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William J.
Catalona, M.D., answers your questions...
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Professor of Urological
Surgery at Washington University Medical Center in St. Louis,
MO.
Dr. Catalona has received the
Benhamin Stockwell Barringer Medal from the American Association
of Genito-Urinary surgeons for his cancer research. He was also
designated
by American Health magazine
as one of the Best Doctors in America. Dr. Catalona edits QUEST,
published by the Urologic Research Foundation. |
Q. What does
it mean when there is blood in the semen and what should be done to
treat it?
A. The most common
causes of blood in the semen are irritation, inflammation, and/or
infection in the prostate gland (prostatitis). There may be
associated symptoms of pain or burning in the urinary tract, urinary
frequency, slow urinary stream, or urinary urgency. However, in
some cases, bleeding may be the only symptom. In most cases, the
bleeding will eventually clear as the inflammation or infection is
handled by the body's natural immune defenses, but in most cases
taking antibiotics will hasten the return to normal.
Blood in the semen can also occur
with prostate cancer, but this is an unusual cause. In our study of
men who underwent biopsy because they had a PSA higher than 4 or
suspicious findings on digital prostate exam, if they had not other
symptoms, 24 percent had biopsies that showed cancer. If they also
had blood in the semen, 36 percent had biopsies that showed cancer.
This indicates that blood in the semen is more common in patients
with cancer, but it is important to point out that these men also
had other evidence of cancer (PSA ore rectal exam abnormalities).
(Reference: Catalona et al. J Urol 151:1283, 1994.).
I recommend that men with blood in
the semen be treated with a two to four week course of antibiotic
therapy. If the bleeding persists, I recommend that the patient
undergo cystoscopy (looking into the urine channel with a small
flexible scope) and biopsy of the prostate to rule out the presence
of prostate cancer.
Q. Are there
measures that can be taken to prevent the development or progression
of prostate cancer?
A. Prostate cancer is
influenced by both heredity and environmental factors. Prostate
cancer is almost certainly caused by changes (mutations) in the DNA
that affect the regulation of the growth of normal prostate cells.
It is probable that several mutations have to occur before a
full-blown cancer occurs. These mutations can accumulate over time,
causing the gradual progression to prostate cancer. Some mutations
may cause a precancerous condition called prostatic intraepithelial
neoplasia (PIN), others may cause a slowly growing form of the
cancer, and still others may cause a rapidly progressive form of the
disease. It may take decades for some prostate cancers to develop,
while others may develop more rapidly if a more serious mutation
occurs. Some men may inherit one or more of these mutations from
either his mother or his father. In this case, fewer additional
mutations would be needed before cancer occurs. Nevertheless, it is
possible that preventive measures might prevent the development or
progression of prostate cancer.
Chemoprevention is treatment
that prevents the development and/or the progression of cancer.
Some potential chemopreventive agents for prostate cancer may be
medicines, herbs, or food supplements. Recently, considerable
attention has been focused on nutrients as possible prostate cancer
preventive agents. The most promising are soy products (called
phytoestrogens and isoflavones), vitamin D, vitamin E, selenium, and
lycopene.
Some researchers have speculated
that the high ingestion of soy products is responsible for the lower
death rate from prostate cancer in Japan, where the death rate is
4-5 times lower than in the United States. Some studies have
suggested that prostate cancers develop and progress more slowly in
Japan. It has been shown that soy slows the proliferation of
prostate cells, and part of this effect may be mediated through
lowering the levels of male hormones. Soy contains steroid-like
chemicals that may alter the chemical reactions in prostate tissues.
Soy proteins are changed by
intestinal bacteria to produce estrogenic and antiestrogenic
compounds. This increases the levels of binding protein levels in
the blood that tie up the male hormone, testosterone, which normally
stimulates prostate cancer cells to grow. Soy proteins also have
numerous other potential actions. They alter enzyme functions,
alter protein synthesis, alter the action of growth factors,
directly affect the growth rate of prostate cells, and alter the
production of blood vessels that allow tumors to grow.
Genistein is one of the most
prominent components in soy. Genistein has been shown in animal
prostate cancers to slow the rate of tumor growth. There is
sufficient experimental evidence to justify the use of soy proteins
in clinical trials for preventing prostate cancer, and these studies
will provide important information in the future.
