Friday, 6 December 2013

Screening & Prevention - Prostate Cancer

The prostate gland is about the size and shape of a walnut.
Prostate cancer is the most common cancer found in men in Canada. In 2013 the Canadian Cancer Society is expecting 23,600 cases of prostate cancer to be diagnosed. 40% of these cases will be diagnosed in men aged 60 to 69 years old (Canadian Cancer Statistics 2013).

The good news is that prostate cancer is almost 100% treatable if caught (Prostate Cancer Foundation). In many cases it doesn't need to be treated at all, just monitored. One of the questions that weighs on the medical community is how best to screen for prostate cancer so that monitoring and/or treatment can be offered?

A digital rectal exam (DRE) is a simple physical assessment that your health care provider can perform. The examiner will have you lay on your side and will insert a finger into the rectum to feel the prostate gland. If the gland feels large, lumpy, or asymmetrical this may be an indication of a problem. Some men are worried about the DRE but in fact it takes a matter of seconds and is not painful.

Another way to check the prostate gland is the PSA blood test. Prostate specific antigen (PSA) is a protein released by the prostate gland into the blood. The PSA blood test measures the level of PSA present in the blood. If the prostate gland is irritated or diseased it will release more PSA into the blood stream and the test will show higher readings. Pretty simple right? Not so quick.

The problem is that PSA can be released into the blood stream with any kind of irritation to the prostate gland. Elevated PSA levels can indicate that a man has prostate cancer. But it could also be the result of non-cancerous enlargement of the prostate (benign prostate hypertrophy), prostatitis (inflammation of the prostate or urinary tract infection), or physical irritation of the prostate gland (recent strenuous exercise just before the blood test, recent digital exam by a health care provider, or recent stimulation of the prostate gland and/or ejaculation during sexual activity) (MOHLTC).

When a man has a high PSA reading generally the first thing we do is repeat the test. We look for trends not single elevations. Are the levels steadily climbing? How high are the readings going. If PSA levels are climbing or if the provider feels something abnormal during the digital rectal exam the patient is usually offered consultation with a urologist and will likely have an ultrasound and biopsy of the prostate gland.

I know that most of this sounds fairly straight forward. At a certain age you go to your clinic, get your digital rectal exam and a blood test, and if there's anything abnormal you go and see the specialist and make sure it's not cancer.

But the challenge with prostate cancer is that although it is incredibly common it is often not harmful. In many men prostate cancer grows so slowly that it causes no harm and will not be the disease that ends a man's life (NCI). So the question we ask ourselves in the medical field is should we screen for and diagnose a condition in a person, inducing a considerable amount of stress, if the condition isn't going to hurt them and doesn't need treatment? Detecting small slow-growing tumours that are not life-threatening is considered "over diagnosis". And treating small slow-growing tumours is called "over treatment" (NCI & Canadian Urological Association).

But what if it's not small or slow-growing? What if a man turns out to be one of those cases where the prostate cancer is fast-growing and aggressive and can be fatal? How do you find these cases if you aren't looking? Well the problem is that we don't know if detecting these cases early has any impact on death rates from prostate cancer (NCI). The slow-growing cancers aren't going to hurt anyone and the fast-growing cancers may do what they are going to do regardless of detection or treatment.

Confused yet? Don't be. In fact screening or not screening for prostate cancer is a very personal decision for each individual. The most important thing is that men make an informed decision about screening. That means knowing their individual risk of prostate cancer, understanding what the different tests can offer and what it means if a test shows a "positive" or "negative" result, and understanding what the options are if they are diagnosed with prostate cancer. I would encourage any man of any age to have a discussion with their Nurse Practitioner or Physician about prostate cancer and screening so they can get all the facts and discuss how this relates to them individually.

So here are some of the basics and some references and resources listed below. Consider using this information as a starting point for a discussion with your health care provider.

Risks for Prostate Cancer:
  • Age: men over age 55 have higher risk. Risk continues to increase with age.
  • Race: men of African descent have higher risk than Caucasians. Asian men have the lowest risk. 
  • Family History: higher risk if a 1st degree relative (father, brother, son) has had prostate cancer.
            (Canadian Urological Association & Sunnybrook Hospital)..  

