, EBR is as effective a treatment for prostate cancer as RP, although there is a slightly higher risk of metastasis.(2) Complications include impotence in 20-30% of patients, bowel dysfunction in 10% and urinary incontinence in 7%. Up to one-third of patients whose cancer is at an early stage and limited to the prostate gland itself are still cancer-free three years after treatment. The overall survival rate is estimated to be 85%.(13)(14)

In cases where metastasis has already taken place, the role of EBR is limited to providing a good measure of pain relief.(15)(16) There are other risks associated with EBR that should be discussed on a case-by-case basis with a doctor.

Androgen Deprivation Therapy (ADT)

In patients with prostate cancer that has spread to the lymph nodes, a combination of ADT, which involves lowering the amount of naturally occurring male hormones within the body, and RP has been shown to improve survival and reduce the risk of recurrence.(17) After metastasis has occurred, ADT(18) improves symptoms, but does not seem to make a difference in mortality. Possible complications include problems with constriction or dilation of the blood vessels, loss of libido, swelling of the breasts, weight gain, osteoporosis and loss of muscle mass.(19)

Chemotherapy

Chemotherapy decreases pain and discomfort in some men with prostate cancer. It makes no difference as far as survival rates are concerned.(20) Serious complications are rare.(21)

Conclusion

While better treatments are improving the prognosis for men with prostate cancer, there are great differences of opinion within the medical community about the diagnosis, screening methods and treatment for this difficult disease. For this reason alone, it is important for all men to educate themselves about this disease and stay informed about new treatments and screening methods. It is currently recommended that all men over 50 should consider discussing screening for prostate cancer with their doctor. Certainly any man who has significant risk factors or who suspects that he might have some symptoms should see a doctor immediately.

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