Lycopene
Lycopene is found in tomato products. It belongs to a type of
chemical called a carotenoid. Lycopene has one of the greatest
capacities for preventing mutations in DNA. Chemicals that have
these properties are called antioxidants, and lycopene is one of the
stronger antioxidants. In addition, lycopene has other biological
activities related to cell-cell communications and growth control.
Experimental animal studies show that lycopene can slow the growth
of prostate cancer cells.
Epidemiologic studies have shown
that consumption of lycopene is associated with a lower risk of
prostate cancer. In one important study, lycopene was the only
antioxidant found in significantly lower levels in prostate cancer
patients than in men without prostate cancer. There are also
studies suggesting that taking lycopene before prostate cancer
surgery may result in more favorable treatment results. Lycopene
concentrates are available at pharmacies and health food stores and
can be purchased over the counter without a prescription.
Vitamin E
Vitamin E is a fat-soluble vitamin that also has the potential to
decrease DNA damage through its antioxidant effects. In addition,
vitamin E affects the immune system. Vitamin E deficiency is
associated with decreased immune function that increases the
susceptibility to cancer and infections. Vitamin E may not only
prevent the development of prostate cancer but also may slow its
progression, especially in smokers. Vitamin E may also lower the
activity of some cellular signals that increase cell growth.
Studies suggest that vitamin E may be especially important in
inhibiting the growth of prostate cancer cells induced by a high-fat
diet.
Many fat-soluble vitamins such as
vitamin E can cause side effects if taken in large doses. Some (but
not all) studies suggest that too much vitamin E may interfere with
blood coagulation and lead to post-surgery bleeding due to its
effect on platelet function. Vitamin E exists in several forms; 200
to 800 of the alpha tocopherol form of vitamin E are well
tolerated.
Selenium
Selenium may also act as an anticancer agent due to its antioxidant
properties. Selenium suppresses cell growth and enhances the immune
response - thus functioning similarly to vitamin E. Studies have
suggested that prostate cancer risk was reduced by 60% among those
who take supplemental selenium. Selenium may also exert its
antitumor effects by other mechanisms, such as inducing programmed
death in cancer cells, and affecting important enzyme systems. The
recommended dose of selenium is 200 ug/day, which is 2 to 3 times
the recommended daily allowance.
Vitamin D.
Vitamin D is important primarily for bone and mineral metabolism.
It induces differentiation of prostate cancer cells into normal
cells and blocks the growth of prostate cancer cells. Vitamin D may
act by blocking the progression of cells through the cell cycle and
initiating programmed cancer cell death. Prostate cancer cells have
receptors for vitamin D. Vitamin D may be important in preventing
prostate cancer and is also being studied as an agent for the
treatment of advanced prostate cancer. The recommended daily dose
is 10 ug/day. Higher doses may cause high blood calcium levels.
Q. What do you
do when Lupron stops working?
A. Hormonal therapy can be
divided into two phases, primary and secondary. Primary Hormonal
Therapy
Most prostate cancer cells either
die or go into a dormant phase when the blood male hormonal level
(testosterone) level is dramatically lowered. Male hormone levels
can be lowered or rendered less effective by either removal of the
testicles (called castration or orchiectomy) or by injections
(called Lupron [leuprolide], Zoladex [goserelin], or by antiandrogen
pills, such as Megace (megestrol), Eulexin (flutamide), Casodex (bicalutamide),
Nilandron (nilutamide), by estrogens (diethylstilbestrol, estrace),
by inhibitors of androgen synthesis, such as ketoconazole, by
antiestrogens, such as tamoxifen, by herbal estrogen compounds, such
as PC spes, or by glucocorticoids (such as prednisone or
dexamethisone). The phase of so-called "androgen-dependent"
prostate cancer can be quite variable, lasting from only a few
months to as long as 18 years, in my experience.
Secondary Hormonal Therapy
There is a second phase in which the tumor can grow even though the
male hormone level is level is low. During this phase, the tumor
cells still can be controlled by discontinuing some drugs that were
being taken previously or by switching to a different drug. This
administration and withdrawal of hormones is called secondary
hormonal therapy. The principle behind secondary hormonal therapy
is that while the patient is taking a hormone (such as Eulexin) that
blocks the growth of the cancer, the cancer cells can mutate or
change in a way that makes the Eulexin stimulate their growth. In
this situation, simply stopping the Eulexin can have a beneficial
effect and may lower the PSA for a period of 3 to 9 months in 20% to
50% of cases.
