What Your Doctor May Not Tell You About(TM) Prostate Cancer

ACCLAIM FOR
WHAT YOUR DOCTOR MAY NOT
TELL YOU ABOUT^(TM) PROSTATE CANCER

"The complexity of prostate cancer and treatment options can be overwhelming for patients. Dr. Bubley's well-written, concise, and contemporary book will be a great companion for patients and their families for making some of the difficult decisions that need to be made."

—Philip Kantoff, M.D., chief, Division of Solid Tumor Oncology, Dana Farber Cancer Institute, and professor of medicine, Harvard Medical School

"This is one of the best books for men with prostate cancer. The basics of diagnosis and treatment are all presented in a very clear, easy-to-understand way. It has the best discussion anywhere of clinical trials and how you might benefit from them."

—Charles E. Myers, M.D., director, American Institute for Diseases of the Prostate

"An important and unique resource for patients and their families who are facing the personal battle against prostate cancer . . . With remarkable clarity, this book highlights the relevant issues and provides an understandable, succinct, yet comprehensive guide for a practical manner whereby patients and their families can approach the broad range of treatment options."

—Martin G. Sanda, M.D., visiting associate professor of urology, Harvard Medical School

The author (GJB) wishes to dedicate this book to
his patients with prostate cancer for all they have
taught him. He also wishes to thank his family,
Lynn, Matt, and Janna for their support,
encouragement and sense of humor.

Introduction

For me, fighting prostate cancer is personal. I have not been diagnosed with the disease, and neither has anyone in my immediate family, but I have spent almost every day for the past twenty-five years thinking about prostate cancer and what can be done to prevent or treat it. I have dedicated my professional life to treating men with advanced prostate cancer, men for whom conventional treatments have failed and hope for a cure has started to dwindle.

Over the years, I have seen too many good men die from this disease. I have also seen a growth in the number of men who add years to their lives through the use of new treatments and experimental therapies. By the time I retire, I fully expect that prostate cancer will have become a much more manageable disease, one that can be controlled with regular medication. Some men with the most aggressive forms of the disease may never be "cured" and declared cancer-free, but they may be able to use a number of treatments either currently available or in development to keep the cancer from spreading. In essence, prostate cancer will be stalemated; it will continue to linger in the body, but it will be much less likely to have the power to kill.

This vision of manageable prostate cancer will soon become a reality. Researchers already have quite a few treatments in development that may prove useful, at least for a time. When one therapy fails, doctors have others to try. This approach to disease management requires that both doctors and their patients remain on top of the research about appropriate and effective treatments. This can be a daunting and overwhelming task, but this book can help you make sense of the dizzying array of treatment choices so that you can find the approach that is right for you or the person you love. It will also explain benign prostate problems, which afflict many men as they grow older.

PROSTATE CANCER: EVERY MAN'S DISEASE

A decade ago, most men dismissed prostate cancer as a disease of older men, those in their seventies and beyond. Too often it was not diagnosed until after the cancer had spread to the bones or other organs. Today, prostate cancer is recognized as every man's disease. Due to increased public awareness and improved screening tests, the disease is detected much more often in men in their forties and fifties; and, more important, it is much more often identified at the earliest and most treatable stages.

Consider the grim statistical reality: In the United States, men have an alarmingly high one-in-six lifetime risk of developing prostate cancer, making the disease the most common type of cancer among American men and the second leading cause of cancer death. Each year, about 180,000 American men are diagnosed with prostate cancer, and nearly 32,000 die from the disease. In other words, every three minutes a man is diagnosed with prostate cancer, and every sixteen minutes another man dies from the disease.

What Causes Prostate Cancer?

Prostate cancer is a complex disease with a number of contributing factors. A diet high in fat and low in fruits and vegetables may play a role in causing prostate cancer. (The role of diet is discussed in detail in chapter 10.) High levels of the hormone testosterone may also play a role in younger men; testosterone both stimulates the growth of prostate tissue and jump-starts the growth of cancer cells once the cancer takes hold.

There is a definite familial or genetic component to prostate cancer risk in men of all races. If a close relative (brother or father) has cancer at a young age (under sixty), the genetic link appears stronger than if the same relative develops cancer at age eighty-five. For more information on genetic links, see chapter 11, Brothers and Sons.

