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Renowned prostate cancer specialist Sheldon Marks offers the definitive guide for men concerned about or diagnosed with prostate cancer.

Prostate cancer is one of the most common cancers affecting American men, with over 186,000 new cases diagnosed in the United States annually; 1 in 6 men will be diagnosed with prostate cancer during his lifetime.

Since the third edition (2003), there have been significant changes in treatment and resources. Working with Dr. Judd Moul, the Chairman of Urology at Duke and one of the world’s top experts on prostate cancer, Marks provides the most up-to- date information on diagnosis, treatment, and common questions.

FOREWORD

I first met Sheldon Marks in the early 1990s and we immediately struck up a friendship. He asked me to write the foreword to the book and I agreed; at that time, I had no idea just how important and informative his book would be. Over the years through the first three editions, countless patients—both my own and those I met at conferences throughout the country—mentioned to me that they had Prostate & Cancer. I'm thrilled and honored to be a part of the fourth edition of this outstanding patient-friendly book.

Much has changed since the first edition of this book. Much of the research in prostate cancer has been a result of the U.S. Army's commitment to it, through both the Department of Defense Center for Prostate Disease Research (DoD-CPDR) and the Department of Defense Prostate Cancer Research Program (DoD-PCRP). I served as the director of the DoD-CPDR from its founding in 1991 to the time of my retirement from active duty in 2004. Both of these institutions have contributed a great deal to our current knowledge of prostate cancer; you'll find fruits of this research in this book.

One of the most critical changes has to do with PSA screening. In the early 1990s, we were still in the "Early PSA Era" when the impact of PSA screening wasn't fully known. Up to 20% of men presented with metastatic prostate cancer at first detection! In those "bad old days," it was not uncommon to see men come to us with back pain, leg weakness or even paralysis and soon find out that they were suffering with devastating advanced prostate cancer. Despite hormonal therapy, the prospects for two- to three-year survival were questionable—and five-year survival was rare. Compare this bleak picture with today's more "mature" PSA era when less than 2% of men have metastatic prostate cancer at first detection. This tenfold improvement is due to disease awareness and screening with the PSA blood test.

As I continue my career as the director of the Duke Prostate Center at Duke University Medical Center, I am optimistic and excited about the prostate cancer field. From a treatment perspective, prostate cancer surgery, prostate radiotherapy and prostate cryotherapy are very different now than they were when the first edition of this book was written. Although not perfect, radical prostatectomy is now much less associated with the dreaded complications of incontinence and impotence. Both the minimally invasive open as well as the robotic prostatectomy can be performed by experienced surgeons with much less bleeding, far fewer side effects and much shorter hospitalization than in the past. You'll find out more about these crucial procedures in the following pages. The prostate surgery performed by most urologic oncologists is far different today than in the not-so-distant past. Similar comments can be said of other techniques that have been vastly improved through better equipment and greater experience. There are other advancements you'll discover in these pages. Procedures such as high intensity focused ultrasound (HIFU) are on the horizon, as are better strategies for "focal therapy," and Dr. Marks addresses crucial questions about these. There have also been multiple advancements in medications; herein you'll find information about the latest FDA-approved treatments. The field is continuing to change and evolve; here, Dr. Marks gives you the most up-to-date information to help you and your loved ones make the best, most informed decisions regarding your health care.

Thanks to Dr. Sheldon Marks and his tireless efforts, patients and loved ones have a clear, concise and thorough resource. For men and their families facing a diagnosis of prostate cancer, Prostate & Cancer is invaluable.

JUDD W. MOUL, M.D., FACS
Professor of Surgery and Chief, Urologic Surgery
Director, Duke Prostate Center
Duke University Medical Center

DEDICATION

This book is dedicated to all the men and their families who courageously live the fight every day against their prostate cancer. Only they understand the battles that must be fought to win the war.

I also dedicate this book to the tireless efforts of all the men and women in research labs around the world who have dedicated their lives to finding new answers to the questions about prostate cancer, its prevention and its cures.

PREFACE

Prostate cancer continues to be a highly visible public cancer, often mentioned with the diagnosis of elected officials and celebrities. As more public figures have announced that they have cancer of the prostate, it has become a frequent news item and topic of discussion in many households throughout the country.