After a while, the PSA will again
begin to rise. When this occurs, other similar drugs of the
antiandrogen family, such as Casodex, Nilandron, Megace, may be
started and the PSA will again decrease for a period of time. If
the cancer cells again mutate and again become stimulated to grow by
the new drug, the new drug may be stopped and again, in some cases,
the PSA will again decrease. In this way, it is sometimes possible
to use a variety of drugs, switching from one to another, to achieve
an additional response. Megestrol acetate should be avoided in
patients with heart disease, high blood pressure, or diabetes.
When antiandrogen drugs no longer
work, it is possible in some cases, to achieve additional responses
with other hormonal agents, such as Nizoral (ketoconazole), Cytadren
(aminoglutethimide), Stilphostrol (diethylstilbesterol diphosphate),
PC Spes (Chinese herbal estrogen preparation). Some of these drugs,
such as Nizoral and Cytadren require the additional use of
cortisone-like medications, because they suppress the production of
cortisol by the adrenal glands.
Hormone-Resistant Prostate Cancer
Even after prostate cancer cells reach the stage at which they are
no longer responsive to hormone therapy, they still may be sensitive
to treatment with radiation, chemotherapy or experimental drugs.
Patients may not develop symptoms of metastatic prostate cancer
(such as pain or weight loss) until the PSA has reached a level of
100 to 300. Some patients with very advanced disease have PSA
levels in the thousands. Each tumor is somewhat unique in its
behavior, as is each patient. Measurement of PSA levels is the best
way of determining the response of therapy. In general, if the PSA
level can be decreased by 50%, there is usually a prolongation of
survival.
Chemotherapy
Significant responses can be achieved with chemotherapy, although,
in general, chemotherapy is less effective and has more side effects
than primary hormonal therapy. However, there are some regimens
that are very well tolerated and offer reasonable prospects for
benefit. One such regimen is mitoxantrone plus prednisone. This
regimen may improve the quality of life, but does not appear to
prolong survival. Another combination that is also sometimes
effective is estramustine in combination with vinblastine. Other
combinations include etoposide, doxorubicin, and cyclophosphamide.
Recently taxol drugs (docetaxel)
have been combined with estramustine and hydrocortisone for men with
hormone refractory prostate cancer. One regimen combines these
drugs with thalidomide, which works as an antiangiogenesis agent
that blocks the growth of blood vessels that feed the tumor.
Spot radiation therapy can be
effective is reducing pain from bone metastases and protects against
the development of pathologic fractures. Biphosphonates (pamidronate
and etidronate) inhibit bone resorption and may also be used to
prevent fractures and to treat bone pain.
The goals treating advanced prostate
cancer are to maintain a high quality of life, relieve symptoms, and
prolong survival. These goals can require the use of other
medications such as nonsteroidal anti-inflammatory agents as well as
stronger narcotic medications.
Several new drugs and approaches are
under investigation. Further research will certainly bring new and
more effective treatments for hormone-refractory prostate cancer.
Q. What should
I do when my PSA level begins to rise after radical prostatectomy?
I believe
it is unknown where the cancer cells reside in my body. If they lie
outside of the prostate bed or pelvis, the radiotherapy will not
benefit me. How often does recurrence in the prostatic bed occur?
How many patients have lifelong chronic problems with the rectum or
bladder, including bleeding? Would a lesser dose of radiation
eliminate all of the malignant cells and completely avoid
complications? Is there any way of avoiding loss of sexual
relations after surgery and/or radiotherapy?
A. Depending upon the stage
and grade of the tumor, and the preoperative PSA level, a rising PSA
occurs after radical prostatectomy within 7 years in about 20% of
patients who were thought to have cancer that was contained within
the prostate before surgery. In about 70% of these patients, the
PSA level will return to the undetectable range following radiation
treatment to the bed of the prostate. Based on our data, the PSA
has remained in the undetectable range in about 70% of those
patients for as long as we have followed them (70% of 70% equals
about 50% overall long-term favorable response). These findings
suggest that the cause of the rising PSA is tumor cells remaining in
the bed of the prostate in about 70% of patients. About half of all
patients with a rising PSA level either have the tumor cells that
are outside the pelvis or have tumor cells in the pelvis that are
resistant to the doses of radiotherapy that can be safely given.