Prostate cancer deserves your respect, but for most men the diagnosis is not a death sentence. With proper treatment, prostate cancer can be controlled. Many men have an indolent or less aggressive form of the disease. More than half of newly diagnosed patients respond well to traditional treatments and remain free of prostate cancer for the rest of their lives. Those men whose cancer recurs must face a second round of treatment, but a majority of them respond to follow-up care. And even those men with aggressive cancers that return time and again can make use of a number of new and effective treatments.

We live an era of new hope, and this book can help you take advantage of all the therapies currently available. I support a truly integrative approach to treating prostate cancer, one that takes an impartial and balanced look at the best of both mainstream and experimental treatments. My goal in this book is to provide you with a clear and decisive guide to living with prostate cancer as well as information that will transform more advanced prostate cancer from a fatal condition to a treatable one. Remember also that many people are now engaged in trying to make headway in this disease. The future looks bright, so be on the lookout for newer innovations.

NO CLEAR ANSWERS

Prostate cancer can be a confusing cancer to treat. Unlike other tumors, prostate cancer may respond well to several different approaches. As a result, there is no clear answer to the question: Which treatment is best for me? For many of the different stages of prostate cancer, especially low-grade cancer that has not spread beyond the prostate, doctors do not agree on a single approach to treatment; in other words, there is no uniform standard of care. In these cases, it is up to the patient to work with his doctor to weigh the advantages and disadvantages of each treatment. In later chapters, I will review the preferred standard of care, when it exists, and explain the factors that should be taken into consideration when comparing various approaches to treatment.

As men become more educated about the disease, they tend to focus on the unpleasant side effects to treatment that may lie ahead. For many men, choosing a treatment plan means opting for the trade-offs that they may find easier to tolerate. Anecdotal stories of your best friend's uncle who had a radical prostatectomy and became impotent or your neighbor who had radiation resulting in rectal pain may have no bearing on you and your experience of this cancer.

In my practice, I spend a great deal of time helping men honestly assess their options and make appropriate choices. Treating prostate cancer can be very time-consuming for doctors, who need to take the time to explain each patient's specific situation to him. A well-informed patient is an empowered patient. He has the knowledge to weigh his options and make informed decisions about his health care.

I also remind my patients with prostate cancer that they need to continue to visit their primary care physician. They need to exercise, to eat right, to check their cholesterol levels, to avoid smoking, to manage their diabetes and other chronic conditions. The chances are good that these other health issues will pose a greater risk to their long-term health than prostate cancer will. Men with prostate cancer need to put money in their 401(k) accounts, they need to plan for their grandchildren's graduation, they need to get on with the rest of their lives. For the majority of men, prostate cancer will be a bump in the road, not the end of the line.

USING THIS BOOK

Whether you have already been diagnosed with prostate cancer or are concerned about preventing it, the information in this book will be of use to you. The overall objective of this book is to turn this confusing disease into a more understandable one, thereby helping men with prostate cancer get through the bewildering process of choosing a treatment program that best meets their needs.

The first part of the book provides a comprehensive explanation of what the prostate is, how it works, and what can go wrong with it. Chapter 1 offers a brief anatomy lesson, describing the function of the prostate and the male reproductive organs. It also covers common prostate problems, including benign prostatic hyperplasia (BPH), prostatitis, and, of course, prostate cancer.

Chapter 2 describes the diagnostic blood test known as the PSA (prostate-specific antigen) test, which changed our understanding of prostate cancer. Partly as a result of this new test, prostate cancer came "out of the closet" as men began to discuss openly their experiences with this disease. In addition, this chapter covers other tests used to identify prostate cancer at its earliest stages.

If a man learns he has prostate cancer, he will be referred to a specialist for treatment. All doctors have biases in treatment; chapter 3 can help you understand your doctor's biases so that you can choose the right physician to manage your treatment. Every doctor will work toward your complete recovery, but you must understand that the experts have honest differences of opinion about how to treat prostate cancer.

As a man progresses through the medical establishment, he will learn about how prostate cancer is staged and graded. Chapter 4 describes the various scores and measurements for prostate cancer. These scores measure the aggressiveness of the cancer, which is an essential factor to consider when choosing among treatment options.

The middle section of the book describes treatment options. Chapter 5 covers traditional treatments; chapter 6 highlights experimental treatments that may not be familiar to some doctors. Experimental treatments are usually available only in clinical trials, which raises the issue, covered in chapter 7, of whether should you participate in one.

