Prostate Cancer

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Prostate cancer is a disease in which malignant (cancerous) cells form in the tissues of the prostate - gland  which is located under the bladder and in front of the rectum in men. The function of the prostate gland is to  produces a fluid component of semen which transports sperm during ejaculation. The prostate gland is about the size of a large walnut but and enlarge throughout life in a process called benign prostatic hypertrophy.

Presenting symptoms: Many men, these days are found to have prostate cancer following a routine blood test showing a raised PSA. Many of the urinary are actually caused by an enlarged prostate gland which although could be caused by the cancer is more likely to be caused by a benign swelling of the gland (not cancer).

 Possible symptoms of localised prostate cancer include:

• Passing water more frequently at night
• Reduced urine flow,
• A feeling that you are not emptying the bladder
• Rarely blood in the urine or semen, 
• Erectile dysfunction

Rarely cancer can present with signs that it has already spread to other organs or structures:

• Pain in the bones (metastasis to the bones)
• Pain in the perineum (area between testes and anus)
• Swollen legs (caused by enlarged lymph nodes)
• Nerve pain or even loss of use of the legs (spinal cord compression)

UK incidence: The risk of this condition increases with the age, generally men over the age of 50 are affected. In the UK nearly 32,000 men are diagnosed every year with prostate cancer which causes more than 10,000 deaths every year. Overall, one man in fourteen will get prostate cancer at some point in his life. Of the 2 million people living with cancer at any one time in the UK43% of the men will have prostate cancer.

Types of prostate cancer: Although there are several cell types in the prostate, nearly all prostate cancers start in the glandular tissue itself, called an adenocarcinoma. Other rare cancer are:

• Primary transitional and squamous cell cancers (mostly direct invasion from adjacent bladder cancers.)

• Carcinoid and small cell carcinomas (tumours may be sensitive to chemotherapy but are highly malignant with a very poor prognosis) 

• Sarcomas represent approximately 0.1% of prostatic malignancy. 

• Rhabdomyosarcomas are described in younger patients. Leiomyosarcomas occur usually after the age of 50. 

• Non-Hodgkin’s lymphoma may arise within the prostate and both chronic lymphocytic and acute leukaemias may cause prostatic infiltration. 

• Secondary tumours of the prostate such as malignant melanoma and bronchial carcinoma have been rarely reported

Risks factors for prostate cancer: Most cases of this condition are diagnosed in men over the age of 65. There are usually no predisposing risk factors but there is some evidence of associations with a previous poor diet (high in fat, low in fruits and vegetables), being a black male, men who have a strong family history of the disease are at greater risk. 

Tests to determine a diagnosis and help decide on treatment options: Prostate-Specific Antigen (PSA) blood test, Digital Rectal Examination (DRE), transrectal ultrasound (TRUS), biopsy (find out more)

What determines the treatment options and prognosis:

• The stage - Whether it is palpable on rectal exam, spread outside the gland, into local lymph nodes or elsewhere (you will need a number of scans to determine this including Rectal ultrasound, CT scan, Bone scan or MRI
• The type of  cancer cells - mainly adenocarcinomas (originate from glands) 
• How aggressive they look under a microscope (gleason grade) 
• Age and general health of the patient
• Whether the condition has just been newly diagnosed or has recurred
• Level and rate of rise of PSA

Treatment options Ideally, treating any type of malignancy should cure the disease as well as be easily tolerated, and cause minimal or no problems. This concept is particularly important in treating prostate cancer. Although some men have an aggressive form that can lead to early spread and death, many have slow growing tumours that would never cause problems during a patient’s natural lifetime.  It is important that medical intervention does not convert this group of healthy men into sufferers from medical care related side effects. Prostate cancer treatment depends on several factors such as the stage, type and grade of the disease as well as on the patient's age, general health and preferences. Before deciding which option is appropriate in your case you may need more than one visit to the clinic to discuss all your concerns and questions.