With postoperative radiotherapy,
there is concern that the bladder and rectum may be damaged, and
this does occur to a chronic bothersome degree in about 3% to 4% of
patients who receive the prescribed dose of 6400 cGy at 180 cGy per
day. Radiotherapy also significantly reduces erections in about
half of patients and may decrease urinary continence in a small
percentage as well. However, current evidence suggests that a
lesser dose that would completely avoid bladder and rectal
complications would be less effective in eliminating all of the
cancer cells. Therefore, the "worst case scenario" could have the
patient have chronic inflammation of the bladder and rectum with or
without bleeding and still have the PSA rise and have to be treated
with hormonal therapy as well.
For this reason, some patients who
have a very slowly rising PSA after a long interval following
surgery correctly assume that their tumor is not highly aggressive
and elect not to receive radiation therapy, but rather opt for
hormonal therapy either immediately or in the distant future, if
necessary. However, patients with slowly rising PSA long after
surgery are the very patients who respond best to radiation
therapy. So, it is a difficult decision to make. The patient must
balance the potential benefits of the radiation therapy completely
eliminating the cancer against the risks of long-term side effects.
Erections can be restored in nearly
all patients. This may be accomplished with oral Viagra, intra
urethral MUSE suppositories, injections of prostaglandin into the
side of the penis, a vacuum erection device, or a penile prosthesis
(surgery required). Although each of these options has its
drawbacks, the ability to have sexual relations may outweigh the
drawbacks for many patients and their partners.
Q. How does
the doctor determine how many samples to take in a prostate biopsy?
A.
Initially, most doctors take six to
eight samples. However, it is known that the first biopsy procedure
misses the cancer in 20% of patients. Accordingly, in patients who
continue to have a rising PSA level or other features that are
worrisome for prostate cancer, more biopsies are taken during repeat
procedures. The exact number taken depends upon how uncomfortable
the patient finds the procedure and may include 15 to 20 samples.
Q. . Does the
natural size of a man's prostate have any relationship to later
development of an enlarged prostate or prostate cancer?
A. The normal prostate size
for an adult male is 15cc to 30cc (one half ounce to one ounce).
Prostate size may increase because of swelling from inflammation,
benign enlargement which usually begins at age 40-50, and cancer
which also is unusual before age 40-50. Accordingly, men whose
prostate gland is larger than 30 cc are more likely to be diagnosed
with either benign hyperplasia (enlargement) or prostate cancer than
those whose prostate is in the normal range.
Q. What is PIN
and is it a precursor to cancer? What is its relationship to
cancerous tumors and to the prediction for such tumors developing?
A.
Prostate cancer is caused by changes
(mutations) in the DNA that affect the regulation of the growth of
normal prostate cells. It is probable that several mutations (at
least 5 or 6) have to occur before a full-blown cancer occurs.
These mutations may accumulate over time, causing the gradual
progression to prostate cancer. It is likely that certain mutations
may cause a precancerous condition called prostatic intraepithelial
neoplasia (PIN). PIN is also found as a satellite lesion
surrounding a prostate cancer or elsewhere in a cancerous prostate
gland. Approximately 30% to 50% of men who have an elevated PSA
level and high-grade PIN are subsequently found to have prostate
cancer within four years. Accordingly, repeat biopsies are
routinely recommended in men with PIN.
Q. Can the
amount of selenium in a man's body predict if he is more or less
likely to develop prostate cancer? Is there a test for such
predictions and how would the measurements be interpreted?
A. Selenium is a trace
element that is not routinely measured in blood samples to predict
prostate cancer risk. Studies suggest a 50% to 66% reduction in
risk for advance cancer in men with the highest selenium status as
determined by the level of selenium in toenail clippings.(Yoshizawa
K, et al. Study of prediagnostic selenium level in toenails and the
risk of advanced prostate cancer. J Natl Cancer Inst. 1998; 90:
1219-1224).