This book will help you make treatment decisions every step of the way, but chapter 8 will pull together this information and help you put together your own treatment plan. It will help you assess the likelihood that your cancer has spread elsewhere in your body, and which treatments may be most effective.

The final section of the book covers steps you can take that may help prevent prostate cancer (or its recurrence if you already have the disease) and avoid benign prostate disease. Chapter 9 covers natural remedies, including herbs and nutritional supplements. Chapter 10 describes the potential role of a balanced diet in reducing your cancer risk. Men with close relatives who have had prostate cancer face a greater risk of developing the disease; chapter 11 describes steps your loved ones can take to lower this risk as much as possible.

Finally, it is important to know that millions of men share your situation. Chapter 12 describes how you can find a support group, which can be an outstanding source of information and emotional support for you and for your family members.

BEFORE YOU BEGIN

When making decisions about your medical care, you should openly discuss all matters with your physician or physicians. Use the information here to open dialogue about treatment options and about possible changes in your diet and lifestyle to help prevent cancer. Do not begin using any herbs, nutritional supplements, or other over-the-counter products without informing your supervising physician. Some of these natural remedies can interfere with test results or cause unwanted side effects. Your physician must remain fully informed of all steps you are taking to combat this disease and improve your prostate health. The best way to end up with a treatment program that will suit your individual needs is to work with your health care provider.

Chapter 1

It's Time You Got to Know Your Prostate: Understanding the Organ and What Can Go Wrong with It

Most of my patients—even well-informed men—don't know where their prostate is or what it does. Of course, they are familiar with their external sex organs, such as their testes and penis. They know about semen and ejaculation, but they aren't sure exactly where the ejaculate comes from. The prostate is a neglected organ; men don't usually think about it—and they don't really need to—until something goes wrong.

Unfortunately, many men will someday learn about this "hidden" organ when they experience prostate disease or prostate cancer. Each year, more than 1,000,000 men are diagnosed with a prostate disease, and another 180,000 with prostate cancer.

In general terms, there are three potential prostate problem areas: benign prostatic hyperplasia (BPH), prostatitis, and prostate cancer. In this chapter, I will explain the function of the prostate in the body and review the most common noncancerous problems that can arise. The material in chapters 9, 10, and 11 will help you treat and prevent these conditions. Prostate cancer will be discussed in the remaining chapters.

UNDERSTANDING YOUR PROSTATE

The prostate is a walnut-shaped organ sandwiched between the bladder and the rectum. It performs several functions in the body:

• The prostate produces most of a man's semen or ejaculate fluid. Semen consists of sperm (produced in the testes), prostatic fluid (produced in the glandular tissue of the prostate), and seminal vesicle fluid (produced in the seminal vesicles, which are attached to the prostate). Seminal fluid nourishes the sperm and helps it survive and move through the acidic environment in the vagina. As figure 1.1 shows, a tube, known as the vas deferens, joins the prostatic urethra. During orgasm and ejaculation, the sperm passes from the testes to the prostatic urethra, where it mixes with the clear fluid secreted directly into the urethra by the prostate and the seminal vesicle. This mixture then passes through the urethra and out the end of the penis.

• The prostate helps pump fluid out of the penis. The prostate switches into gear during the early phase of sexual excitement, before ejaculation takes place. During orgasm, the muscles in the prostate squeeze the fluid out of the glandular tissue and into the urethra; the same muscular contractions pump the fluid mixture out of the penis. (The prostate is about 70 percent glandular tissue and 30 percent fibromuscular tissue.)

• The prostate helps protect a man's urinary tract from infection. (The word prostate comes from the Greek word for "protector.") Prostatic fluid may help neutralize and wash away harmful bacteria that may enter the urethra.

Figure 1.1 As this illustration shows, the prostate (located just below the bladder) is surrounded by a number of other organs and vulnerable structures.

LIFE WITHOUT A PROSTATE

The prostate is an expendable organ; a man can live without it. Surgery to remove part or all of the prostate is sometimes recommended when a man has prostate cancer or certain forms of benign prostate disease described later in this chapter. Because the prostate is surrounded by a number of critical arteries, nerves, and muscles, prostate surgery leaves a man vulnerable to impotence, incontinence, and other complications.