Prostate cancer has touched the lives of high-profile people such as presidential candidates Rudy Giuliani and John Kerry; golfer Arnold Palmer; Senators Bob Dole, Ted Stevens, Richard Shelby and William Roth; General Norman Schwarzkopf; Colin Powell and actors and entertainers such as Bill Bixby, Telly Savalas and Frank Zappa, to name a few.

More than 186,320 men were diagnosed with prostate cancer in 2008, and more than 28,660 men previously diagnosed will die as a result of it in 2008. Prostate cancer has become the most-diagnosed non-skin cancer in America and the second-leading killer of men. Articles appear in national magazines, questions are called in on radio talk shows and newspapers frequently report a new idea or breakthrough in the field of prostate cancer.

It seems the more we hear and read, the more confused we become. Even many primary-care doctors seem confused about whether prostate cancer is a significant disease and which treatment options are best, if any.

I believe that the fear of the unknown is the most overwhelming and traumatic result of all the confusion about this disease. Unfortunately, short of spending an hour or two in personal consultation with a urologist, there is really no complete and accurate source of information available.

There are numerous books on prostate disease in general, or on men's health, usually with a chapter on prostate cancer. These books often tell you what the author thinks you should know about prostate cancer. But the topic of prostate cancer is too important and too controversial to confine its discussion to just a few pages. There are many books about prostate cancer, but many of the patient's real questions are left unanswered. When the first edition of Prostate & Cancer came out in 1995, no one had any idea how much this book would be accepted and used around the world. Since then, many dozens of books have been written, often using the format or even pieces of this book. Yet none really seem to be as effective as this. In this fourth edition, I continue focusing on the questions and concerns that real people have. Too many books come across like lectures, often quoting confusing and unnecessary statistics and numbers. Others are simply personal accounts and opinions.

As the men's health expert for WebMD for more than five years, I have continued to answer questions and calm readers' fears through education and understandable facts.

Many of us will spend months researching a new car or weeks reading up on the latest lawn mower. But when it comes to our health and our bodies, many of us, especially men, are satisfied with a five-minute explanation of the problem. Some men will accept the doctor's recommendations without question. The choices we make will definitely impact on the quality of our remaining years and very possibly the length of our lives.

You have a right to understand exactly what is going on with your body, the treatment options you have and the long-term impact of the decisions you make about your care. This book will educate you and answer your questions about your prostate and cancer. It will give you what you need to be an informed consumer. It will enable you to take control and make the best decisions about your future that will affect your health and well-being.

At my patients' suggestion and urging, I have taken my notes and expanded them into this book to provide the basic information necessary for an individual to make an informed decision regarding the evaluation and treatment of prostate cancer.

Prostate & Cancer is intended to serve as a resource to give you a foundation for informed discussion about your health with your doctor. This book is not intended to replace your physician, who can individualize your particular situation while considering other factors, such as your general health, your family longevity and the specifics of your problem.

This book can't possibly cover all the details specific to you. Likewise, there is no way you should make decisions regarding your health based solely on my comments here. This book is written from my own personal experiences and is not intended as a comprehensive resource on the subjects. It contains my interpretation of current philosophies and controversies regarding cancer of the prostate. I have also brought together the latest ideas and cutting-edge research from world-class specialists, professional meetings and journals. This book is to be used to stimulate intelligent discussions and conversation with your doctors, and to get you to ask questions and seek out more information on the topics relevant to you.

The continued worldwide demand and positive feedback from physicians, nurses, patients and their families has led us to produce this updated and revised edition.

I wrote this book to empower and educate men and their families with questions about prostate cancer. If this book was given to you, please thank the friend, doctor or company that made it possible. Only through positive feedback will they continue to distribute and sponsor this book and other educational resources. If you have any thoughts or suggestions, we encourage you to let us know.

It is my sincerest hope that this book will answer many of your questions and thereby ease your fears so you can be your own best health advocate.

Knowledge is power.

