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Doctors frequently prescribe an inappropriate drug to men with early prostate cancer. Though the consequences of this treatment are severe, most men reported a high degree of satisfaction with their care. These paradoxical findings come from the first major study to look at the quality of life for men who were not treated surgically or with radiation therapy.

This study is an important contribution to the debate about whether the prostate-specific antigen (PSA) screening test for prostate cancer causes more harm than good. As its use increased dramatically over the last decade, so too has the diagnosis of early prostate cancer. The blood test is now routinely given to men with no symptoms, though studies show that most prostate cancers remain dormant an entire lifetime. Consequently, many men are treated unnecessarily. Previous studies of men with early disease who remained untreated showed that their prostate cancer death rate was similar to that of men given a prostatectomy. Neither the PSA test, nor any other, can accurately identify the minority of prostate cancers destined to be fatal. And there is no proof that treating the potentially fatal version at an early-stage saves lives.

There is a consensus among researchers, though not among urologists, that the decision to remain untreated is a valid choice. This used to mean: no treatment until symptoms occur (”watchful waiting”). But now it appears that many men who forego a radical prostatectomy or radiation therapy are being treated with a drug that stops their production of the male hormone, androgen. Known as androgen deprivation therapy (ADT), the treatment amounts to a medical castration, usually with the injectable drug, Lupron.

Lupron has been tested and proven useful only as a palliative treatment for men with advanced prostate cancer. A palliative treatment means that the drug can only alleviate symptoms. And now the drug is being prescribed for early-stage cancer in men without symptoms–at a great physical cost, according to the new study published recently in the Journal of the National Cancer Institute (3/20/02). “There is no definitive evidence that early ADT alone improves length or quality of life in men with clinically localized prostate cancer,” according to the study’s authors, Arnold L. Potosky, PhD, and colleagues.

All of the men who agreed to take part in this study had been newly diagnosed in 1994-5 with cancer that had not spread beyond the prostate gland. They are participants in a much larger project called the Prostate Cancer Outcomes Study (PCOS), initiated by the National Cancer Institute to investigate variations in the treatment of prostate cancer and to determine how the men fared afterward. Significantly, the PCOS is primarily following men who were treated at community medical practices, as opposed to a research-based cancer center. The participants include men under 60, as well as African-Americans and Hispanics, represented in higher proportions than white men over the age of 60.

Out of the PCOS database of over 3,000 men, Dr. Potosky and colleagues concentrated on the 661 who had not been treated with surgery, radiation, or cryotherapy (destruction of the gland by freezing it) and were followed for at least one year. They found that an astonishingly high proportion–37%–had been given ADT alone as their primary treatment, which was described as “an indication authoritatively endorsed nowhere in the medical literature,” by James A. Talcott, MD, in an editorial that accompanied the new study.

Compared with men who were just observed–that is, given no treatment, the ADT-treated men were five times more like to have breast swelling and hot flashes. Those who were sexually potent prior to ADT were more than twice as likely to be impotent afterward. The overall physical functioning and vitality tended to be poorer among the men given ADT.

Though no scientific evidence supports the use of ADT for preventing or delaying onset of symptoms, Potosky and colleagues were able to identify a rationale for the doctors’ prescription by going through the men’s medical records. The ADT-treated men were more likely to have palpable tumors, more poorly differentiated tumors and a baseline PSA values over 10 ng/dL. In other words, their condition at diagnosis was viewed as worse than men with non-palpable, well differentiated tumors and a PSA under 10 ng/dL. The characteristics of the ADT-treated men indicate that their cancers could have spread outside the prostate.

Though it seems logical to treat the men whose cancer might be slightly more advanced, it is illogical to prescribe a drug that can only relieve symptoms in men who have none. Surprisingly, despite the distressing side effects, more ADT-treated men (56%) reported that they were “pleased” or “delighted” with their treatment (56%) than men who decided to remain untreated (45%). Additionally, the ADT-treated men believed themselves to be free of cancer at a 12% higher rate.

