How common is it?

Relative to other cancers, prostate cancer is common, with approximately 180,000 new cases diagnosed in the U.S. per year. It is also the second leading cause of cancer deaths among men in the U.S. (approximately 32,000 of these men dying each year).

What is the prostate?

The prostate gland is normally a small, walnut-sized gland in men. It is located below the bladder and surrounds the upper portion of the urethra. It lies in front of the rectum, and thereby allowing doctors to examine it during a digital rectal examination (finger placed in the rectum). The primary function of the prostate is to secrete fluid that makes up part of the semen. Unfortunately, it may be a source of many health problems in men, including enlargement (BPH), infection (prostatitis), and cancer.

What are the causes and risks associated with prostate cancer?

The reason(s) why prostate cancer develops is not completely understood. It is likely that prostate cancer occurs due to many reasons. Aging alone appears to be an important factor, as prostate cancer is commonly seen in the prostates of elderly men who died of other causes.

Although it is a common cancer worldwide, there is a notable variability in incidence and mortality among the world regions. The incidence is low in Japan, and intermediate in regions of Central America and Western Africa. The incidence is higher in North America and Northern Europe. Some of these differences may be explained by differences in screening programs for prostate cancer and the risk of other diseases among the world regions. However, there are likely reasons based on genetic predisposition as well as dietary habits.

There appears to be ethnic determinants of risk. Blacks are in the highest group, with an incidence of about 224 cases per 100,000 black men as compared to 150 and 82 (per 100,000) in Caucasian and Asian, respectively. In addition, black men tend to have the disease at a younger age and often presenting with more advanced disease.

Family history of prostate cancer shows a strong risk correlation with the number of first-degree relatives (father, brother, uncle) affected by prostate cancer and the age of onset. The risk in these families ranges from 2 to 11 times greater than men without a family history of prostate cancer.

As mentioned, dietary differences may be a risk factor, with higher risk seen in the high fat group. In Asian countries where the incidence of prostate cancer is lower, diets contain much less fat and animal proteins, and higher soy proteins. Recent research is suggesting that substances including lycopene, selenium and vitamin E may reduce the risk of developing prostate cancer. Cooked tomatoes are rich sources of lycopenes, which are anti-oxidants that may protect cells from becoming cancerous.

Finally, the correlation of vasectomy and prostate cancer risk remains controversial. Many well-designed studies have failed to show such a correlation.

What are the symptoms of prostate cancer?

In its early stages, prostate cancer often causes no symptoms. Some men may have voiding symptoms such as urinary frequency, hesitancy, and weakened urine flow, but these symptoms are non-specific and are commonly seen in men with prostate gland enlargement. In the advanced stages, symptoms may include bony pain, and possibly blood in the urine.

What does prostate cancer screening involve?

Currently, digital rectal examination (DRE) and PSA testing are used for prostate cancer screening. The American Urological Association (AUA) recommends screening for men beginning at age 50 years. Men with presumed higher risk (African-American men, and men with positive family history) should consider screening at age 40 years.

DRE: The doctor inserts a gloved-finger into the rectum to examine the prostate gland, noting any abnormalities in size, contour or consistency. It is also a reasonable way to detect rectal and colon cancer.
PSA test: This is a blood test that measures the level of PSA, a protein substance that is predominately produced by the prostate. Currently, it is the best test available for prostate cancer screening, but it is not a perfect test. It requires proper use and interpretation to avoid unnecessary prostate evaluations due to the fact that other prostate conditions (enlargement, inflammation/infection) can cause the PSA level to be elevated.

How is prostate cancer diagnosed?

Like other types of cancer, prostate cancer requires tissue from the tumor(s) for diagnosis. Tissue is obtained through a biopsy procedure, most often performed by using a transrectal ultrasound device for guidance of the biopsy needle being passed through the rectal wall and into the prostate gland. This procedure is usually performed in a doctor's office, under local anesthesia. Preparation for a biopsy procedure often requires stopping any medicine which may increase the risk of bleeding (such as aspirin, ibuprofen, and warfarin), taking antibiotics to minimize the risk of infection, and using a Fleet enema for cleansing of the rectum.

The number of biopsy cores taken varies with the size and appearance of the prostate gland, with more cores for larger glands in order to achieve adequate sampling. The average gland generally requires about 10 cores. The biopsy tissue is then sent to a laboratory for examination by a pathologist (a physician who specializes in examining human tissue for diagnosis of diseases).

Important information from the pathologist's report includes the number of cores showing cancer, the grading of the cancer if present, and sometimes the location of the positive cores.

What is the next step if my prostate biopsy was negative (no cancer found)?