If a man has his prostate removed and remains potent, he will probably experience a reduction in overall semen volume, or "dry ejaculate." In other words, he will feel the sensation of orgasm, but little fluid will be produced. Sperm may be present, but almost never enough to impregnate a woman, although it can happen.

While complications of prostate disease can be significant, most men do not need to face these issues until later in life. From birth until puberty, the prostate grows very little. At puberty, the prostate usually doubles in size, reaching a weight of about one ounce. In most men, the prostate then remains unchanged for the next few decades. After age forty, however, most men experience some degree of prostate growth that can lead to BPH (see below). The more significant problem as men enter this stage of life is not prostate cancer, but other complications.

BENIGN PROSTATIC HYPERPLASIA (BPH)

Benign prostatic hyperplasia (BPH) is so common that it is often considered an inevitable part of growing older. According to estimates by the American Foundation for Urologic Disease, more than half of men age fifty and above have enlarged prostates. The number steadily increases with age; by eighty, about 80 percent of men have prostate enlargement, and many will need treatment.

In simple terms, BPH is the medical term for a prostate enlargement that leads to the decreased flow of urine through the prostatic urethra, a tube that passes through the center of the prostate, allowing urine to drain from the bladder out through the penis. Where the urethra connects to the bladder, there is an external sphincter—a circular muscle that allows a man to start and stop urinating at will. At another location within the urethra is the internal sphincter, a similar muscle that operates involuntarily to stop semen from flowing back into the bladder during ejaculation. If the central region of the prostate becomes enlarged, it can press against the urethra, blocking the flow of urine. This can cause painful or difficult urination; it causes men to have trouble voiding completely or to feel the frequent need to urinate.

Figure 1. 2 These drawings depict a healthy prostate and one with BPH.

When men detect urinary or prostate problems, most will visit their family doctor or internist first. Based on the severity of the problem, patients might be referred to a urologist. Some physicians base their diagnosis strictly on prostate size, classifying BPH in all men with enlarged prostates (more than forty grams in size). Most physicians, however, use the designation only when a man experiences some degree of functional impairment in the flow of urine, regardless of the size of the gland.

Diagnostic methods include a family medical history, a questionnaire known as the International Prostate Symptom Score sheet, uroflowmetry, ultrasound, residual urine measurement or post-void residue, urodynamic studies, and cystoscopy.

Family and personal medical history. This should include a detailed medical history and a physical exam. It is very important for your doctor to know your entire medical history. For example, an injury to the urethra (from having a catheter inserted into the bladder during a surgical procedure, perhaps) can create a urethral stricture—scar tissue that narrows the urethra—that has nothing to do with the prostate, but can mimic BPH or even very advanced prostate cancer that blocks the urethra. Blood in the urine or pain in the bladder could point to a bladder tumor or kidney stone.

International Prostate Symptom Score questionnaire. You may be asked to score the degree of your symptoms—and how much they bother you—on a questionnaire called the International Prostate Symptom Score (I-PSS) sheet (See Appendix A) The American Urological Association has developed this questionnaire to assess the severity of BPH and to measure treatment outcomes from the various treatments. Each question is answered on a scale that runs from 0 (not present at all) to 5 (always present). The sum of these questions results in a BPH symptom classification of 0 to 7 (mild), 8 to 19 (moderate), or 20 to 35 (severe).

The last question of the questionnaire is perhaps the most important: How much do the symptoms bother you? This is critical because BPH is not life threatening. All of its treatments are directed at relieving symptoms, which means the symptom score will be the main basis for selecting therapy. The big question is up to you: Could you live the rest of your life this way? Are you changing your life? Planning your day around trips to the bathroom? Or fatigued because you have to get up so many times at night to go to the bathroom? If not, you may want to delay treatment.

Uroflowmetry. This test measures the speed of your urinary stream and the amount of urine you pass. It is conducted as you urinate, using a device somewhat like a radar gun used to measure baseball pitchers' throws. To ensure an accurate result, it's important that you urinate at least five or six ounces. This test can identify men whose maximum flow rate is minimally diminished and may not benefit from treatment, or men who have a great deal of resistance to the passage of urine and are very likely to benefit.