Although the prostate-specific antigen (PSA) test has been in widespread use as a cancer screening tool for well over a decade, early detection and treatment remain clouded by unresolved questions. The argument over the value of PSA testing in asymptomatic men has been highlighted on several occasions in American Family Physician.

Updated prostate cancer screening guidelines(1) from the American Cancer Society are as follows: (1) The PSA screening test and a digital rectal examination should be offered annually to men, beginning at age 50, who have a life expectancy of at least 10 years. (2) Men at high risk should undergo initial screening at 45 years. (3) Before screening tests are conducted, patients should be given the opportunity to learn about the benefits and limitations of testing for early prostate cancer detection and its subsequent treatment.

The American Academy of Family Physicians supports the need to review with patients the appropriateness of screening for prostate cancer, recommending that men be made aware of the uncertain benefits of and the potential risks associated with screening.(2) The U.S. Preventive Services Task Force(3) does not recommend the use of PSA screening until available evidence indicates that the test saves lives.

Although the recommendations have not been changed, evidence now demonstrates that mortality rates and the incidence of advanced metastatic disease have substantially decreased since the onset of PSA-based prostate cancer screening. Whether this reduction is the result of PSA screening and the subsequent treatment of early disease can be argued; however, the recently identified decline in prostate cancer mortality in white men under 85 years of age to levels below those of the pre-PSA era, combined with a reduction in the incidence of distant disease, is highly suggestive of a positive effect of PSA testing.(4,5) Population-based studies(6,7) demonstrate a decline in mortality related to prostate cancer–apparently associated with PSA testing. A more definitive prospective randomized trial is in progress,(8) but the results will not be available for several more years. Meanwhile, the use of PSA screening continues to expand. As physicians, what are we to do?

We daily offer patients many preventive health interventions; for some of these interventions, effectiveness and mortality reduction are evidence-based (e.g., mammography) and, for other interventions, they are self-evident but not “proved” through randomized, controlled trials (e.g., Papanicolaou smears). Where in our busy schedule does the PSA screening test fit? How much discussion and education are appropriate? Patients no longer accept health care being dictated to them on a “doctor knows best” basis, but they still depend on us for guidance and direction. In light of the current state of the science related to the PSA test, our responsibility is to make our patients aware that the PSA assay is available and to help them understand the associated implications.

Patients should be helped to understand that the PSA assay is not specific for cancer, that some benign conditions can result in an “abnormal” level, and that some cancers may exist despite a PSA value within the normal range. The conversation should also include the “next steps” that would be necessary if the test result is abnormal, including referral for additional tests (e.g., ultrasonography, needle biopsy).

Discussing selection of therapy and choosing among various options, including watchful waiting, can be specifically framed only in the context of a known histologic diagnosis and tumor grade. Patients should, however, have a general understanding that any benefit associated with testing and a reduced risk of mortality from prostate cancer can be obtained only by use of treatment interventions that also have risks.

We should advise our asymptomatic patients when routine consecutive testing most likely will be of little benefit because of advanced age or the presence of serious comorbid conditions. We should advise patients of the need for vigilance when they are at increased risk (because of race or a family history of cancer) of developing or dying of prostate cancer. They should be aware that the PSA test can detect prostate cancer at an earlier and potentially more treatable stage and may improve their chance for survival. This is the essence of an informed decision.

It has been suggested that, given the limited time available to discuss preventive issues, we should focus our efforts on interventions with known efficacy. A decision on our part not to present patients with the option of PSA testing is tantamount to placing patients who may have asymptomatic prostate cancer into treatment with watchful waiting without their consent. However, this is not an informed decision, and the patient may not be pleased with the outcome.

While counseling is time-consuming, it seems that the best option is to provide patients with the most current information and allow them to select the best course of action. We are much more likely to have satisfied patients in the future if we make the necessary investment of time to allow them to participate in the decision-making process today.

