Prostate cancer is among the most common malignancies affecting Canadian men. An estimated 25,000 will be diagnosed this year alone.1 But before I scare you any further, let’s take a step back and start with some of the basics.

The prostate is a gland (a fancy word for organ) found in men that is involved in the production of semen. It is located in the pelvis, or lower part of the abdomen, sandwiched in front of the bladder. Although it is not responsible for the production of urine, the urethra runs right through the prostate carrying urine from the bladder to outside the body. Although some things in life get better with age, prostates, unfortunately, aren’t one of them. They just continue to grow! Men straining to pee and taking longer to empty their bladder may be showing signs of obstruction from an enlarged prostate. This is not usually considered a sign of prostate cancer.

Prostate cancer is a malignant tumor that forms in the prostate gland itself. Usually it is a type of cancer called an adenocarcinoma. Generally these cancers are found in the outer core of the prostate and, when enlarged, can be felt on a rectal examination. Most men with early prostate cancer don’t actually have any symptoms. So don’t get stressed out about urinary tract issues like frequency, urgency and straining because these things are usually caused by an enlarged prostate gland, called benign prostatic hyperplasia (BPH), and are not related to cancer. So, how can prostate cancer be diagnosed early and how is it treated? The rest of this article will provide you with some key information to better answer these questions.

Prostate Cancer Screening and Early Detection
This is arguably one of the most controversial topics in mens health: should we screen for prostate cancer or not? And, what does screening entail? This is testing men between the ages of 50-70 (with no history of prostate cancer) with a regular PSA, or Prostate Specific Antigen, blood test as well as rectal examination of the prostate. (PSA is a protein that is expressed by both normal and cancerous prostate tissues.) The aim of screening is to help find aggressive prostate cancers earlier.

What Should Men Be Doing?
Canadian urologists are big believers in the benefits of prostate cancer screening.2 If you are between the ages of 50-70 then you should have your PSA and prostate checked. If you are suffering from a serious debilitating medical illness, or you’re above the age of 70, PSA screening may not be of benefit. Take the time to discuss this with your health care provider.

The Details Behind Prostate Cancer Screening
The evidence behind prostate cancer screening is a little hard to interpret and has resulted in much controversy. (Meanwhile, some guys are just looking for any excuse that will get them out of the rectal exam.) For years, researchers and health care professionals have grappled with the best way to study the effects of screening over time. Unfortunately, and despite the best of intentions, few studies have done a good job so it’s easy to see why there are conflicting opinions. In 2014, much to the opposition of the urological community in Canada, the Canadian Task Force on Preventative Health Care released a guideline recommending against prostate cancer screening.3 Their conclusion was that screening does not reduce prostate cancer mortality and resulted in increased harm from over-treatment of prostate cancer.

The problem with this recommendation is that it’s based upon flawed data, which wasn’t totally apparent at the time. For example, the Canadian Task force cites the PLCO study (the Prostate, Lung, Colorectal, and Ovarian Cancer screening trial) as one justification for not recommending screening. The PLCO is a large American study that randomized more than 70,000 men to receive annual screening versus no screening at all (the control group).4 In 2009, authors of the PLCO published their results in The New England Journal of Medicine, concluding that after 10 years of follow up, screening had no impact on reducing the rate of mortality from prostate cancer. In 2016, new findings emerged that largely debunked the conclusions from the original PLCO study. External researchers reviewed the PLCO data and identified that upwards of 85 percent of the control group — which was supposed to have no screening — had undergone PSA testing during the trial.5 This made it impossible to compare the two groups and determine whether there were any benefits from PSA screening.

To find successful examples of prostate cancer screening, one need only look to Göteborg, Sweden (leaving aside any hockey biases aside for a moment). Commonly referred to as the Göteborg study, Swedish researchers followed 20,000 men over a 14-year period and concluded that routine screening resulted in a 50 percent reduction in prostate cancer mortality.6 A more recent Swedish study highlighted the benefits of starting routine PSA testing between the ages of 50-54, determining that doing so reduced the risk of death from prostate cancer by about 70 percent, compared to not screening at all.7

The Downside To PSA
There is definite agreement among urologists that PSA testing is not perfect. In general, PSA can be reassuring when levels are very low. But when the PSA level is elevated, it can indicate things other than cancer. This is an important point to remember: PSA is specific to the prostate gland but not specific for prostate cancer. Unfortunately, an elevated PSA can be the source of a lot of undue anxiety, leading to many trips to the doctor. There are numerous causes for an elevated PSA level that are unrelated to cancer, including: infection, inflammation (or irritation) of the prostate, benign prostatic hyperplasia (enlarged prostate gland), recent urinary catheter insertion or recent urinary and pelvic procedures. My advice is: if you’ve had any one of these things, it’s probably best to wait before getting your next PSA. Most urologists would agree waiting two months before repeating a PSA is quite reasonable, assuming that infection or inflammation has resolved.

