Men of a Certain Age
As they get older, men need to know the facts about prostate cancer
As a man ages, there are new and challenging health concerns that inevitably crop up, complications that would have seemed completely foreign to him in his youth. Joint pain. Hair loss. The inability to play basketball without knowing there’s a heating pad and some ibuprofen close by. And while these problems can be defeating, they hardly come as a surprise. Men know they’re coming; it’s less a question of “If?” than it is “When?” and “How bad is it going to be?”
With its potentially life-threatening nature — so much so that the National Football League (NFL) started a campaign to raise awareness for it — men today need to get the facts about prostate cancer. According to the Urology Care Foundation, the official foundation of the American Urological Association, approximately one in six men will be diagnosed with prostate cancer in his lifetime. Prostate cancer is the second-most common cancer — and second-most common cause of cancer death — in males, with an estimated 28,000 men dying from the disease each year.
These daunting statistics illustrate just how widespread prostate cancer can be, making it critical that men, as well as their loved ones, have a clear understanding of the condition — who is at risk, how it can be detected and what treatment options are available.
Who is at risk?
Part of the male reproductive system, the prostate is a walnut-sized gland under the bladder and in front of the rectum. Age is the primary consideration in determining the likelihood of getting prostate cancer. Nearly two out of every three cases are found in patients 65 or older, and the risk increases with age. But this is just one of the factors according to Gustavo Ayala, MD, professor and director of UTPath Urologic Pathology at The University of Texas Health Science Center at Houston (UTHealth) Medical School.
“Like most cancers, there is a familial aspect. If you have close relatives — a father, a brother — who have had prostate cancer, you are at a higher risk,” Ayala says. “There are also racial and ethnic differences, not just in the incidences, but in the aggressiveness of the disease. African Americans not only have the highest incidence, but also a more aggressive disease, followed by Caucasians, then followed by Hispanics and Asians.”
Ayala explains that all men, if they live long enough, will eventually get prostate cancer, though the majority of those cases will be deemed clinically insignificant, and therefore will not cause any harm. Making the diagnostic process more challenging, there are generally no external indicators that the disease is present. Urinary symptoms, such as urinating often, a weak flow, stopping and starting while going, the inability to hold it in, and painful ejaculation, are often caused by prostate health issues other than cancer.
“By the time you get any warning signs, it is usually an advanced disease. That’s why screenings are so significant,” Ayala says.
Men who would be considered high-risk — African Americans and those with a family history of prostate cancer — should consult their doctor about getting screened yearly when they turn 40, he says. For those who do not meet any of the at-risk criteria, the age gets bumped to 55, according to the American Urologic Association.
Detecting prostate cancer
There are two ways to be screened for prostate cancer, with each serving as a guiding tool to help doctors formulate an accurate diagnosis. The first is a blood test that measures the level of prostate-specific antigen (PSA), a protein that, as its name suggests, is produced exclusively by the prostate. High levels of PSA — and the threshold varies from patient to patient, Ayala notes — does not necessarily indicate that you have prostate cancer; it indicates that there is a greater probability that cancer is present, and that the matter should be investigated further. In fact, according to the NFL’s aforementioned “Know Your Stats” campaign, less than one-third of high PSA results are caused by prostate cancer.
The other screening method is the digital rectal exam (DRE), in which the doctor inserts a finger through the rectum to physically examine the prostate. This is commonly done as part of an annual checkup once a man’s age and family history dictate that he is now at a higher risk for the disease. Like the PSA test, if irregularities are detected, the physician then knows to take a more in-depth look at what is potentially going on with the patient.
While the PSA test and DRE can point doctors in the right direction, a biopsy can help doctors detect if cancer is present. If the biopsy does reveal cancer, doctors then must decide if it is clinically significant or not, and whether treatment is required. Utilizing, among other considerations, the Gleason Grading system, doctors identify the stage and grade of the tumor; the higher the Gleason score, the more aggressive the cancer.