Neurologic complications continue to pose problems in patients with metastatic prostate cancer. From 15 to 30 percent of metastases are the result of prostate cancer cells traveling through Batson’s plexus to the lumbar spine. Metastatic disease in the lumbar area can cause spinal cord compression. Metastasis to the dura and adjacent parenchyma occurs in 1 to 2 percent of patients with metastatic prostate cancer and is more common in those with tumors that do not respond to hormone-deprivation therapy. Leptomeningeal carcinomatosis, the most frequent form of brain metastasis in prostate cancer, has a grim prognosis. Because neurologic complications of metastatic prostate cancer require prompt treatment, early recognition is important. Physicians should consider metastasis in the differential diagnosis of new-onset low back pain or headache in men more than 50 years of age. Spinal cord compression requires immediate treatment with intravenously administered corticosteroids and pain relievers, as well as prompt referral to an oncologist for further treatment. (Am Fam Physician 2002;65:1834-40. Copyright[C] 2002 American Academy of Family Physicians.)

Prostate cancer is second only to lung cancer as the leading cause of cancer-related deaths in men.(1) Histologic evidence of prostate adenocarcinoma is present in 30 percent of men more than 50 years of age and in 70 percent of men more than 80 years old. About 9.5 percent of men will have a clinical diagnosis of prostate cancer in their lifetime, and 2.9 percent will succumb to this malignancy.(2,3)

Although most men with prostate cancer have asymptomatic, indolent disease, central nervous system (CNS) complications often occur with advanced metastatic disease(4,5) (Table 1).(4-6) CNS involvement may present as back pain caused by spinal cord compression resulting from bone metastasis via the paravertebral venous plexus or, less commonly, as headache or neurologic changes caused by the hematogenous spread of prostate cancer to the brain. Paraneoplastic syndromes, including neuropathies (sensory, peroneal, etc.), cerebellar ataxia, and limbic and brain-stem encephalitides, may also occur; discussion of these rare complications is beyond the scope of this article.(7,8)

TABLE 1

More Common Neurologic Complications in Patients with Metastatic
Prostate Cancer[*]

Complication
(incidence, %)      Clinical clues (incidence, %)

Spinal cord         Localized back pain
compression         (90 to 95)
caused by         Weakness (75 to 80)
metastasis (7)    Autonomic dysfunction (57)

Sensory changes (50)

Brain metastasis    No symptoms (?)
(1 to 2)          Headaches (34)
Motor deficits (26)
Altered mental status (23)
Seizures (8)

Complication
(incidence, %)      Treatment options

Spinal cord         Dexamethasone sodium phosphate (Decadron):
compression         16 to 100 mg administered as an intravenous
caused by           bolus; then 4 mg given intravenously four times daily
metastasis (7)      for 3 days; tapered over about 14 days
Morphine, hydromorphone (Dilaudid),
fentanyl (Duragesic), or oxycodone
(Roxicodone) for pain management
Oncology referral

Brain metastasis    Dexamethasone, as above, if magnetic
(1 to 2)            resonance image shows edema
Anticonvulsants (not as prophylaxis, and
not phenytoin [Dilantin] if radiotherapy
is anticipated, because of the risk
of Stevens-Johnson syndrome with
concomitant treatment)
Oncology referral

? = unknown.

[*]–The rarer neurologic complications include paraneoplastic syndromes
such as peroneal neuropathy (peroneal nerve palsy related to local
metastasis), cerebellar ataxia, limbic encephalitis and brain-stem
encephalitis.

Information from references 4, 5, and 6.

Lesions in the brain and spinal cord require prompt treatment. Hence, family physicians need to consider metastatic prostate cancer in the differential diagnosis of new-onset back pain or headache in men more than 50 years of age.

Anatomy and Metastasis of Prostate Cancer

The pudendal nerve innervates the few striated muscles within the prostatic capsule. The parasympathetic nerves emanate from S2 to S4 and form the pelvic nerve. The sympathetic preganglionic nerves, which reside in the thoracolumbar region between T6 and L2, provide the major neural input to the prostate and reach the pelvis through the hypogastric nerve (Figure 1).

