Prostate Cancer Wrap Up and Prayer

Prostate cancer in the second most common cancer in men worldwide and the single most common cancer in men in the United States. (1) Worldwide over 1000 men are expected to die from prostate cancer every day. (2) In the United States men have a 12-13% lifetime risk of developing prostate cancer. (3) Prostate cancer presents a unique risk to men with no easy answers on how to find this disease at an early stage. Let’s review what we learned about prostate cancer so far. Afterwards, I would like to pray for you.

There is controversy around the best way to find prostate cancer in men. One way is to have a blood test for the Prostate Specific Antigen (PSA). Touching and feeling the prostate has fallen out of favor over time, but this method may be used by your doctor, especially if you are high risk or have a history or prostate cancer. The age at which to get this blood test depends on your risk. Age, ethnicity and a family history of prostate cancer are risk factors for this disease. Age is one of the strongest risk factors for prostate cancer. Prostate cancer is rarely found before the age of 40 years, and In the United States, over 90% of new cases of prostate cancer are found in men ages 55 years and older. The 5-year survival for prostate cancer approaches 100% when found early. Therefore, it is important to know when you should be tested. For those who are considered average risk, it is suggested that a discussion should take place at or after the age of 55 to determine if a PSA blood test is the right choice. For African American men, carriers of the breast cancer (BRCA) gene or those with a father or brother with prostate cancer before the age of 65 should have this discussion at a younger, specifically at or after the age of 40. (3)

When looking further into risk, ethnicity and family history play a major role as well. African American men at the highest risk of developing prostate cancer and are more than twice as likely to die from prostate cancer when compared to other ethnic groups. Furthermore, African American men tend to be diagnosed with prostate cancer at an earlier age. When prostate cancer is diagnosed in African American men, it tends to be more aggressive. (3)

It is not only important to know if there is a family history of prostate cancer, but other cancers as well. Interestingly, the breast cancer or BRCA gene can also be found in men. Men with aggressive prostate cancer are tested for BRCA (Breast Cancer) mutation as this gene can also cause prostate cancer. Therefore, a family history of prostate cancer is not only important for men, but women also. If a woman in your family had breast cancer before the age of 50 or ovarian cancer, you may be at increased risk for prostate cancer. If anyone in your family had a history of cancer of the colon or pancreas, your risk of prostate cancer may also be higher. (4)

Prostate cancer is a difficult disease to pick up based on symptoms alone. In most cases, prostate cancer grows very slowly and many men never realize they had cancer in their prostate. At other times, this disease can be aggressive and deadly. It is important to realize that it is our goal to detect prostate cancer before symptoms develop. More prostate cancers are found when there are not symptoms at all. Instead, a high Prostate Specific Antigen (PSA) may be found on blood testing. When symptoms of prostate cancer come about, this can mean that the cancer has spread beyond the prostate. At other times, the symptoms of prostate cancer can be confused with other conditions of the bladder and prostate. This may include difficulty urinating or being unable to urinate. These symptoms can also be seen with an enlarged prostate, also known as Benign Prostatic Hyperplasia (BPH). It is also possible to have blood in the urine and semen, but this can be seen with infections of the bladder and testicles respectively. (5) When prostate cancer has spread beyond the prostate, the symptoms can be broad as well. Unintentional weight loss is a common symptom of all cancers. If you are losing weight unexpectedly, you should see you doctor immediately. It is possible to have erectile dysfunction (ED), but this condition can also be seen with diabetes and advanced age. Otherwise, prostate cancer tends to spread to the bones, therefore worsening or new onset back and bone pain can be a symptom of cancer that has spread beyond the prostate gland. It is also possible to have weakness due to a mass pressing on the spinal cord. (6)

It is important to know your prostate number and when you should see a urologist. When receiving your test results, it is not enough to know if you test was “positive” or “negative.” You need to know your number. When your PSA level is less than 4, this can be thought of as a negative test result and your risk of prostate cancer is low. The is a catch. If you PSA level is less than 4, but has risen from last year, it is very important than you speak with your doctor to find out if this rise in your PSA should be investigated further. (7) Even more, when the PSA level is less than 1.0, it is very unlikely that prostate cancer is present. Speak with your doctor about your PSA, they ca help interpret what is number means.

The decision for a prostate biopsy is a difficult one, but this procedure is an important means to help separate slowing growing harmless cancers from aggressive and deadly ones. There are no set parameters for deciding when to get a biopsy. How your prostate feels on digital rectal exam, the PSA level, family history and age can all play a role in your decision to get a prostate biopsy. Such a complicated discussion is best made in conjunction with you urologist who can help tease out the fine details of the risks and benefits of a biopsy. In most cases, getting an MRI before a prostate biopsy is a good idea. Most urologist, or prostate doctors, follow this approach. The MRI can help determine if you need a biopsy of not when a PSA blood test is high. If a biopsy is needed, the MRI will help the doctor know where to samples the tissue.