SHELDON H.F. MARKS, M.D.
850 North Kolb Road
Tucson, Arizona 85710

Adjunct Assistant Professor
Department of Urology
Tufts University School of Medicine
Boston, Massachusetts

Clinical Associate Professor
Division of Urology
Department of Surgery
University of Arizona College of Medicine
Tucson, Arizona

ANATOMY AN D FUNCTION OF THE PROSTATE GLAND

The prostate gland, essential for reproduction, is one of those body parts that a man rarely thinks about—that is, until he begins to have problems or concerns. Over time and under the influence of normal male hormones, the prostate can enlarge or develop cancer.

To understand prostate disease and its impact, it is important to have a general understanding of the normal pelvic and genitourinary anatomy that are involved.

The function of the prostate gland is to add vital nutrients and fluid to the sperm. The prostate is a relatively small, walnut-sized gland that sits just below the urinary bladder in the bottom of the pelvis, surrounding the urethra. It is this position that can lead to difficulties later in life. As the gland enlarges from normal growth or from cancer, it can squeeze down on the urinary passage and make it increasingly difficult to urinate.

When fathering children is no longer a goal, the prostate no longer serves its main purpose.

When fathering children is no longer a goal, the prostate no longer serves its main purpose. However, the gland remains, and in the presence of normal male hormones, the prostate continues to grow until at some point it may cause problems.

PROSTATE CANCER CROSS-SECTION. Cross-section of prostate gland shows location of nerves and blood vessels, as well as prostate position next to rectal wall.

The prostate gland is actually a collection of tiny glands that secrete fluid encased as one organ. The outside of the prostate is surrounded by a thin capsule of compressed fibrous tissue. Outside the prostate is a layer of fat.

Behind the prostate, just a few millimeters away, is the front wall of the rectum. On each side of the gland are nerves and blood vessels. These nerves are all-important when we address the treatment choices for prostate cancer and problems that can occur.

The prostate is divided into right and left sides, called lobes. The tip of the prostate farthest from the bladder is the apex. The wider portion next to the bladder is the base. The front is called anterior, and the rear posterior.

Doctor's Note!

Over the years it has become clear to me that most men have absolutely no idea what their prostate is or where it is located. One of my patients, a retired engineer, had obviously done extensive reading before he visited my office. He was proud that he knew so much about his prostate. That is, until he asked me what the prostate did for women and why women didn't have prostate problems.... Sometimes a little information is just that, a little information.

PROSTATE DESCRIPTION. Side view of prostate gland shows terms used to describe the top (base), bottom (apex), front (anterior) and back (posterior).

PELVIC ANATOMY. Prostate is located immediately below the bladder in the pelvis. Seminal vesicles and the vas deferens from both testicles drain into the prostate.

UROGENITAL ANATOMY. Kidneys filter the blood and drain urine down the ureters into the bladder. Here it is stored before coming out the urethra, through the prostate.

The vas deferens is the tube that leads the sperm from the testicles and empties into the urethra inside the prostate. Fluid from adjacent glands called the seminal vesicles also drains into the prostate. These glands are next to the prostate and below the bladder. The testicles not only make the sperm but also produce the male hormone testosterone, which is delivered directly into the bloodstream. (See illustration above.)

The bladder sits above the prostate, in the bottom of the pelvis. It serves two purposes. First, the bladder is a container, or reservoir, for urine, so you can build up urine and empty when you choose to, rather than when it is created. The second function is to serve as the muscle that squeezes out the urine when given the necessary messages from your brain. Urine is made in the kidneys by filtering waste products from the blood. The urine then drains down the ureters into the bladder.

LYMPH DRAINAGE. Lymphatic fluid from the prostate drains into lymph nodes on both sides of the pelvis. Cancer in the prostate can follow this pathway and spread to these lymph nodes.

The urethra is the tube that leads from the bladder through the prostate, past the urinary sphincter and out the penis to the opening, called the urethral meatus.

The urinary sphincter, a collection of circular muscle fibers just below the prostate, helps to prevent leakage of urine when you cough, move or are physically active. Much of the control (called continence) of urine actually occurs at the bladder neck. There, all of the circular muscle fibers come together like a funnel.

Veins of the prostate drain blood out and up toward the heart alongside the spinal column. The lymphatics drain from the prostate to a number of small lymph nodes clustered along the wall of the pelvis on both sides.

