- Dr. Ray Baker
In medical school we learned that if you were male and lived long enough, you would likely get prostate cancer. We also learned that males are more likely to die with prostate cancer than to die from it. There are some things we can do to improve the likelihood that prostate problems can be found earlier, hopefully resulting in improved outcomes.
Location and function
The size of a walnut, wrapped like a cuff around the urethra (the tube leading from the base of the bladder to the penis) this little organ is important for reproduction. The journey that spermatozoa must travel to fertilize the ripe ova is perilous, through acidic vaginal secretions, up the cervical passage, into the uterus and through the openings of the fallopian tubes. These delicate, mobile cells need a safe medium in which they can easily move without being damaged. Like the fire retardant foam sprayed on the runway to cushion the aircraft's contact during a forced crash landing, during ejaculation the prostate secretes an alkaline, nutritive fluid into the urethra to be mixed with sperm traveling from testicular tubules, to create semen which is deposited in the female genital tract.
Types of prostate problems
Growth and activities of prostate cells are under the influence of sex hormones, such as testosterone. Like old men's noses and ears, the prostate gets bigger with age, a process called benign prostatic hypertrophy. As the gland enlarges it pushes on nearby structures, including the urethra. This can block bladder emptying and might require treatment, medical or surgical, to remove the obstruction. The prostate may become infected, resulting in a painful condition sometimes difficult to eradicate. Infections cause inflammation and swelling, resulting in partial or complete urinary obstruction, pain and fever. Because the fatty tissues of the prostate are poorly infused with blood, Antibiotics such as Cipro® or Septra® need to be continued for several weeks to eradicate the infection.
Much like the glandular cells of the female breast, prostate cells, influenced by hormones, can become cancerous. At first these cancer cells stay put and replicate slowly, resulting in gradual enlargement of the tumour. Once the cancer mass reaches a certain size it can be detected by rectal exam. After a period of in-situ growth the cancer spreads or metastasizes to other parts of the body, especially to bone.
Prostate cells put out a small amount of protein, called prostatic specific antigen (PSA), that may be detected using a blood test. Since the amount of prostate tissue increases with age, PSA levels normally increase with age, so the normal range gradually increases from under 0.7 ng/ml between the ages of 40 and 50 to as high as 1.5 ng/ml by the age of 70. Elevated levels of PSA can be caused by prostatic enlargement, infection, manipulation or prostate cancer. More recent techniques have been able to separate and identify two kinds of PSA: free PSA and a complexed PSA that is attached to other molecules. In prostate cancer the ratio of free PSA to total PSA is much lower than in other prostate conditions, so this ratio provides important information to plan further investigations and treatment.
Treatments and side effects
The traditional treatment for benign prostatic hypertrophy has been removal of a small amount of the glandular tissue via the cystoscope, inserted through the penis; an operation called transurethral prostatic resection (TUPR). Possible side effects include temporary obstruction requiring catheterization, infection and, occasionally, erectile dysfunction. More recently drugs have been discovered that block the nerve and hormonal stimulation of prostate cells, allowing them to decrease in size.
Prostate cancer can be treated with surgery to remove the cancer tissue, castration to remove the hormones that stimulate tumour growth, drugs that inhibit production, secretion or the activity of tumour-stimulating hormones, radiation and chemotherapy. As well as the common side effects of surgery and chemotherapy, temporary urinary tract obstruction, erectile dysfunction and loss of libido are frequently caused by these treatments. Detected early, improved rates of long-term remission are obtained for patients with prostate cancer.
There is disagreement about whether PSA screening, performed on all men over 40 is a good idea. Proponents of routine PSA screening point out that it improves early diagnosis of a common, curable cancer at an earlier stage than can be detected by physical exam. Those who oppose routine screening state that it is costly and will result in unnecessary, invasive biopsies and treatment of people whose prostate problems would not have resulted in significant disease. Although the jury is still out on this, the reader might be interested to know that I, and just about every middle-aged male physician I know, pay the price to have periodic PSA testing done. Screening protocol recommendations vary, but most experts agree that rather than the absolute PSA level, it is the relative change that is important. So, a baseline level at 40 to 45 years old is valuable because PSA levels can be rechecked every few years and compared to it. This provides a very sensitive alarm system to pick up cancers early.
The bottom line
Prostate cancer is the second most common cancer experienced by men. Women get breast cancer and we men get prostate problems. With both conditions there is controversy about the best methods of screening and treatment. But there is general agreement for both that earlier detection results in better outcomes.
Watch for changes in urinary stream: difficulty beginning the urine stream in the morning, slower bladder emptying, pain or discomfort. Get regular physical exams, and if you are over 40, expect a rectal exam. Consider asking for a PSA, but don't be surprised if you have to pay about $40 for it.
In this aging man's opinion, it just seems like pretty cheap insurance.
Dr. Ray Baker is Assistant Clinical Professor in the Faculty of Medicine at the University of British Columbia. He has been awarded fellowships in both Family Medicine and Addiction Medicine. He has been a practicing physician for over 23 years. From 1993 to 1997 he represented Canada on the Board of Directors of the American Society of Addiction Medicine, North America's credentialing body in this specialized area of medicine. His area of special clinical expertise is in assessment and treatment planning of the worker disabled by one of the "invisible disabilities", stress, depression, chronic pain syndrome or substance use disorder.
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