Relevant Tests & Examinations:
  • DRE - see above. traditionally start age 50. Some recommend age 40 (Prostate Cancer Canada).
  • PSA - see above. traditionally start age 50. Some recommend age 40 (Prostate Cancer Canada). If a man meets the high risk criteria for prostate cancer the blood test is covered by OHIP in Ontario. If a man does not meet the high risk criteria he can have the blood test but is charged a fee (MOHLTC). PSA is always performed after prostate cancer diagnosis to monitor the condition. There is ongoing work to improve the accuracy of the test e.g. Free versus total PSA levels, age specific PSA reference ranges (NCI & Canadian Urological Association)
  • Prostate ultrasound - usually only done if prostate cancer is suspected e.g. climbing PSA levels.
  • Prostate biopsy - done with radiologist only if prostate cancer is suspected. Interesting stat - only 25% of patients with elevated PSA levels test positive for prostate cancer when biopsied (NCI).

Treatment Options for Prostate Cancer:

Treatment options for prostate cancer are the working domain of specialized urologists. The various options are constantly evolving. Some treatments are only available at specialized centres (e.g. robotic prostatectomy) and may or may not be covered by OHIP if they are still being tested. It's very important to note that in recent years the big news in prostate cancer is that the most common treatment is "watchful waiting" or "active surveillance". Below is a brief overview of treatment options. All treatments have side effects. For a more detailed description of these treatments please see one of the websites listed at the bottom of this article. 
  • Active Surveillance: exactly as it sounds. You are monitored by the urologist to ensure that the prostate cancer isn't progressing. Monitoring is most commonly done by using the PSA test to ensure levels are not climbing and periodic DRE (Canadian Urological Association, Sunnybrook Hospital).
  • Radiation: some people require radiation treatment. This is either done via traditional radiation where you go to the hospital and have radiation directed at the prostate gland - often daily for a number of weeks. There is also a method called brachytherapy where radioactive pellets are inserted into the prostate gland (Canadian Urological Association, Sunnybrook Hospital)..
  • Prostatectomy: this is the surgery where the prostate gland is removed. This is usually performed as a standard surgical procedure however there are some centres that are testing robotic procedures (Canadian Urological Association, Sunnybrook Hospital, Mayo Clinic)..
  • Hormone therapy: patient is given injections. often used when prostate cancer has metastasized (spread) to other areas in the body (Sunnybrook Hospital).
  • Chemotherapy: less commonly used but sometimes employed when prostate cancer has metastasized (spread) to other areas in the body (Sunnybrook Hospital).  

Prevention or "Risk Reduction" for Prostate Cancer: 

The best treatment for prostate cancer is to avoid getting it in the first place. There are clearly some risk factors that you cannot alter - your gender, age, race, and family history. But there are some changes you can make that may reduce your risk:
  • Healthy Weight: obese men (BMI >25) are more likely to get prostate cancer.
  • Reduce or eliminate processed or charred meats: these increase risk.
  • Increase vegetable & fruit intake: sulphur containing vegetables like cabbage, broccoli, brussel sprouts, and cauliflower are rich in antioxidants that my prevent cancer. Lycopene, found in tomatoes, papaya and watermelon are beneficial (more available if food cooked).
  • Drink Green Tea: men who drink green tea have a lower risk of prostate cancer.
  • Increase Omega-3 fatty acids: thought to protect against prostate cancer. e.g. oily fish
  • Exercise regularly: also thought to reduce your risk of prostate cancer.
  • Stop smoking: believed to prevent the development of prostate cancer. 
  • Vitamin D: men with higher levels of vitamin D in their bodies have lower rates of prostate cancer. However, it is not yet proven that taking vitamin D supplements can reduce your risk. 
        (all from Canadian Urological Association, Mayo Clinic).

Thanks for reading Getting Healthy With NP Sam. Comments welcome - please click the pencil icon below. 


Prostate Specific Antigen (PSA) (Canadian Urological Association)
Prostate Cancer Prevention (Canadian Urological Association)
Prostate Specific Antigen (PSA) Test - National Cancer Institute (NCI)
Prostate Cancer and the PSA Test (MOHLTC)
Canadian Cancer Statistics 2013 (Public Health Agency of Canada + StatsCan + Canadian Cancer Society)
Prostate Cancer screening & treatment (Sunnybrook Hospital)
Prostate Cancer (Prostate Cancer Foundation)
Prostate Cancer screening and detection (Prostate Cancer Canada)
Prostate Cancer Prevention (Mayo Clinic)
Robotic Prostatectomy (Mayo Clinic)


Radhika Ganesh said...

very true information ..
Chronic diseases prevention

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