What is the lymphatic system?

The lymphatics serve as the cleaning system for the body. All cells of the body are bathed by lymph fluid—clear, slippery fluid that sometimes oozes from scrapes or abrasions. This fluid is filtered through lymph nodes, where any impurities, germs or cancer cells are captured. The filtered lymph fluid then flows back into the bloodstream.

PELVIC ANATOMY, SIDE VIEW. Bladder sits behind pubic bone and immediately in front of rectum. Prostate gland is below bladder and surrounds urethra just as it leaves the bladder.

Noncancerous Prostate Enlargement (BPH)

For reasons still unclear, the prostate in most men slowly grows and increases in size. This growth, called benign prostatic hyperplasia, or BPH, is not cancerous. It can, however, seriously impact on a man's quality of life by causing blockage to the urine flow. This can result in a number of annoying and bothersome symptoms, such as frequent daytime and nighttime urination, dribbling and difficulty starting and stopping the urinary stream. (See the list of symptoms on page 38.)

For years, treatment options for BPH were limited. Most men who had the problem ultimately had surgery. During the past decade, however, new breakthroughs and advances have provided a wide range of options that can often reduce the symptoms without the risks and potential side effects of surgery.

Does having an enlarged prostate increase my odds of getting prostate cancer?

Having enlargement of the prostate (BPH) does not increase your risks for developing prostate cancer.

Do I need treatment if my prostate is enlarged but I don't have any problems urinating?

No, not usually. Unless your prostate is causing real problems with your bladder from incomplete emptying, infections or bleeding, you don't need any treatment.

What are the options for treating the symptoms of an enlarged prostate?

There are five basic options, each with definite advantages and disadvantages:

1. Doing nothing

2. Taking alpha-blocker medication (Hytrin, Cardura Flomax, Uroxatral or Rapaflo

3. Taking a 5 alpha reductase inhibitor (Proscar, Avodart) or saw palmetto

4. Having minimally invasive therapy—laser surgery, vaporization, thermal or microwave therapy

5. Having a standard surgical resection of the prostate

How is doing nothing a treatment choice?

You can always choose not to treat your symptoms. If you are not bothered much by blockage symptoms, then it may be reasonable just to watch and wait. You may find that you are doing better, staying the same or getting worse. Of course, if the symptoms do become a problem for you, then you should talk to your doctor about your other choices.

It is always interesting to talk to two men who have the same urinating problems. One may be miserable getting up twice each night to urinate, while the other is thrilled that he's not getting up more often.

What is an alpha-blocker?

This type of medication was originally used only for the treatment of high blood pressure. We knew this medication worked by relaxing a very specific type of muscle fiber found in the walls of blood vessels. We soon learned that these muscles are also found around the prostate and bladder base. When these muscles contract, they squeeze the urethra shut and can cause the annoying symptoms often associated with an enlarged prostate. When these muscles are relaxed by taking an alpha-blocker every day, the urethra and prostate open up. This can result in a rapid and dramatic improvement in urination.

What are the names of these alpha-blockers?

Hytrin (terazosin), Cardura (doxazosin), Uroxatral (alfuzosin) and Flomax (tamsulosin) are commonly used alpha-blockers for the symptoms of blockage. A brand-new medication, Rapaflo (silodosin), was released at the end of 2008.

The use of alpha-blockers over the past few years has eliminated the need for surgery for many men.

Do alpha-blockers work for most men?

The good news is that most men who try these medications will see a dramatic improvement in their urination, with a reduction of their annoying symptoms. This usually happens within a few weeks. I have been very impressed with how well most of my patients respond in a short time. A small number may not tolerate the medication or may not experience an improvement.

Does taking alpha-blockers for my prostate protect me from getting prostate cancer?

No. These are excellent medications to relax the muscles that squeeze the prostate, thus improving urination. For many men, these medications may eliminate the need for surgery. Taking them does absolutely nothing to reduce your risks of developing prostate cancer.

Are there any side effects from taking alpha-blockers?

In the first few days on the medication, some men may experience dizziness, light-headedness or fatigue, and on very rare occasions may faint. This can be prevented if you stand up slowly during the first few days as your body adapts to the medication. I mention this only as a precautionary note. These symptoms are less of a problem with Flomax, Rapaflo and Uroxatral, which are more selective third-generation alpha-blockers.