Because not all prostate cancer is life-threatening, Ayala says it is not uncommon for doctors to take a wait-and-see approach known as “active surveillance” or “watchful waiting.” Often employed when the cancer is detected early, this strategy involves regular PSA tests and rectal exams, allowing the doctor to monitor the situation closely while saving the patient from unnecessarily enduring any uncomfortable side effects. When going this route, it is imperative that the outlined regimen of checkups is strictly followed in order to limit the possibility of the cancer reaching dangerous levels or from spreading beyond the prostate.
What treatment options are available?
If the cancer is deemed to require immediate attention, it is then time to choose a course of action. There are currently two standard methods most frequently used — and as with everything regarding the disease, what that proper approach is depends on the individual.
For patients in good health who have at least a 10-year life expectancy (determined by assessing a person’s age and wellness), and whose cancer is localized to the prostate, having the prostate removed surgically may be the best route to go. By taking out the entire gland, you ensure that all of the cancer cells are taken out with it, which offers many men peace of mind. Before selecting this option, though, patients should talk with their doctor to make sure that they are up to the physical and emotional challenges associated with a major operation, such as anesthesia, a multiday hospital stay and the use of a catheter afterwards.
For patients who are older or who would prefer a less invasive approach, there is radiation therapy. The most common form of this is external beam radiation therapy, or EBRT, which does not involve anesthesia or surgery. EBRT sends targeted beams of high-energy rays to the prostate to kill off the cancer cells. Treatments last only a few minutes each, and the process is done once a day, five days a week for seven to eight weeks. The key to EBRT’s success, Ayala explains, is for doctors to dial in a specific strategy for each specific patient. “What you’re trying to do is radiate the prostate cancer, not the rectum, which is right next to it. The only way to do that is to understand in three dimensions the anatomy of each individual.”
Both surgery and radiation have proven to be effective — and both also carry the risk of side effects, notably impotence and incontinence. The main difference, Ayala points out, is that with surgery, if a patient is going to experience these side effects, he will experience them in the early aftermath of the operation. With radiation, they may not surface until months or years following the completion of the treatment.
Regardless of which approach is taken, and regardless if the cancer is ultimately deemed completely gone, doctors will still put a post-treatment checkup plan in place, conducting regular PSA tests and/or DREs to ensure that the tumor has not come back.
While surgery and radiation are currently the two most prominent treatment options (hormonal therapy and chemotherapy can also be used in certain cases), there are constant strides being made to identify new ways to combat the disease. Look no further than the work done by Ayala, who is the Distinguished Chair in Pathology and Laboratory Medicine at UTHealth Medical School. Through research and relentless effort in the lab, Ayala has made a key discovery — what it is that affords the cancer its sustainability.
“We have found that nerves are very, very important for prostate cancer; it cannot grow without nerves. That is why people with spinal cord injuries have a much lower incidence or prevalence of the disease,” he says.
This revelation then begs the question: Is it possible to somehow disrupt the link between the cancer and the nerves that fuel it? The answer, Ayala says, is yes, and it can be done through the use of a surprising denervating agent that, to this point, has commonly been relegated to superficial, cosmetic use: Botox.
In the same way that it eliminates skin wrinkles by blocking the signal between nerve and muscle, when Botox is injected into the prostate, it chemically disconnects the surrounding nerves from the cancer, and thus cuts the tumor off from its life source. “We are finding that the cancer is dying,” Ayala says.
Though his research is still in the clinical trial phase, the hope is that it will one day lead to a new and effective way to counteract the disease.
“It will be one more tool for treatment. You could get a yearly injection of Botox, or you could do Botox before surgery, or you could use Botox before radiation therapy. That is the future,” Ayala says.
In the meantime, the best thing men can do is find a doctor they trust, and once they enter the high-risk category, go for regular screenings. And while there are not any clear, proven measures that can be taken to definitively prevent getting prostate cancer, Ayala offers up some straightforward lifestyle advice for everyone regardless of age or family history: Exercise, eat low fatty foods, do not smoke, and lead a good, healthy life, so that it is harder for cancer to grow.