"You have prostate cancer"
Doug is a real person. In 2002, he was 49 years old. When he went for his annual check-up, his family physician found a "pebbly" lump in his prostate with a digital rectal exam (DRE). The doctor assured him that he probably had nothing to worry about, but, being a thorough physician, he sent Doug for a follow-up prostate-specific antigen (PSA) test. Doug's PSA score was very low and safely outside the cancer range. Just to be sure, however, the doctor sent him to a urologist, who ordered a biopsy a month later. He had prostate cancer, and it was on the brink of spreading beyond his prostate.
Doug had had no warning signs, nothing more than a bit of feeling of urgency and frequency of urination. He was only 49; the average age a man is diagnosed with prostate cancer is 65. Nobody in his family has ever had prostate cancer. He was in total shock. "It can destroy your confidence when you get cancer," Doug explains. "Most of time you do a test and it comes back negative – you get used to getting the all-clear."
Prostate cancer is considered a slow-growing cancer, so screening is the number one way that a man can win the battle. Prostate cancer shares many of the symptoms of benign prostatic hyperplasia (BPH), a generally harmless condition, but it can often have no symptoms at all.
The DRE – the first screening
The digital rectal exam (DRE) is a simple, painless examination. Your doctor inserts a gloved finger into the rectum to feel the prostate for changes in size, density, texture, and any other abnormalities. An enlarged prostate does not necessarily mean there are any cancer tumours present; it may just be a sign of BPH. BPH is not related to prostate cancer, and about half of all men over 50 have it. However, enlargements and other irregularities such as lumps and hardening should still be investigated and may require more tests.
The PSA – follow-up to a DRE
The prostate-specific antigen (PSA) blood test is used to detect prostate cancer by measuring levels of PSA. Men with prostate cancer often have more PSA, so their score is higher. There are some cases where some men with prostate cancer will have normal PSA levels, like Doug. This test is considered a better indicator of whether a man may have prostate problems. However, there are other conditions that can cause elevated PSA levels. PSA testing is best done in conjunction with a DRE.
Biopsies confirm cancer
The next step of diagnosis is to perform a biopsy of the prostate. This is the only way to confirm cancerous tissue. A biopsy is a simple procedure that involves the removal of tissue so it can be further analyzed to determine if cancer cells are present and to estimate how aggressive it is. If cancer is present in the prostate, you will begin to discuss treatment options with your doctor.
Other tests are also available to help diagnose prostate cancer and/or rule out other conditions.
Analyzing prostate cancer
The most common cancer
The cancer Doug was diagnosed with (see "You have prostate cancer" in this feature) is the most common cancer in Canada. 1 in 8 men will be diagnosed with it over their lifetime. In 2014, about 23,600 men were diagnosed with prostate cancer and about 4,000 men died of it.
Prostate cancer is uncontrolled growth of the cells of the prostate gland. The prostate plays an important role in sexual functioning, urination, and reproduction. In prostate cancer, the cells within the walls of the prostate begin to multiply and eventually leave the prostate gland, spreading to invade the body parts close to the prostate – the lymph nodes and bladder – or elsewhere, particularly to the spine. About 37% of men diagnosed with prostate cancer end up dying of it. Men have about the same chance of dying of prostate cancer as women have of dying of breast cancer.
The Gleason score
When a biopsy shows that a man has prostate cancer, the pathologist will apply a "Gleason score" to it. The Gleason score is an important number, as it defines how aggressively the tumour is growing and will reflect the treatment options available. The lower the score, the better a patient's chance of survival. When Doug's cancer was biopsied, it was assigned a Gleason score of 7 – a score of 8 or higher is considered "very aggressive."
The stages of prostate cancer
Prostate cancer is also "staged" – assigned a stage based on the tumour's characteristics, such as its size and whether there is evidence that it has spread. Staging also helps determine the prognosis and treatment options.
- In Stage T1, the cancer tumour is microscopic and actually can't be detected by a DRE. A biopsy is needed to find traces of the tumour.
- In Stage T2, the tumour has grown but is still confined to the prostate itself and can be removed by taking out the whole prostate. The doctor can detect it at this stage by DRE.
- By Stage T3 or T4, the cancer is deadlier because it has spread outside the prostate gland to the seminal vesicles (which produce semen) or to the bladder (where urine is stored).