Prostate cancer has been shown to metastasize by following the venous drainage system through the lower paravertebral plexus, or Batson’s plexus.(4,9) Although hematogenous spread of other malignancies is most commonly to the lungs and liver, 90 percent of prostatic metastases involve the spine, with the lumbar spine affected three times more often than the cervical spine. Prostate cancer also spreads to the lungs in about 50 percent of patients with metastatic disease, and to the liver in about 25 percent of those with metastases.(4)

A 62-year-old man with androgen-independent metastatic prostate cancer that had failed to respond to multiple treatment regimens stopped all conventional therapy and began 10 mg/day of lycopene and 300 mg of saw palmetto 3 times per day. The prostate-specific antigen (PSA) level decreased from 365 ng/ml to 140 ng/ml after 1 month and to 8.1 ng/ml after 2 months. A repeat bone scan revealed an improvement of bony metastases. He has continued the lycopene and saw palmetto and has remained asymptomatic for an unspecified period of time.

Comment: Androgen-independent prostate cancer is difficult to treat and has a relatively poor prognosis. This case report, which demonstrates a partial remission, is therefore quite promising. The authors of the study attributed the benefit solely to the lycopene, since saw palmetto does not typically reduce PSA levels in men with BPH. However, it is not possible to rule out an anti-cancer effect of saw palmetto in this patient. Moreover, it is difficult to believe that such a small amount of lycopene, which can be obtained from less than 3 tablespoons of spaghetti sauce per day, could by itself have such a profound impact on a patient with advanced, treatment-resistant prostate cancer. Clearly, additional trials with these natural compounds are warranted.

Whether a therapeutic technique is the best prostate cancer treatment for a patient depends on various factors. In selecting the treatment, a patient and his doctor should take into consideration the patient’s age and expected life span, the stage and grade of the cancer, possible side effects and other health problems that the patient might have.

One of the best prostate cancer treatment techniques, particularly for older men and those who suffer from other serious illnesses, is the expectant management or watchful waiting method. Watchful waiting involves the close monitoring of the cancer through prostate specific antigen testing. It does not involve active treatments like surgery and radiation therapy and is recommended mostly to those who have no symptoms. It is also used when the cancer is contained within one area of the prostate gland and is expected to grow very slowly.

Another option available to prostate cancer patients is surgery. This can be radical retropubic prostatectomy, radical perineal prostatectomy, laparoscopic radical prostatectomy (LRP) or transurethral resection of the prostate (TURP). In retropubic prostatectomy, the surgeon makes an incision in the lower abdomen to remove the prostate gland. Lymph nodes around the prostate might also be removed depending on whether the cancer has spread to these parts. In perineal prostatectomy, the incision is made in the perineum or the skin between anus and scrotum. This procedure is use less often because the lymph nodes cannot be removed and there is a high probability that the nerves will be affected.

LRP, on the other hand, involves the use of several smaller incisions and specialized instruments. This highly complex procedure is known for its high precision and control. In the hands of experienced surgeons, it becomes an advantageous option compared with retropubic and perineal prostatectomy. TURP, meanwhile, makes use of an instrument called a resectoscope which is passed through the end of the penis into the urethra at the level of the prostate. The electricity that passes through the instrument cuts or vaporizes the issue in the prostate. TURP is done to relieve symptoms and is also used for benign prostatic hyperplasia.

Radiation therapy is the method in which high-energy rays or particles are used to kill cancer cells. This, like surgical procedures, is another example of a highly developed method of dealing with cancer. Radiation therapy is classified into two main types, the external beam radiation therapy (ERBT) and brachytherapy.

In treating localized prostate cancer, a procedure called crysosurgery is sometimes used. It involves the freezing of the tissues using very cold gases. Aside from cryosurgery, hormone therapy and chemotherapy are also options that prostate cancer patients can explore. Hormone therapy does not cure cancer but is primarily used to lower levels of male hormones in a patient’s body. Chemotherapy, meanwhile, is a procedure more commonly used in cases when the cancer has spread beyond the prostate gland.

