July 27, 2007

Doctor’s Corner

The Prostate: the most misunderstood organ

By Dr. Eduardo Grunvald

When my fiancé and I first started dating, she asked me during a casual conversation about doctor appointments, “should I have my prostate checked”? I responded with a chuckle, “if you need your prostate checked, I’m in trouble.” For me, this was just another example of how this small organ is so misunderstood.

For quite some time I have wanted to write an article educating people about this male gland. Many people do not even know where it is located or what it does, and when it comes time for me to discuss prostate cancer with my male patients, it becomes quite challenging to explain the reasons, risks, evidence, and nuances of screening for the disease.

Prostate cancer is not rare. In fact, it is the most common cancer – not including skin cancer - in the United States. In 2006, more than 230,000 cases were diagnosed. It is the third leading cause of cancer death, only recently being overtaken by colorectal cancer, accounting for over 30,000 deaths per year in this country.

The prostate gland is about the size of a walnut, located in a man’s pelvis in front of the rectum, and surrounded by pelvic muscles. Its function is to provide fluids necessary for the transport of sperm. As men get older it is common for the prostate to enlarge, causing uncomfortable symptoms such as frequent urination, pain, slow urination, urinary tract infections, and even incontinence. There are many medications that can be used to offset some of the symptoms, and as a last resort surgical procedures are available to treat this problem.

The challenge lies in differentiating the enlarging prostate common in an older man from prostate cancer. In its early stages, prostate cancer does not cause any symptoms and is not life threatening until it spreads to other parts of the body. Detection of the disease early on is accomplished by screening, which involves a simple blood test called a Prostate Specific Antigen (PSA) and a digital rectal exam (DRE), whereby the doctor feels the gland during a rectal examination. The embarrassment of this exam is one of the reasons some men put off seeing a doctor, but ask a man dying of prostate cancer if that makes any sense.

Compared to some other cancers, prostate cancer is a very slow disease. In fact, it would take many years for someone to die of the disease if it were left untreated. This is desirable of course, but poses some challenges when trying to decide whether or not to screen someone. Let’s say you are 50 years old and potentially could live to be 80 or 90. Most people would want to detect the problem early on and embark on treatment to cure the disease.

On the other hand, let’s say you are 75 years old and also could live to be 80 or 90. If you undergo screening and detect an early prostate cancer you could be left with a difficult decision regarding treatment that could lead to permanent side effects, adversely affecting your quality of life. The evidence suggests that many older men will die with prostate cancer, not from prostate cancer. In other words, many older men would not be bothered by this problem if left alone.

Puzzling as it may sound, these uncertainties parallel the confusing body of evidence pertaining to prostate cancer screening. Early studies have shown evidence that detecting the disease at an early stage decreases one’s risk of death from the illness, but these studies have been criticized because of the statistical methods used. Furthermore, studies have not proven a reduction of death in general as a result from early detection. Again, in some cases screening and treatment for prostate cancer may do more harm than good, especially with respect to men in their 70’s and 80’s. There are currently two large clinical trials under way – one in the U.S. and one in Europe – that will hopefully shed more light on this murky issue. The results should be available in 2008.

Treatment options include surgical removal of the prostate, radiation therapy, or treatment with hormones, all with potential risks.

Let me throw in another confusing twist. The blood test – PSA – generally uses a value of 4.0 as the cutoff for normal. But men between the ages of 50 and 60 with a PSA higher than 2.0 may be in a danger zone. The problem is that there are many conditions other than prostate cancer that can make this value go up, such as age-related enlargement, infection, or recent sexual activity. Sometimes it is not so much the actual number that is important, but rather how rapidly over time the PSA is rising. As you can see, the issue of screening is not black and white. The only certain way to confirm or rule out prostate cancer, if warranted by an elevated PSA or abnormal exam, is to perform a biopsy.

Currently the American Cancer Society (www.cancer.org) and American Urological Association (www.auanet.org/patients) recommend prostate cancer screening starting at age 50 for most men, and at age 40 for men of African descent (at higher risk) or anyone with an affected first degree relative (father or brother). The U.S. Preventive Service Task Force recommends screening only after the patient has made an informed decision based on a thorough discussion with his doctor. Although prostate cancer is less common in Hispanics, it is still the most common cancer diagnosed in this group.

The moral of the story — whether you are a man, or a woman who has a male loved one — is to understand prostate cancer and to have a face-to-face discussion with your doctor about your health maintenance options.

Dr. Grunvald is Associate Clinical Professor, Department of Medicine at the Perlman Internal Medicine Group, UCSD Medical Center.

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