Prevention
An ounce of prevention is worth a pound of cure, right? We are constantly looking for ways to improve our health and lower our risk of getting cancer. In this regard, prostate cancer prevention may be a little challenging. Two of the biggest risk factors for prostate cancer are not really modifiable: increasing age and genetics or family history. No need to despair. Researchers have shown that engaging in activities that improve cardiovascular health can actually help ward off your risk for aggressive prostate cancer. Smoking cessation and regular physical activity may be linked with better outcomes if you’re diagnosed with prostate cancer. They may also reduce side effects of treatment as well as depression and anxiety. Currently, research is ongoing to better understand the link between exercise and prostate cancer.

Can Supplements Decrease The Risk Of Developing Prostate Cancer?
If you’re a believer in the power of natural supplements, there is little evidence that these help prevent prostate cancer. In a large North American study determining if supplements could prevent prostate cancer in healthy men, 35,000 men were randomized to receive selenium, vitamin E, or a placebo.8 After about six years of follow up, there was no evidence that any supplement use decreased the risk of developing prostate cancer. Vitamin E, in fact, was associated with a slightly higher risk for prostate cancer. Similarly, other trials have failed to demonstrate any benefit to the use of vitamin C, soy, lycopene or multivitamins. So, my advice is to beware of false advertising and those making bold claims about their products. If you are taking any supplements, be sure to let your doctor and pharmacist know. In high doses, some supplements can have dangerous interactions with other medications that you may be taking.

Prostate Cancer Grading
All prostate cancers are not equal. Gleason grading (or Gleason score) is the official composite scoring system used around the world to categorize prostate cancer. The scoring mechanism is a detailed process but, as a general rule, the more the cancer resembles the normal prostate gland, the less aggressive the cancer and the lower the grade. Higher-grade cancers are more aggressive. Under the microscope they are often poorly differentiated, meaning they have little to no resemblance to the original prostate-gland architecture.

Treatment options for Prostate Cancer
If you or a loved one has been diagnosed with prostate cancer, it’s important to remember that this is not a death sentence — not by a long shot. A large number of Canadian men diagnosed with cancer will have the low-grade disease that is slow growing and not considered life threatening. In the past decade, prostate cancer research has come a long way to advance how we treat and care for men in a way that promotes longevity and a better quality of life.

Treatments

  1. Active Surveillance
    Active surveillance is the preferred management for men with low-risk prostate cancer. It is simply defined as the postponement or avoidance of treatment, combined with careful observation. Since most low-grade prostate cancers are slow growing, their potential for metastasis (spreading beyond the prostate) is extremely low. Active surveillance can be performed safely without decreasing a man’s potential for cure. Although men on active surveillance avoid potential treatment-related side effects from surgery or radiation, they need to be followed closely by their doctor with regular PSAs, rectal exams and repeat prostate biopsies. Some of the best data supporting active surveillance comes from a Canadian study, where more than 900 men were followed for 15 years.9
  2. Radical Prostatectomy
    Radical prostatectomy is the surgical removal of the prostate. For men who are not active-surveillance candidates, surgery is a standard treatment option. In Canada the most common methods of surgery are open and robotic. Open surgery is performed through a midline incision underneath the belly button. Robotic surgery is performed through multiple ports (or key holes) that are inserted into the abdomen through six very small incisions. Although some men may prefer one modality to another, most experts agree that, in terms of overall outcomes and recovery, both open and robotic are relatively equal.10 Research has proven that what’s essential is not how your surgery is done but who is doing it. Surgeon experience is probably the most important factor when determining successful outcomes of either open or robotic prostatectomies.11 Erectile dysfunction and urinary incontinence are some of the feared complications of surgery. There is, however, good news. The majority of men with normal (pre-surgery) erections that undergo a “nerve sparing” prostatectomy should have good potency afterwards.12 Nerve sparing is a term for preserving a bundle of nerves (called the cavernous nerves) that run alongside the prostate and are responsible for erection. Since cancer control is the ultimate goal of surgery, urologists will help men determine if they are appropriate candidates for a nerve sparing operation. Having complete urinary incontinence (or leakage) after surgery is quite rare. However, the majority of men experience some degree of leakage after surgery, which usually resolves on its own. Long-term incontinence more than a year after a prostatectomy is uncommon.13
  3. Radiation Therapy
    Another standard treatment option is radiation therapy. In general, radiation is considered as effective as surgery. Radiation to the prostate can be administered in two different ways, either through external beam radiation or brachytherapy. Brachytherapy is the implantation of small radiation “seeds” directly into the prostate. The advantage of brachytherapy is that it can be completed in a single visit, whereas external beam treatments are administered over one-to-two months with several sessions per week. The downside to brachytherapy is that it requires an anesthetic to complete the procedure. In general, those with a history of inflammatory bowel disease (especially involving the rectum) or those with bad urinary symptoms (frequency or urgency) are not good candidates for either external beam radiation or brachytherapy. Worsening urinary symptoms can occur after radiation, as well as rectal irritation and occasional rectal bleeding. Similar to surgery, erectile dysfunction can also occur as a possible side effect of radiation.