Choosing the best prostate cancer treatment depends on a lot of factors. What is considered appropriate for one patient might not be good for another, that’s why options should be discussed in detail with doctors before proceeding to the treatment stage.

Cancer can attack any part of the body; lungs, stomach, reproductory organs and many other parts. A common form of cancer in men is testicular cancer. This is a cancer that occurs in the male sex glands in the scrotum. Testicles produce and store sperms while producing male hormones.

Testicular cancer is also known as germ cell tumor and is of two kinds - seminoma or nonseminoma. About 40% of testicular cancer are seminoma type and the other are divided into four sub-types; choriocarcinoma, teratoma, embryonal carcinoma and yolk sac tumors. The cancer can sometimes also be a combination of both cancers, and are called mixed germ-cell tumors.

Testicular cancer is prevalent in men aged between 15 and 35 and is more common in white men than Asians and blacks. The exact causes are still unknown, but there are various risk factors that can induce testicular cancer. Underdevelopment of testicles, Klinefelter’s syndrome where the man experiences sterility, small testes, breast enlargement and lesser male hormones and those who have had testicular cancer are all prone developing cancer on the other testicle in the 25 years after the attack.

There is nothing that can be done to prevent testicular cancer; the most that could be done is its early detection. Testicular self-exam is a great means of diagnosing testicular cancer; it is always better to test testicles immediately after bathing as this is when the scrotal sac is relaxed. The testicles have to be rolled between the forefinger and thumb for any signs of lumps.

Besides a lump, swelling in the testicles or some changes in the feel of the testicle are symptoms for testicular cancer. Accumulation of fluid in the scrotum or pain in the scrotum is also considered as symptoms of testicular cancer. Though these symptoms may signify other conditions, it is always better to have a physician evaluate the condition. Testicular cancer can also be diagnosed through ultrasound of the scrotum or a biopsy. Once testicular cancer is detected, treatment is rendered according to the extent of the condition.

Depending on whether testicular cancer is seminoma or nonseminoma, and its stage, is its treatment determined. All treatments involve the removal of the affected testicle. However, as this can affect fertility and sexuality, this has to be discussed with the family. With the removal of a testicle, the other testicle is capable of producing sperms and an erection so that it is possible to father a child.

However, any other surgery, radiation and chemotherapy also affect sperm production and ejaculation. So the treatment should be discussed before adapting it. In nonseminomas, the lymph nodes are also removed to find out the extent of tumor spread. However, this is not necessary in seminomas as CT scans provide sufficient information.

Radiation is preferable for seminomas, and not for nonseminomas as they are not sensitive to radiation. When giving radiation, the remaining testicle is usually shielded to prevent radiation reaching it as this may hamper its ability in producing sperms. Though sperm count may reduce after radiation, it returns to normal in a few years of treatment.

Chemotherapy is administered after surgery through injections or orally to kill any tumor cells there may be in the body. Whatever the treatment adapted, it is necessary to have follow up testing because there is always the chance of a recurrence of a second tumor. There are different follow up testing routines to be adapted; it all depends on the case.

There are approximately 25 000 men newly diagnosed with prostate cancer every year in the United Kingdom. For these men the risk of dying from their prostate cancer depends on a number of risk factors. For example if the cancer is confined to the prostate gland at diagnosis the chance of surviving to 5 years is 70%. If the cancer has already spread e.g. to the bones then only 20% of men will survive to five years. Of all the men who currently have prostate cancer in the UK approximately 10,000 will die of the disease each year. The prostate cancer survival rate is much higher in the developed world - unsurprisingly.

When a man is first diagnosed with prostate cancer then the doctor who has found the cancer (most often a “urologist” – a surgeon who specialises in looking after problems to do with the kidneys, prostate and bladder) will arrange a series of tests to help assess the risk for that individual patient. The results of these tests will in turn help the doctor and patient to decide the best treatment for that patient.