The most common options for disease confined to the gland include:

• Surgery  - local kind of therapy which includes removal of either the whole organ (radical prostatectomy) or part of the organ (transurethral resection)
• Radiotherapy  - therapy using either external radiation beam that is focused and delivered to the affected area of the organ (external beam radiotherapy = conformal radiotherapy) What to expect | External beam | Side effects
• Brachytherapy. Tiny radioactive seeds are inserted directly into the cancerous gland  which allows higher doses of radiation to be delivered without damaging the surrounding organs.
• Hormone therapy - aims to treat this condition by depriving the body of hormone testosterone (male sex hormone). Given before radiotherapy or as an additional therapy for 1-3 years afterwards. Zoladex, Prostap, Casodex, Drogenil,  Cyproterone, Stilboestrol
• Active surveillance (Watchful waiting) - active monitoring of a low grade and less aggressive type of this condition with no immediate active treatment can be an option as well. This involves regular blood tests for PSA. In some cases this may be the only option used as the disease may progress very slowly or at all. This way other treating techniques, with the associated side effects, may be avoided.
• Less common treatment - Cryotherapy, High frequency ultrasound
• Chemotherapy

Lifestyle strategies and prostate cancer

Smoking. Trials have linked smoking with more aggressive cancers and a higher risk of erectile dysfunction and pelvic damage after radiotherapy - tips to give up smoking

Weight control. A variety of studies have linked obesity with and high rate of prostate cancer, more aggressive forms of cancer and a higher risk of relapse following successful initial therapies - tips to help control a healthy weight

Exercise. Exercise helps to counterbalance the negative effects of androgen deprivation such as weight gain, osteoporosis and mood changes. Exercisers have lower risk of pelvic damage after radiotherapy. Two large international studies have linked exercise with a lower risk of relapse. - more about exercise and local facilities

Diet factors have been linked to a higher risk of prostate cancer particularly those who eat excessively, have a high fat and processed meat intake with a low intake of vegetables, fruit, herbs and spices - read more about diet 

Polyphenols and anti-oxidants.  There are some evidence that certain foods have specific anti-cancer properties via their polyphenol and antioxidant ingredients. They are thought to work in a number of different ways:

• Promoting differentiation (slowing cellular growth),
• Encouraging apoptosis (encouraging cells to die when they have reached the end of their natural cycle)
• Preventing further DNA damage via the antioxidant process (absorbing the super-oxide free radicals produced from our environment )
• Stopping new blood vessels growing into tumours (anti - angiogenesis)

By ensuring adequate intake of polyphenol and anti-oxidant rich foods not only is the initial risk of prostate cancer reduced but some evidence suggests that  indolent malignant or pre-malignant cells may not progress into more aggressive types and hence more advances disease especially if combined with other healthy lifestyle strategies (full evidence see - Lifestyle after Cancer - the facts). The foods generally thought of as beneficial include:

• Green vegetables; cabbage, spinach, broccoli,
• Salad; Dark green lettuce leaves (rocket), leaks, onions, celery
• Citrus fruits (especially ripe); pomegranates, kiwis, plums, apples, lemons, apricots, plums, pears, oranges, nectarines, strawberries, bananas, grapes.
• Mushrooms; white and wild varieties
• Dried fruits; raisin, prunes, apricots.
• Berries: Cherries, blueberries, blackberries, cranberries, goji berries, gac.
• Legumes; beans, lentils, chick peas
• Nuts: Hazelnuts, peanuts, cashews.
• Herbs & spices; Garlic, parsley, mint, coriander, thyme, rosemary

Nutritional supplements In general taking additional vitamin and mineral supplements have not been shown to decrease the risk of prostate cancer. In fact, some studies have shown that minerals such as zinc and vitamins such as A and E can increase the cancer risk if taken in excess - Trials which have measured base line vitamins and minerals before supplementation have usually demonstrated a benefit in correcting a deficiency but harm in taking them if pre-intake levels were normal or excess. The trouble is there is no way of knowing what our baseline levels are unless they are measured - see micronutrient testing. 

There may be a benefit in taking whole food supplements which have been dried and concentrated - these supplement do not increase individual extracted chemicals but a range of natural polyphenols found in the whole food. Some small or non randomised trials have shown a benefit for green tea and pomegranate seed. Definitive data will be available when the pomi-t supplement study is published in 2013. The rationale for combining four different whole foods types (berry, vegetable, spice and leaf) was to provide a wide spectrum of natural polyphenols, avoiding over-consumption of one particular type.