 

[1] Canadian Cancer Society’s Advisory Committee on Cancer Statistics. Canadian Cancer Statistics 2015. Toronto, ON:Canadian Cancer Society; 2015.
[2] Izawa JI, Klotz L, Siemens DR, Kassouf W, So A, Jordan J, et al. Prostate cancer screening: Canadian guidelines 2011. Can Urol Assoc J. 2011;5:235-40.
[3] Canadian Task Force on Preventive Health C, Bell N, Connor Gorber S, Shane A, Joffres M, Singh H, et al. Recommendations on screening for prostate cancer with the prostate-specific antigen test. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne. 2014;186:1225-34.
[4] Andriole GL, Crawford ED, Grubb RL, 3rd, Buys SS, Chia D, Church TR, et al. Mortality results from a randomized prostate-cancer screening trial. The New England journal of medicine. 2009;360:1310-9.
[5] Shoag JE, Mittal S, Hu JC. Reevaluating PSA Testing Rates in the PLCO Trial. The New England journal of medicine. 2016;374:1795-6.
[6] Hugosson J, Carlsson S, Aus G, Bergdahl S, Khatami A, Lodding P, et al. Mortality results from the Goteborg randomised population-based prostate-cancer screening trial. Lancet Oncol. 2010;11:725-32.
[7] Carlsson S, Assel M, Ulmert D, Gerdtsson A, Hugosson J, Vickers A, et al. Screening for Prostate Cancer Starting at Age 50-54 Years. A Population-based Cohort Study. European urology. 2016.
[8] Lippman SM, Klein EA, Goodman PJ, Lucia MS, Thompson IM, Ford LG, et al. Effect of selenium and vitamin E on risk of prostate cancer and other cancers: the Selenium and Vitamin E Cancer Prevention Trial (SELECT). Jama. 2009;301:39-51.
[9] Klotz L, Vesprini D, Sethukavalan P, Jethava V, Zhang L, Jain S, et al. Long-term follow-up of a large active surveillance cohort of patients with prostate cancer. J Clin Oncol. 2015;33:272-7.
[10] Yaxley JW, Coughlin GD, Chambers SK, Occhipinti S, Samaratunga H, Zajdlewicz L, et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: early outcomes from a randomised controlled phase 3 study. Lancet (London, England). 2016;388:1057-66.
[11] Trinh QD, Bjartell A, Freedland SJ, Hollenbeck BK, Hu JC, Shariat SF, et al. A systematic review of the volume-outcome relationship for radical prostatectomy. European urology. 2013;64:786-98.
[12] Kundu SD, Roehl KA, Eggener SE, Antenor JA, Han M, Catalona WJ. Potency, continence and complications in 3,477 consecutive radical retropubic prostatectomies. J Urol. 2004;172:2227-31.
[13] Sanda MG, Dunn RL, Michalski J, Sandler HM, Northouse L, Hembroff L, et al. Quality of life and satisfaction with outcome among prostate-cancer survivors. The New England journal of medicine. 2008;358:1250-61.