Marc Laniado MD FRCS(Urol) FEBU
CONSULTANT IN UROLOGY

Prostate Cancer Frequently Asked Questions

1. What is prostate cancer?
2. What types of prostate cancer are there?
3. What increases the risk of prostate cancer?
4. Is diet important in prostate cancer?
5. How common is prostate cancer?
6. Is prostate cancer important?
7. Does prostate cancer produce symptoms?
8. How can prostate cancer be detected early?
9. Should I be tested for prostate cancer?
10. Why shouldn't I be tested for prostate cancer?
11. How can I be tested for prostate cancer?
12. What do I do next if I have a diagnosis of prostate cancer?
13. How do I decide what sort of treatment I should have?

What is prostate cancer?

The body is made up of many types of cells. Normally, cells grow and divide to produce more cells only when the body needs them. This orderly process helps keep the body healthy. Sometimes cells keep dividing when new cells are not needed. A mass of extra cells forms, and this mass is called a growth, tumour or cancer. Prostate cells in cancer tumours are abnormal and divide without control or order. These cancer cells can invade and destroy the tissue around them. Cancer cells can break away and spread through the blood  and lymphatic system. In this way, secondary cancers known as metastases form. The spread of cancer is called metastasis.

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What types of prostate cancer are there?

The majority are known as adenocarcinomas of the prostate, but there are other rare form such as mucinous carcinoma.

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What increases the risk of prostate cancer?

• Age: the older men get, the more likely a cancer might develop in the prostate.
• Race: Afro-Caribbean men are at higher risk than Caucasians and men from the Far East have a lower risk for cancer.
• Family history: If a father, brother or uncle has prostate cancer, the risk is also increased.
• Obesity: increases the risk of lethal prostate cancer
• 'metabolic syndrome'
• Tall stature: increases the risk of advanced prostate cancer
• Occupation: Farmers, firemen, workers in electrical capacitor plants, pesticide workers and rotating shifts workers
• Diet: see the question below.

It is not certain, but a history of gonorrhoea may also be significant. Benign overgrowth of the prostate (BPH) is not a risk factor for prostate cancer. Smoking may make prostate cancer more serious if a diagnosis is made, but it is not known if it significantly increases the chance of prostate cancer. Men with only daughters as off spring also appear to be at great risk than men with both boys or no children (ref)

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Is diet important in prostate cancer?

It is not absolutely proven, but certain types of diet may increase the risk of prostate cancer including:

• red meat
• saturated fat
• low intake of fruit and vegetables
• omega 6 fatty acids (corn, safflower oils and red meats).
• high calorie diet
• high calcium and milk consumption

The following diet appears to be associated with either a lower incidence of prostate cancer or lower chance that prostate cancer will spread or be more serious:

• selenium - seafood, poultry, brazil nuts and especially broccoli florets
• vitamin E (wheat germ, nuts, soybeans, organ meats and vegetable oils)
• beans -- black, pinto, small red and kidney beans are high in fiber, which helps the body rid itself of excess testosterone. Beans are also rich in inositol pentakisphosphate, a known cancer-fighter
• soy and soya products (e.g. 62.5 mg Soy isoflavone aglycones (ADM Novasoy) 
• folate supplementation
• lycopenes -  found in concentrated tomato sauces (e.g. pizza), watermelon and pink grapefruit. These work when eaten with broccoli simultaneously
• cruciferous vegetables (cabbage, broccoli, brussel sprouts, cauliflower, bok choy and kale)
• omega 3 fatty acids found in oily fish (e.g. tuna, sardines, salmon), linseed, walnuts or food supplements
• sweet potatoes, carrots and cantaloupe are rich in beta-carotene, which gives them their orange color and helps the immune system keep cancer at bay
• pomegranate juice (8 oz/day)
• zinc
• milk thistle
• turmeric (curcumin): a chemical found in curry especially in combination with watercress, cabbage, winter cress, broccoli, brussels sprouts, kale, cauliflower, kohlrabi and turnips.
• green tea (the evidence for this is less strong than it was a few years ago)
• quercetin: possibly helpful

A low glycaemic index (GI) diet may also be helpful as this reduces the amount of circulating insulin that . Follow this link for further information.