Choosing a prostate cancer treatment
Making the choice
When Doug was diagnosed with prostate cancer, his first response was to get information. He read countless books, articles, and studies on prostate cancer, which made him feel more prepared for the hard times that lay ahead. He also sought out a second opinion for peace of mind. His wife was of great support, connecting him with the "Man-to-Man" support group of prostate cancer survivors.
If you are diagnosed with prostate cancer, an oncologist (a doctor specializing in treating cancers) will give you your treatment options and will be responsible for your care. You may have to try more than one treatment, or combine treatments, depending on your age, medical condition, and overall health, and on the size, aggressiveness, and spread of the cancer.
Doctors gave Doug a choice between radiation and removal of the prostate. Both specialists told him surgery for total removal of the prostate, called a radical prostactectomy, was the best option, but it was his decision.
Making a decision about cancer treatment is tough. "The key is to do your research – no one choice is right, it has to be right for you. Do it, get on with it and don't ever regret," Doug reflects. In the end, he chose surgery.
What treatment(s) are available for prostate cancer?
- Surgery (prostatectomy) – removal of the prostate gland. The entire tumour is normally removed in a one-time procedure. This form of treatment has the highest survival rate, at 97%, and men opting for this choice generally live longer, with a 15-year survival rate of 80%.
- Radiation/brachytherapy – tumour cells are killed by external beam radiation therapy (EBRT) or brachytherapy (surgical implantation of radioactive seeds). This is a good option for older men or for men who are not considered good candidates for surgery. This treatment choice offers about a 65% 15-year survival rate.
- Hormone therapy – blocks hormones such as testosterone from helping tumours grow. This therapy targets testosterone, which is known to help tumours grow; this therapy can thus help cause the tumours to shrink.
- Cryotherapy – freezing the tumour with liquid nitrogen to kill cancer cells. This treatment avoids surgery and may be more suitable for men who are not good surgery candidates (older men, men with other medical complications).
- Chemotherapy – drugs that can target and destroy cell that grow rapidly, such as cancer cells. Chemotherapy travels in the blood stream and can reach cancer cells in distant organs that may have not been removed by surgery or may not be the target of radiation treatment.
Prostate cancers that are detected and treated at the earliest stages are often cured, but often at the expense of some degree of continuing incontinence or impotence. Nevertheless, in some cases, the cancer can recur or spread to other organs in the body. Frequent physical exams and PSA blood tests are used to determine whether the cancer has returned.
Is treatment always necessary?
Some slow-growing early-stage prostate cancers may not require immediate therapy. Through regular testing, the progress of the disease and the level of your physical comfort can be monitored. For older men with other medical problems, this "watchful waiting" may be less disruptive than starting cancer therapy. Men who choose the "watchful waiting" treatment option generally have a 50% to 60% 15-year survival rate.
Life after prostate cancer
During Doug's surgery on December 4, 2002, it was discovered that his tumour had grown to 40% of the weight of his prostate.
After the surgery
Radical prostatectomy is major surgery. Doug was in a lot of pain, but he returned to work six weeks after surgery. Life began to get back to a "new normal." By May 2003, he started exercising again, having lost 30 pounds.
But life never is the same. "The day after surgery I was elated," Doug says. "But once I got into February, I started worrying about recurrence – you don't think of this at first. But it creeps up and nags at your brain. Did they get it all?"
A changed life
Cancer takes a toll on you both physically and emotionally. Doug is frank: "There is an emotional recovery – my sense of immortality was shattered – with cancer, your body turns on itself."
Prostate cancer has changed Doug – his life has new challenges. He gets up two or three times a night to go to the washroom. He lost one nerve during the procedure, and it can take a while for complete function to return. "My body feels different. I am more aware of my symptoms – is this just a headache or back pain? You get in the habit of checking things out."
In many ways, though, Doug's life has become enriched.
"Am I lucky or unlucky to have had cancer? My focus now is that I survived cancer and I am stronger – I can do anything. I want to think I am lucky that I appreciate life more and what is important. I've stopped doing things that don't add value to my life. You have to choose: do you live life fully or not?"
What is your risk of prostate cancer?
Prostate Cancer Risk Factor Quiz
Take this quiz to learn about what can affect your risk of developing prostate cancer. While we don't know the exact causes of cancer, there are trends that men with prostate cancer share.