Ultrasound. This is a painless imaging technique. It works by creating a picture with high-frequency sound waves, like sonar on a submarine. It can be performed from the outside, through the abdomen, or transrectally, using a wand inserted in the rectum. Though not recommended for most men with BPH, ultrasound may be helpful in diagnosing such problems as obstruction of the kidney, stones, or a hidden tumor in the upper urinary tract; in estimating how well the bladder is emptying; and in determining the size of the prostate.

Residual urine measurement. If you are not emptying your bladder completely, this important test will show you exactly how much urine you're leaving behind. This can be done indirectly, by an ultrasound examination of the lower abdomen immediately after you urinate, or directly, by inserting a small catheter into the bladder and measuring urine quantity after you completely urinate. If you have large amounts of residual urine, your doctor may suggest that you seek treatment to avoid chronic urinary tract infection, improve your quality of life, or avoid damage to your kidneys or bladder.

Urodynamic studies. Your urologist may want to do these studies if there is evidence that the primary problem is with the bladder, not the prostate. Cystometry is a way to measure bladder pressure and function. It's performed by threading a tiny catheter into the penis, through the urethra, and into the bladder to monitor pressure changes as the bladder is filled with water. Pressure-flow studies, using a small catheter, check bladder pressure as you urinate. In these tests, pressures within the bladder are compared to the rate at which urine is flowing. This can determine whether men with high peak urinary flow rates have obstruction. Imagine squeezing water out of a balloon with a small opening; the water will flow if you squeeze hard enough, but generally under high pressure.

Cystoscopy. This test, usually performed in an outpatient setting, is somewhat uncomfortable but usually not painful. A cystoscope is a slender, lighted tube (often flexible) that works like a periscope. It is inserted in the tip of the anesthetized penis, and threaded through the urethra into the bladder; this allows the urologist to see the bladder, prostate, and urethra, and spot anything abnormal, such as a stone, stricture, or enlargement. With cystoscopy, your doctor may also be able to see thickened muscle bands in the bladder. Like rings in a tree trunk, these tell a story—that a condition or bladder obstruction has probably evolved over months or even years. Cystoscopy can also be used to rule out other conditions, such as the presence of a bladder stone or bladder tumor. If your doctor wants to biopsy your prostate or bladder during cystoscopy, it is necessary to have more than local anesthesia. This is called an operative cystoscopy, as opposed to the office cystoscopy, and is performed in an operating room setting.

BPH stems from an enlargement of the prostate, specifically within the area traversed by the prostatic urethra called the transition zone. The enlargement might be the result of an increase in the size of the glandular (epithileal) cells. BPH can also stem from a constriction of the smooth muscle or stromal cells within the transition zone. These two different processes may occur to different degrees in the same patient.

BPH Symptoms

Many men have BPH before experiencing symptoms. In many cases, the bladder muscles will compensate for the restricted urine flow by working harder to push the urine out. (This can cause hypertrophy, or increase in size, of the detrusor muscle in the bladder.) It may be years before the prostate is enlarged enough to create noticeable symptoms.

Common symptoms of BPH include:

• Urinary frequency (an increase in the number of times you urinate that is not caused by excessive drinking or diabetes).

• Urinary urgency (the feeling that you have to pass urine often).

• Nocturia (waking up to urinate one or more times during the night).

• Hesitancy or difficulty in starting urination.

• Decrease in force of the urine stream.

• Incomplete emptying (feeling that there's more urine left in the bladder after you've finished urinating; this symptom is usually caused by actual urinary retention, which occurs because the urine remaining in the bladder toward the end of urination does not have the force necessary to shoot itself through an obstructed urethra).

• Dribbling or trouble shutting off the urine stream.

• A burning or painful sensation during urination.

• Pain during ejaculation.

• Problems achieving erections.

Some men develop severe symptoms before the prostate enlarges significantly, while others fail to show symptoms even when the organ has grown well beyond normal size. If you experience any of the symptoms of prostate disease, visit your doctor. The vast majority of cases involve benign enlargement. In fact, it has often been noted that these symptoms are not typically the result of prostate cancer. It is, however, important you make sure that the retention of urine does not result in urinary tract infections or damage to the bladder muscle.

BPH Causes

No one knows the exact cause of BPH. I suspect that BPH, like so many other medical conditions, is caused not by a single factor but by a combination of triggers working together.

Although higher levels of testosterone can result in prostate enlargement, testosterone level changes have not been noted in patients with BPH compared to unaffected men. Also, levels of testosterone tend to decrease as men age.