Q. What is a
TUR or TURP and what purpose does it serve?
A.
Transurethral resection of the prostate
is an operation performed to relieve symptoms of urinary obstruction
caused by either benign enlargement of the prostate or prostate
cancer. It is performed through a scope and involves removing
prostatic that is obstructing the flow of urine. During this
operation, the "resectoscope" is passed through the urethra into the
prostate gland. Then using an electrified wire loop, dozens to
hundreds of raisin-sized pieces of the prostate gland are removed
from the inside of the prostate gland and washed out through the
scope. This operation is often called a "Roto-Rooter" procedure or
a "scraping" of the prostate. It enlarges the urinary channel and
allows the patient to urinate more freely.
Q. What is the
pattern for return of sexual function after prostate surgery?
A.
Usually erections return slowly beginning 3-6 months after surgery
and continue to improve for 18-24 months. There is a lot of
variation. Usually erections are not as firm as before surgery
unless the patient had "perfect" erections to being with. If the
nerves can be partially or completely saved, Viagra usually improves
the erections. If not, prostaglandin injections, MUSE urethral
suppositories, or a vacuum erection device must be used. Some
patients prefer to solve the problem with a surgically implanted
penile prosthesis.
Q. Regarding
my bladder incontinence, how much better control, can I expect to
have and is it going to change in dramatic steps? (Question from
someone operated on for prostate cancer)
A.
About 92% of patients regain normal control. Of the remaining 8%,
most have mild stress incontinence that requires minimal protection
(a pad). Only 1 – 2% have severe incontinence or implantation of an
artificial urinary sphincter to correct. Usually, continence
returns quickly, but sometimes it returns slowly, over a period of
18 months to two years.
Q. How do the
exercises given after my operation work to help bladder incontinence
A.Exercises
work by increasing the bulk and strength of the one remaining
sphincter muscle. This muscle helps to create a seal by
approximating the walls of the urethra. There is a fine line
between being wet and being dry. It is like a leaky faucet that can
be fixed by replacing a washer that differs very little in
appearance from the old washer. It is just a little more plump and
flexible, but that makes the difference between wet and dry.
Q. Please give
sources for information about cancer
A. The Cancer
Information Service (CIS) of the National Cancer Institute (NCI)
provides up-to-date cancer information and can answer questions (in
both English and Spanish) in nontechnical language. To reach CIS,
call 1-800-4-CANCER (1-800-422-6237) or visit
http://rex.nci.nih.gov, the NCI
web site. This site includes information on new and experimental
therapies.
To contact the American Cancer Society (ACS), visit the ACS Web site
at http://www.cancer.org or call
1-800-ACS-2345 (1-800-227-2345).
Q. What about
freezing of the prostate as a treatment for prostate cancer?
A. It's an unproven
treatment. One of the real worries is that the freezing process
starts in the center of the prostate and goes out to the edge. But
most of the prostate cancers arise very near the edge of the
prostate. In order to protect the surrounding tissues (especially
the rectum) from freezing, doctors don't freeze out to the edge in
all area so many patients with the freezing treatment will have
recurrences of the cancer out near the edge of the prostate.
Available studies would suggest that freezing is not as effective as
surgery or radiation therapy.
Q. What could
cause a PSA level to rise other than cancer?
A.
Three things can cause the PSA to rise: cancer, benign enlargement,
and inflammation (prostatitis). With cancer and benign enlargement
the PSA goes up persistently; the slope is steeper with cancer.
With inflammation, the PSA can rise with a flare-up and come back
down with resolution of the inflammation (with or without antibiotic
treatment). Interpreting the pattern is complicated because some
patients have two or all three of these conditions at the same time
Q. Can
frequent sex with a penile implant make a PSA level rise?
A.
Sexual activity can cause a transient rise in the PSA level. This
rise is usually minimal and does not last for more than 6 – 24
hours. Sex with or without a penile implant does not make a
difference. It is ejaculation that causes the PSA to rise. It is
ideal to avoid sex for 24 hours before PSA testing.
Q. What is
nerve-sparing surgery and how does it work?