Do alpha-blockers interact with other medications?

Because these medications can also lower high blood pressure, it is important for you to coordinate with your primary-care physician or cardiologist, especially if you are already taking other medications for high blood pressure. Flomax and Uroxatral do not usually affect blood pressure. If you take a medication for erectile dysfunction, you should check with your doctor because the combination can cause a dangerous drop in blood pressure.

How do Proscar and Avodart work?

Proscar (finasteride) and Avodart (dutasteride), called 5 alpha reductase inhibitors, work by blocking the normal formation of male hormone byproduct in the prostate. This byproduct, called DHT, is a very powerful stimulator of prostate growth, far more powerful than testosterone. When DHT is blocked, the prostate may shrink in size and this shrinking can improve urination. As with alpha-blockers, if Proscar or Avodart are successful, you will need to take the medication daily as long as you want to have the benefits.

Does taking Proscar or Avodart reduce my risks for getting prostate cancer?

Studies suggest that yes, if you are at risk for prostate cancer, taking either of these medications can prevent prostate cancer development.

What are the side effects of Proscar or Avodart?

The side effects of Proscar or Avodart are primarily sexual, with about 4% of men describing impotence and less than 4% complaining of a reduced sex interest.

NONCANCEROUS PROSTATE TISSUE. A. Noncancerous prostate tissue (BPH) grows and compresses the urethra, resulting in urination difficulty. B. Following transurethral resection of the prostate (TURP), this nonmalignant tissue is removed, leaving the prostate capsule intact.

What are the benefits of taking Proscar or Avodart?

Proscar and Avodart have been shown to prevent serious complications and urinary retention as well as reduce the need for surgery for men with enlarged prostates. This is especially true if the prostate specific antigen (PSA) is greater than 1.7 or the prostate is larger than 30 cc (golf-ball size).

Can taking Proscar or Avodart cause problems?

There are some concerns that Proscar or Avodart may confuse the interpretation of the PSA level. This is because Proscar and Avodart can reduce PSA levels (see Chapter 6)—sometimes drastically—from 10% to 90% of what they actually are.

How does laser surgery work?

The urologist can use a laser to destroy the prostate tissue that is causing blockage. A laser is pointed into or placed in the tissue through the urethra. Usually performed under anesthesia, this operation can be performed as an outpatient procedure. The patient can return to work or normal activities the next day. The laser surgery is safe for on patients who are taking Coumadin (warfarin).

Are there any problems with laser surgery?

This is one of many treatment options; urologists are learning exactly what technique works best for each patient. Only time will tell if laser surgery is as effective as more standard surgery. Personally, I am very happy with results for the men I have treated with the laser. In the past it was my preferred treatment for prostate obstruction.

How is an enlarged prostate surgically treated?

The standard treatment for many years was always the TURP, or transurethral resection of the prostate. This operation is performed under anesthesia through a fiber-optic instrument. It requires no incision, and is very well tolerated with rapid recovery. A TURP is the gold standard against which all other treatments are compared.

Looking through the instrument that is placed up the penis, the prostate tissue that is causing the blockage can be seen. It is this tissue that is literally scooped out with the instrument, leaving only the shell of the prostate remaining. For very large prostate glands, urologists sometimes perform an operation through an incision in the lower abdomen (open prostatectomy), but this technique is less common. The tissue removed is examined to be sure no cancer is present.

Does having my prostate opened up with a TURP mean I don't have to worry about getting prostate cancer?

No. Even though the tissue causing the blockage has been removed, you are still at risk of developing prostate cancer in the rim of tissue left behind. You must get an annual evaluation and PSA blood test to be sure no cancer develops.

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On Sale: Jun 30, 2009
Page Count: 384 pages
Publisher: Da Capo Lifelong Books
ISBN-13: 9780738215648

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Sheldon Marks, MD

About the Author

Sheldon Marks, MD, is a specialist in prostate cancer. He received his training at Tufts University, the New England Medical Center, and the Mayo Clinic. He lives in Tucson, Arizona.

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