There was concern that flax seed may be dangerous for prostate cancer, because it is rich in alpha-linolenic acid. However, this is probably a red herring and is probably safe. See the discussion on this link: flax seed and prostate cancer.

Some drugs can also reduce the risk of prostate cancer including 5a-reductase inhibitors (e.g. finasteride, dutasteride). Statins are used to reduce cholesterol and seem to reduce the probability that prostate cancer will spread outside the prostate if develops at all.

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How common is prostate cancer?

For most men, there is a 1 in 6 chance (16%) of being diagnosed with prostate cancer in their lifetime and a 3% chance of dying from it.

The chance of a diagnosis of prostate cancer increases as men get older.

It is possible to estimate the risk of prostate cancer by following this web link: http://www.hyperion-interactive.com/astrazeneca/risk.htm

or this one:

Harvard Center for Risk Cancer Prevention Prostate Cancer Risk Calculator

or this one:

Prostate Cancer Research Foundation of Canada

Go to PSA to see the chance of prostate cancer alone and high grade prostate cancer  by PSA alone.

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Is prostate cancer important?

About 10 000 men a year die with prostate cancer in England and Wales. Recently, there have been suggestions that there is considerable over treatment for prostate cancer. That is partly true, but prostate cancer is important and around 10,000 men still die from it. Many men with prostate cancer die from other problems before prostate cancer, but some men's quality of life can be severely affected whilst living with it. In general, men aged 45 have various causes of death and these are shown diagrammatically below. Heart disease, lung cancer, strokes and emphysema kill more people than prostate cancer, but as these diseases become controlled, there is a chance that prostate cancer will become more important.

The important thing is to try and identify prostate cancer at high risk of progression and causing problems. The factors to consider are: change in PSA over time, change in palpable volume of the tumour, the grade (Gleason Score) of the prostate cancer, and the amount of prostate cancer present in the biopsies (mm in length Ca), versus no cancer in the biopsies (mm in length non-Ca) taken from the prostate.

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Does prostate cancer produce symptoms?

When prostate cancer starts, there are usually no symptoms. As prostate cancer advances, symptoms may include:

• blood in the urine
• frequency and nocturia
• weak urine flow that stops and starts
• discomfort whilst passing urine
• inability to urinate ('urinary retention')
• persistent pain in the back, thighs and pelvis
• inability to get an erection (impotence)

However, these symptoms usually occur for other reasons including a urine infection, benign overgrowth of the prostate or other problems, but not prostate cancer. Therefore, you should not immediately worry and think you may have cancer if you have these symptoms. Nevertheless, they must be checked out by a doctor.

Advanced prostate cancer can cause pains in the bones (e.g. back), urinary problems and weight loss. These must be investigated by a doctor in the appropriate setting.

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How can prostate cancer be detected early?

Usually, there are no symptoms. The only way to detect cancer early is take samples (biopsies) from the prostate. However, this is not necessary in everyone.

Several factors can be used to help determine the risk of prostate cancer. These include:

• PSA exact level(see PSA FAQ)
• Whether the prostate feels cancerous or not when felt on examination
• Age
• Race
• Prostate size or appearance on ultrasound
• PSA density (PSA/prostate volume)
• Certain variations of PSA (eg Free/Total PSA, complexed PSA)
• PCA3 score

These bits of information can be used to predict the risk of finding cancer if biopsies are taken.