A. The
nerves are like railroad tracks and the prostate is like a boxcar on
top of the railroad tracks. In this surgery, doctors try to gently
life the "box car" off the railroad tracks without damaging the
"tracks". If the cancer is detected early, then the prostate can
sometimes be removed very nicely without disturbing the nerves. The
nerves usually get bruised and stretched somewhat during the
operation which is why it can take 3 to 6 months for erections to
begin to return after surgery and up to two years for complete
recovery, but with time the nerves regenerate so it's very important
to detect the cancer while still on the inside of the prostate
before it grows out into those nerves. After it's grown out into the
nerves, it's not safe to try to spare the nerves.
Q. What is so
special about the PSA test?
A.
The
major problem with prostate cancer detection before the PSA test was
that men would not come in for a rectal examination unless they were
really having problems. But the PSA blood test is acceptable to
most men, and it's made prostate cancer detection more acceptable to
men. The PSA blood test is probably the most single accurate test
we have for the detection of prostate cancer.
Q. Why should
men come in for an examination if they take the PSA blood test?
A.
There are some very early cancers that can be felt on the rectal
exam before they cause PSA level to be elevated. There are other
cancers, which will elevate the PSA level before they can be
detected on the rectal exam. To maximize the accuracy of screening,
it's best to have both the test and the examination.
Q. Can certain
vitamins or foods lessen the risk for prostate cancer?
A. Vitamin E
has been shown to improve the effectiveness of the immune system ad
to lower the risk for prostate cancer. Usually the dosage is 200 to
400 units a day. Selenium, taken 200 micrograms a day, has been
shown to lower the risk of prostate cancer. A low fat diet,
especially a diet avoiding animal fat, specifically red meat fat,
has been shown to have an impact on the risk for prostate cancer.
Eating fruits and vegetables is important and it's been shown that a
diet rich in tomato products in also helpful in avoiding prostate
cancer. One of the substances in tomatoes is called lycopene and in
order to get enough of this substance one would have to eat pounds
of tomatoes each day. But now lycopene has come into the market in
pill form. The above recommendations have been evaluated in
published scientific studies. Obviously, many other substances
could be effective but they just haven't been adequately studied at
this time to know if they are helpful or harmful. All of the
factors discussed above are believed to produce relatively minor
effects, and it's still very important to get the PSA blood test and
the prostate check.
Q. What is
external beam radiotherapy and how are its effects different from
those of a radical prostatectomy?
A. In
this method, X-ray treatments are given with a machine that sends
high-energy x-rays through the patient's body, aimed at the prostate
gland and sometimes the pelvic lymph nodes. External beam
radiotherapy is a totally non-invasive treatment used as an option
for men who are considered too old or too ill for a prostatectomy or
who just don't want surgery. It is difficult to determine whether
external beam radiation actually eradicates all of the prostate
cancer, because many patients in whom progression of the tumor is
slowed or halted have what appears to be persistent tumor on
rebiopsy. The best results are obtained when the tumors are less
than 2 centimeters in size at the time of therapy.
Q. What is an
abnormal PSA level and what are grade levels for prostate cancer?
A.
Most doctors would say the PSA level is normal if it's below 4 and
above normal if it's above 4. We feel that the cutoff of 4 is to
high and we have used 2.5 as the cut off in our PSA screening study
since 1995. We have proven that if the PSA is between 2.5 and 4,
there is a 22 percent chance that the man will have prostate
cancer. We routinely recommend a biopsy if the PSA is above 2.5 and
if the free PSA test confirms the advisability of performing a
biopsy. Prostate cancers when looked at under the microscope can
look like almost normal prostate tissue or they can look very wild
and disorganized. They are graded on a scale called the Gleason
grade of between 2 and 10 where 2 is the best, i.e., a low grade,
slow growing prostate cancer, and a 10 would e the worst, i.e., a
rapidly progressing, very aggressive prostate cancer. It turns out
that grade level statistics for prostate cancer fall into a bell
shaped curve. Only about 10 percent of tumors are grade 2,3 and 4
and only about 10 percent of tumors are 8,9 and 10 with the vast
majority being Gleason grades 5,6 and 7.
Q. What is the
free PSA test?
A. One
of the problems with PSA blood tests is that if the PSA level is
elevated, only about 25 to 60 percent (depending on how high the PSA
level is) of those men are actually found to have prostate cancer.