- How old are you?
The older you are, the greater your chance of developing prostate cancer. If you are a man under 50, you have a 3 in 1,000 chance of having prostate cancer. If you are in your 50s, you have a 2 in 100 (2%) chance. Between the ages of 60 and 69, you have an almost 7% chance. And that goes up to almost 12% over the age of 70.
It is a good idea to get screened for any prostate problems as soon as you reach the age of 40.
- Are you overweight?
Calculate your body mass index (BMI): BMI = body weight (kg) ÷ height² (m) (Example: if you weigh 150 lbs (68 kg) and are 5'8" (1.73 m) tall, divide 68 by (1.73 × 1.73), or 2.99, to make 22.74.)
If you are overweight (BMI 25 to 29.9) or obese (BMI 30 or higher), you are at about double the risk for developing prostate cancer compared to at a normal weight. That stands true for most types of cancer. As well, your body needs energy to fight off diseases and illnesses. An overweight body requires more of your body's resources to maintain itself in a normal state. That results in less energy for anything else.
- How much exercise do you get each week?
If you consistently burn fewer calories than you consume, eventually you will be a greater risk of developing prostate cancer and other medical conditions related to weight gain. You also want to keep your blood pressure and your blood insulin levels low, because both of these have been linked to prostate cancer. Exercising 3 times a week, 20 minutes each time, can make a big difference. But you'll see better results if you can fit in at least two hours of exercise each week. And you'll have more energy for all of your activities.
- Have any men in your family had prostate cancer?
Scientific studies have linked a specific gene to prostate cancer; if you carry that gene, you're almost guaranteed to develop prostate cancer by age 85. Two-thirds of men who have prostate cancer by their mid-50s have the prostate cancer gene. 5% to 10% of all prostate cancers are directly from genetics. You're twice as likely to get prostate cancer if either your father or your brother has had it, and that goes up to five times likelihood if both your father and your brother have had it. The positive side is that if we know a specific gene causes prostate cancer, we can focus research on it to help eradicate prostate cancer.
- What is your ethnic background?
Men of African or Caribbean descent have the highest percentage of prostate cancer incidence, followed by Caucasians. Asians and Native Americans have the lowest risk. Why do we see these differences? Genetics and environment may explain it, at least in part, along with lifestyle differences and diet.
However, where you live seems to play a role in your likelihood to develop prostate cancer. The farther away from the equator you live, the higher the incidence of prostate cancer. Scandinavia tops the list, with almost five times as many prostate cancer cases as Asia. Men of African descent living in Africa are less likely to have prostate cancer than their counterparts in North America. And Asian immigrants in North America also have a greater chance of having prostate cancer than if they lived in Asia.
- Do you eat the following foods regularly?
While food alone will not cure prostate cancer, you should take a look at your diet to see if you are getting enough of the following foods:
Fatty fish, such as salmon, sardines, herring and mackerel, could reduce the risk of prostate cancer by a third.
Omega-3 fatty acids help maintain a healthy prostate and repair diseased tissue. They are found in trout, anchovies, bluefish, white albacore tuna, tofu, walnuts, canola oil and leafy green vegetables.
Foods rich in lycopene may help fight prostate cancer. Lycopene is found in guava, papaya, red grapefruit, watermelon, tomatoes, tomato products, ketchup and vegetable cocktails.
Vitamin D is found in shrimp, skim or 1% milk, and fish oils, but is also produced by the body and activated after exposure to ultraviolet light from the sun. Vitamin D is thought to have protective effects against prostate cancer. If you are planning to take extra supplements, speak to your doctor first about the appropriate amount.
Selenium supplementation may decrease prostate cancer incidence by almost half for some men. For a selenium boost, make sure you are eating meats, fish, cereal, dairy products, eggs, Brazil nuts, garlic, mushrooms and asparagus.
Avoid foods that are low in fibre and high in fat – they have been associated with increasing the likelihood of developing prostate cancer.
- Do you use painkillers such as ASA or ibuprofen?
If you are taking Aspirin® (ASA), you may be reducing your risk of prostate cancer. Speak to your doctor if you are thinking of taking an anti-inflammatory painkiller.
- Have you been exposed to asbestos, pesticides (herbicides, PCB), or lead in your workplace, school, or home?
All of these substances have been known to increase your risk of developing prostate cancer.