Once you have been initially evaluated for an elevated PSA and/or an abnormal rectal examination of the prostate, it is crucial that regular follow-up with repeat PSA testing and rectal examination is maintained. Many studies have demonstrated that a significant percentage of patients who have had negative biopsies will eventually be shown to have prostate cancer on subsequent biopsies. Your exact follow-up schedule will depend on your overall risk based upon your prior blood PSA level, your age, your family history, and whether your rectal exam and /or your prostate ultrasound exam was abnormal. Ideally, a follow-up schedule should allow detection of any cancer in its earliest stages, while trying to avoid the potential problem of too frequent and unnecessary testing and evaluation.

What is the next step if my prostate biopsy was positive (cancer found)?

Once prostate cancer has been diagnosed by a prostate biopsy, the doctor will plan to stage the disease; that is, to determine the extent of the cancer. The stage may already be quite apparent based on the blood PSA level as well as the findings on rectal examination and transrectal ultrasound. Due mainly to the widespread use of PSA testing for prostate cancer screening, the majority of newly diagnosed cases will involve cancers that are still contained within the natural boundaries of the prostate gland. In these particular cases, additional tests for staging, such as CT scans and bone scans, offer no additional information and are often unnecessary. These tests are now generally reserved for cases in which the blood PSA level is relatively high (>10, some experts will say >25), the biopsy showed high-grade tumors, and when the tumors are palpable on rectal examination.

Once staging is completed, determining the need for treatment will take place with your urologist. During this time, it is important to keep in mind that your situation is individually unique. It is also important to realize that prostate cancer represents a spectrum of disease. Although some cancers may grow so slowly that treatment may not be needed, others can represent a threat to life. Determining what course of action that is best for you is our ultimate goal. Your doctor will review with you the status of all your health problems, to determine your predicted tolerability for certain treatment options. Patients who are severely affected by other health problems, such as heart and lung diseases, may not need any treatment for prostate cancer, unless the cancer is causing symptoms such as severe voiding difficulties, bleeding, and pain.

For patients who are deciding to have treatment, all the available options will be discussed. Your medical history as well as any prior surgical history may impact your decision. You will be questioned about your voiding symptoms and your current sexual function or dysfunction. It is also important for your doctor to know about your worries or fears as they pertain to the associated risks of any particular treatment option. Currently, most urologists would agree that there are two standard treatment options for localized prostate cancer, surgery and radiation therapy. Our discussion of these two options is covered in separate sections. Some centers are offering cryotherapy (freezing technique) and other energy sources used to destroy prostate tissue (cancer and normal prostate tissue). The experiences of these newer methods are limited, and long-term results are lacking.

Frequently asked questions:

Can prostate cancer be prevented?

Not really. However, some clinical studies are suggesting that some agents like vitamin E and selenium may reduce the risk of developing prostate cancer. Long-term data is not available at this time.

What is the outlook for prostate cancer?

The number of men diagnosed with prostate cancer remains high. However, recent data is showing improving survival rates, suggesting that an active screening program for early detection and treatment improvement are helping. Review of recent statistics gives an overall survival of nearly 90% at five years, while 63% of men with prostate cancer will survive 10 years or longer.

Glossary Terms

benign: not cancerous, not malignant.
biopsies: tissue samples taken from an organ, body part, or a tumor within an organ or body part.
BPH: benign prostatic hypertrophy or hyperplasia, more generally known as prostate enlargement.
cancer: an abnormal growth that can invade nearby structures or spread to other parts of the body.
digital rectal examination: also known as DRE; it involves insertion of a gloved-finger into the rectum to feel the prostate gland.
enema: insertion of a liquid into the rectum to achieve a bowel movement.
infection: a condition resulting from the presence of bacteria or other organisms.
metastasizes: cancer spreading beyond its origin to other parts of the body.
prostatic: pertaining to the prostate.
prostatitis: inflammation of the prostate gland, possibly secondary to an infection by bacteria.
PSA: short for prostate-specific antigen, which is a protein produced by the prostate gland.
radiation: also referred to as radiotherapy; x-rays or radioactive substances used in treatment of certain cancer.
rectal: relating to, involving or in the rectum.
rectum: the lower part of the colon, ending in the anal opening.
transrectal ultrasound: a test using sound wave echoes to create an image of an organ to visually detect abnormalities; it is the most frequently used imaging technique of the prostate.
tumor: an abnormal mass of tissue or an abnormal growth.
urethra: the channel through which urine passes from the bladder to the outside; in men, the channel passes through the prostate gland.
vasectomy: a procedure commonly done to achieve voluntary sterilization in men.

*  This information is not intended to substitute for a consultation with a urologist. It is offered to educate patients on the basis of urological conditions in order to get the most out of their office visits and consultations. Please see our web page disclaimer for addition information.

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