The flip side of that fact is that roughly 40 to 80 percent of men
who have elevated PSA levels don't have prostate cancer and they go
through the biopsy unnecessarily. The free PSA blood test can
eliminate at least 20 percent of these unnecessary biopsies and
still detect 95 percent of these cancers. Another new test is
coming down the road in a year or two called the HK2 test which can
further eliminate unnecessary biopsies, especially in men with PSA
levels between 2.5 and 4. A lot of medical research is being done
to improve the accuracy of PSA testing to avoid biopsies in men who
really don't have prostate cancer and so don't need a biopsy. But
it's always going to be an imperfect world, and it is better to
accept some false alarms to save some lives than it would be to
avoid all false alarms and not save any lives.
Q. Why do some
men not get treated for prostate cancer?
A.
Part of the reason is that they misunderstand some of the public
information about prostate cancer. Some studies have been presented
in the media and lay press that suggest prostate cancer is a
toothless lion, that more people die with it than of it, and that
prostate cancer does not require treatment. So, not wanting to be
treated, some men latch on to the position of watchful waiting or
diet therapy only. Watchful waiting is appropriate in some
patients, but it's generally only for older men with low-grade
tumors that are not very threatening.
Q. Is the PSA
reading different for a man before and after having a prostate
cancer removed?
A. "1"
is a low PSA reading for a man with a prostate, but it is a high
reading for a man whose prostate has been removed. It means there
are cancer cells left behind that are producing PSA.
Q. Is it true
that all men at some pointing their lives will develop prostate
cancer?
A. No,
even though that is often said. It is true that if the prostate
gland were removed and carefully examined under the microscope, up
to 80 percent of men in their 80's would have some microscopic
traces of prostate cancer, but only about 15 to 20 percent of men
area actually diagnosed with prostate cancer during their lifetime.
Prostate cancer will be large enough to detect with a biopsy in only
10 to 15 percent of men.
Q. Do
vasectomies have any effect on prostate cancer?
A.It
was stated in the past that men who had vasectomies were at an
increased risk for prostate cancer, but this subsequently has been
disproved. It was a myth. What seems to be true is that
vasectomies are more likely to be seen by a urologist and if a
urologist sees them, then they are more likely to be screened and
have early detection of prostate cancer.
Q. Is prostate
cancer a fatal disease if not treated?
A.
rostate cancer kills more men than any other cancer except lung
cancer. In some patients, particularly elderly patients, the
prostate cancer might progress very slowly, and they may not need to
be treated right away, but most men who have a life expectancy of at
least 10 years need to have treatment or they are risking death from
prostate cancer.
Q. I
went to see a urologist a couple of months ago for symptoms of
enlarged prostate. After the PSA and rectal examination, my
urologist told me that nothing needed to be worried about and all I
need to do was to come back for yearly examination. My urination was
not too bad and there is little inconvenience in daily life.
However, the major impact is sex. For the past two years, there has
been a rather quick deterioration. The sensation of ejaculation has
mostly lost and the volume of semen has become quite reduced. I
mentioned this to my urologist, but he told me that I should not get
too concerned as long as I still can have sex. I am 51 and have a
younger wife. I feel I should do something about it. Is it true that
people with prostate enlargement normally have pretty bad
deterioration in sex pleasure, even in pretty early stages? Is there
anything I can do about it?
A. It is true
that beginning around age 50, many men begin to develop overgrowth of the
central part of the prostate gland, called benign prostatic hyperplasia.
This can cause compression of the prostatic ductal system that
carries the prostatic fluid from the glands located in the
peripheral regions of the prostate to the urethra, which is fairly
centrally located. Because 90% of the ejaculate is composed of
prostatic fluid, it is common for the volume of the ejaculate to
decrease in men with benign prostatic hyperplasia. This condition
does not cause a decrease in sex drive or erections, however. There
are hormonal, blood vessel changes, and other diseases such as
diabetes or high blood pressure that can occur around age 50 that
can cause decreased sexual function. Other possibilities are
medications that may interfere with sexual function. The best advice
you can be given is to find a urologist whom you have confidence in
and follow your prostate closely with PSA tests and digital prostate
examinations.
William J.
Catalona, M.D.,
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