There are many types of treatments for prostate cancer. When cancer has not spread outside the prostate gland, prostate removal or radiation are treatments to consider. With a low Gleason score, low PSA level and low tumor stage, prostate cancer typically does not need to be treated with medications, radiation or surgery. In this case, prostate cancer can be “watched” from year to year. If the Gleason score, PSA level tumor stage are higher, radiation or prostate removal may be needed. If the risk is very high, ADT, or androgen deprivation therapy may be needed. (8)

When cancer has spread outside the prostate gland, ADT is the mainstay of treatment. Remember, like breast cancer, prostate cancer is a hormone driven cancer. As a result, one of the ways to treat prostate cancer is to take away the hormone that is helping it grow. With ADT, or androgen depravation therapy, you may receive certain medications that will shut down the production of testosterone in the testicles. There are many medications; such as leuprolide and goserelin. Another type of ADT, or androgen depravation therapy, is to removal the testicles. The medical term for this procedure is called an orchiectomy. This is also known as castration. In the United States the majority of men choose to take medication to shut down the production of testosterone instead of castration.

When the start on ADT, men can experience hot flashes and decreased sex drive, weak bones or loss of muscle mass. At times, one might need to have a DEXA bone scan performed to make sure the bones are not too brittle, or have osteoporosis. There are times when prostate cancer does not respond well to castration or medications that shut down the production of testosterone. This is called castrate resistant disease. Whether one is dealing with castrate sensitive or resistant disease, the addition of chemotherapy can be beneficial. (2) Those with metastatic prostate cancer tend to receive radiation as well. Remember it is our goal to find and treat prostate cancer at an early age before this disease spreads to other parts of the body. Even with metastatic prostate cancer, there is hope and a health available to you.

I would like to seal the end of this Prostate Cancer Series with a prayer:

“Jesus, we thank You for walking with us today. We know you never leave. In our confusion and disappointment, we know you are always present. Guide us is such a way that we know it is You that is speaking. Do not let us listen to another voice besides Yours. If we have made poor decisions, bring us back to your path that leads to life. Humble our hearts so that we may listen to those you have assigned to care for our health. We bind every disease that seeks to attacks our bodies. But if it comes, gives us understanding and wisdom to treat and remove it early with no complication. We even bind the thought that we will not trust our doctor. We will trust who you tell us to trust. We will believe what you tell us to believe. We give all the glory and honor to you. Heal what the doctor cannot heal. Fix what the medications can treat. May us new. Bring us closer to you. In Jesus name. Amen.”

REFERENCES
1. World Health Organization. Global Cancer Observatory. Available at: https://gco.iarc.fr (Accessed on September 18, 2021)
2. Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer Statistics, 2021. CA Cancer J Clin. 2021 Jan;71(1):7-33. Erratum in: CA Cancer J Clin. 2021 Jul;71(4):359.
3. National Institute of Health. Surveillance, Epidemiology, and End Results Program. Cancer Stat Facts: Prostate Cancer Available at: https://seer.cancer.gov/statfacts/html/prost.html (Accessed on September 18, 2021)
4. Chen YC, Page JH, Chen R, Giovannucci E. Family history of prostate and breast cancer and the risk of prostate cancer in the PSA era. Prostate. 2008 Oct 1;68(14):1582-91.
5. Bell KJ, Del Mar C, Wright G, Dickinson J, Glasziou P. Prevalence of incidental prostate cancer: A systematic review of autopsy studies. Int J Cancer. 2015 Oct 1;137(7):1749-57.
6. Taplin ME L & Smith JA. Clinical Presentation and Diagnosis of Prostate Cancer. In: UpToDate, Vogelzang AD, Lee RW & Richie JP. (Eds), UpToDate, Waltham, MA. (Accessed on October 10, 2021.)
7. Hoffman RM. Screening for Prostate Cancer. In: UpToDate, Elmore JG & O’Leary MP (Eds), UpToDate, Waltham, MA. (Accessed on October 16, 2021.)
8. Dawson NA. Overview of systemic treatment for advanced, recurrent and metastatic castration-sensitive prostate cancer and local treatment for patients with metastatic disease. In: UpToDate, In: UpToDate, Vogelzang N, Lee RW, Richie JP (Eds), UpToDate, Waltham, MA. (Accessed on April 30, 2022.)