A new test is available and will probably be very useful. This is the PCA3 score. Essentially, PCA3 is a gene found much more in prostate cancer cells than prostate cells without cancer. After examination of the prostate by a finger (DRE), urine is collected and tested for the amount of a product associated with PCA3. High levels are associated prostate cancer. The PCA3 score seems to be more specific than blood levels of PSA alone for the detection of prostate cancer, and so may help predict who may or may not have cancer found if prostate biopsies are taken.

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Should I be tested for prostate cancer?

Many doctors believe it is of benefit to detect prostate cancer early providing you are in good health, younger than 70 years with at least 10 years of life ahead of you. Knowing how many years you can live can be difficult to guess obviously. Try this website from the BBC for an estimate of how long you may live! The risk of prostate cancer can be calculated.

If you have prostate or waterworks problems anyway, detecting prostate cancer and treating it may alleviate symptoms. There is good evidence that treating people with prostate cancer detected because they have symptoms live longer and have a lesser chance of the cancer spreading. However, not everyone wishes to go through the process to find prostate cancer.

The advantages of screening for early prostate cancer are

• peace of mind
• finding a problem, taking further tests and treating a potentially serious cancer
• the opportunity for treatment early when it is still possible for the cancer to be completely removed and be cured
• having early treatment at a younger age, when the body is able to tolerate it
• the treatments available have significantly improved and have fewer side-effects than they did many years ago, so there are less side-effects than before
• the ability to enter an active monitoring scheme i.e. close following of the cancer to determine if it has features suggesting it may be dangerous or benign, and so choose an intervention only when absolutely necessary

If you want to catch prostate cancer early, PSA testing should be begin from 50 years of age. In general, if the risk of prostate cancer is thought to be high enough to worry,  biopsies may be recommended. The risk can be calculated on line as indicated above. If the prostate feels abnormal when examined by a doctor, most doctors would recommend biopsies, as the chance of significant prostate cancer is high. It is important to realise that there is no absolute PSA value that is globally recognised as being appropriate; It is best to calculate the risk of prostate cancer based on algorithms or nomograms. The implications of the test and biopsies must be understood before undergoing the test.

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Why shouldn't I be tested for prostate cancer?

This might sound like a silly question, but it has not yet been proved that detecting men with early prostate cancer and no symptoms through screening improves the quality of the rest of the life. This is so for several reasons:

• using the PSA test to find cancer probably makes the diagnosis occur about 10 years earlier than it would have been made without a PSA test - this can be upsetting and cause anxiety
• it is possible that many of the cancers detected so early would not get worse and not kill or interfere in the lives of the affected men
• the treatments available for early prostate cancer treatment can result in serious side effects. The side-effects are unusual but can include the need to wear pads to stay dry because of incontinence, bowel problems and the permanent loss of erections
• the treatments do not always work i.e. the cancer persists after treatment.

However, what is also known is that there is no cure for prostate cancer unless it is diagnosed when it is confined to the prostate (i.e. early prostate cancer, localised prostate cancer). Furthermore, it is very difficult to predict with certainty which men with prostate cancer will go on and have problems from those that will not. In addition, it younger men are better able to tolerate the main treatments available for prostate cancer than older men. Thus, early detection is the only way currently available to give an opportunity for cure.

Dr Thomas Stuttaford in the Times wrote an interesting article on PSA testing that can be read in the Times Online.

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How can I be tested for prostate cancer?

Ask your general practitioner and have a discussion with him or her about it. Alternatively see Contact Us.

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What do I do next if I have a diagnosis of prostate cancer?

Do not worry unduly. No two men are alike with prostate cancer and many things need to be considered when deciding what to do to. These include:

• Your age,
• general health including the qualify of your sex life
• whether you have urinary or bowel symptoms already
• the grade (severity) of the cancer, which is usually given as the Gleason score.
• PSA level
• whether the cancer is located only within the prostate or has spread outside either beyond the prostate borders, to the lymph glands or elsewhere such as the bones
• your inclination for treatments including radiotherapy or surgery
• to what extent treatment affect the natural history of disease

These issues can be discussed with your doctor.

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