Prostate Puzzles

Rarely, men can get breast cancer. There will be a few less than 2,000 new cases of invasive breast cancer diagnosed in American men in 2010. But women do not get cancer of the prostate, because they don’t have one.


The prostate is a walnut-size gland that sits under the bladder and works with the male reproductive system. People sometimes mistake the name of this gland for the unrelated word “prostrate,” which means to be stretched out facedown on the ground in a submissive position.


A prostate can lay a man low. The gland can have chronic infections or inflammation, as in chronic prostatitis, and it can enlarge with age, causing obstruction of the flow of urine, also called benign prostatic hypertrophy. And the gland can develop cancer. One in six American men will be diagnosed with cancer of the prostate during his lifetime.


Next to lung cancer, prostate cancer is the second-leading cause of cancer deaths for men in this country. When cells in the prostate are transformed into cancerous cells, a protein that is normally made in the prostate in small amounts called the prostate-specific antigen, or PSA, can be detected in the blood at higher levels. The blood PSA level can go up for cancers that are still well contained in the gland as well as for cancers that have already spread (metastatic) outside the gland. The PSA level can also rise in noncancerous conditions.


An elevated PSA does not tell you anything about the spread of cancer. It also does not tell you if it is a small, slow-growing tumor that is unlikely to kill this man, or if this is an aggressive tumor that is much more dangerous. When older men die of something else, slow-growing cancer cells are often found in their prostates that never needed (or got) treatment. For this reason, experts continue to debate the wisdom of testing all men for PSA.


This leads us to the current controversy about how to sensibly screen large numbers of men over 50 for prostate cancer. The United Kingdom’s national screening committee has recently rejected PSA blood testing as the primary method of screening, leaving diagnosis up to the practitioners.


To clarify the issues for our country, I spoke with Dr. Howard Adler, medical director of the Prostate Care Program and clinical associate professor of urology at Stony Brook University Medical Center. Dr. Adler is a strong advocate of risk assessment and screening for prostate cancer.


“Cancer is an emotionally charged subject,” Dr. Adler said. “It used to be referred to as "the big C" because people did never want to say the word. People get frightened and they do not know what to do.” As a result, patients and doctors will often opt for doing more rather than less.


 Prostate cancers in general tend to be slow-growing tumors. That being said, the purpose of widespread screening is to save a few men lives while minimizing the risks of unnecessary procedures and surgery for many. Because noncancer conditions can raise the PSA, many primary care physicians are against testing all men as they get older. The American Urological Association recommends that men begin to be screened for prostate cancer at the age of 40 with an initial PSA blood test and a rectal exam. But only one-third of prostate cancers can be felt with a doctor’s gloved finger.


The U.S. Preventive Services Task Force does not recommend this early screening because of the risk of excessive side effects from diagnostic testing and treatments in these slow-growing tumors. The task force does not recommend screening men over 75 at all.


"Like all of medicine, testing for and treating prostate cancer must be individualized,” Dr. Adler said. “It is not just the PSA and rectal exam. We need to look at previous blood tests, the patient’s overall medical status, and the family history. It’s not a cookbook.”


Definitive diagnosis of prostate cancer is usually made by ultrasound-guided biopsy of the gland. The two most common treatments for the disease are surgical resection and radiation therapy. In skilled hands, the outcomes of these two approaches appear to be fairly similar. There may be issues of practitioner availability, medical stability for surgical risk, and personal choice in making these decisions.


Though experts argue that we are not seeing the benefits of early and widespread prostate cancer screening, Dr. Adler points out the undeniable fact that since we have been doing the screening, it has become rare for a man to first come in with disseminated disease. So he argues that screening and investigation have done recognizable good.


Dr. Adler hopes that soon we will be able to know which prostate cancers will require aggressive treatment by detecting certain cancer proteins, or markers, in the blood. The others could be left alone.


"There is no one right answer,” he told me. “You need to sit down and speak with your physician about the situation. I have never seen anybody die of an elevated PSA all by itself. We urologists can work with your own doctor for interpretation and management so you can have the best possible outcome.”

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