September is National Prostate Cancer Awareness Month. As a urologist and a wellness advocate, prostate cancer is very dear to my heart as one who treats prostate cancer and is at risk for prostate cancer.
Prostate cancer is one of the leading causes of cancer-related deaths among men in the U.S. The burden of this disease is not only shared among patients, but also by their partners, relatives and friends.
My father, a retired urologist, was diagnosed with prostate cancer at age 66 and underwent curative surgery. He is currently 83 years old and thriving. For this reason, I have been diligent in seeing my internist annually for a prostate examination and a PSA blood test. Additionally, I have been proactive in pursuing healthy lifestyle measures to minimize my risk. I also take a medication to decrease my risk.
With the exception of skin cancer, prostate cancer is the most common malignancy among men in Western populations. There are an estimated 175,000 who will be diagnosed in 2019. Prostate cancer is the second leading cause of cancer death among American men, with an estimated 32,000 deaths in 2019. The good news is that in the population of men with prostate cancer, many more men will die with it than of it.
The three major risk factors for prostate cancer are age, race, and family history. The likelihood of developing prostate cancer increases with getting older, thought to be from accumulation of DNA mutations. With each decade of aging, the incidence of prostate cancer increases appreciably.
African-American men have the highest reported incidence of prostate cancer in the world, with an incidence of 1.6 times that of Caucasian men in the United States; additionally, mortality is more than double for African American men. On a worldwide basis, the highest incidence is in North America and Scandinavia and the lowest incidence is in Asia.
Prostate cancer tends to run in families, so if you have a strong family history of prostate cancer, it is important to be checked on an annual basis starting at age 40 with a PSA blood test and digital rectal exam. Risk increases according to the number of affected family members (the more affected, the higher the risk), their degree of relatedness (brother and/or father affected confer a higher risk than cousin and/or uncle), and the age at which they were diagnosed (relatives of patients diagnosed younger than 55 years old are at highest risk).
If you have a brother or a father with prostate cancer, your risk of developing it is doubled. If you have three family members with prostate cancer, or if the disease occurs in three generations in your family, or if two of your first-degree relatives have been diagnosed at an age younger than 55 years, then you have a 50% risk of developing the disease.
Prostate cancer is unique in that it exists in two forms: latent (evident on autopsy studies, but not causing an abnormal digital rectal exam or PSA), which is present in 60-70% of men older than 80; and clinically evident (causing an abnormal rectal exam or elevated PSA), which affects approximately one in six men in the United States.
Overall, men have an approximately 17% chance of being diagnosed with prostate cancer and a 3% chance of dying from it. This high ratio of prostate cancer incidence to mortality suggests that a portion of the cancers are minimal or indolent, non life-threatening conditions.
Most prostate cancers are detected on the basis of a PSA elevation. Widespread use of this simple blood test has resulted in the increased diagnosis of prostate cancer. Patients are being diagnosed at an earlier stage that often cannot be felt on digital rectal exam and are most often confined to the prostate, resulting in a reduction of deaths. This is compared to the pre-PSA era, when most cancers were detected on the basis of a palpably abnormal digital rectal exam and were at a more advanced stage at presentation.
Although screening for prostate cancer remains somewhat controversial, the observed trends in PSA-driven detection of prostate cancer at earlier stages and declining mortality where screening is common provide strong inferential evidence that screening is beneficial.
When detected early, prostate cancer is highly curable, with more than 90% of men diagnosed surviving at least 10 years. Even when not discovered early, it is a very manageable condition, as prostate cancer is relatively slow-growing. Most prostate cancers diagnosed at an early stage behave sluggishly in the initial years after diagnosis. However, in the long-term, local tumor progression and metastases may develop, so early treatment is an important consideration for men with a general life expectancy exceeding 10 years.
Localized prostate cancer typically causes no symptoms and is most often diagnosed by a biopsy done because of a PSA elevation, an accelerated increase in the PSA over time, or an abnormal digital rectal examination. 75% of all newly diagnosed prostate cancers are discovered through a PSA elevation or accelerated change in PSA over time. 25% of diagnoses are discovered by digital rectal exams.
It would be wonderful if we could prevent prostate cancer and it would certainly make my job as a urologist much easier. Unfortunately, we are not there yet—but we do know a thing or two about lifestyle measures that can be pursued to maintain health and wellness in general and to help mitigate the chances of developing prostate cancer in particular.
When Asian men (the ethnic group that has the lowest incidence of prostate cancer) migrate to Western countries and become “westernized” in terms of diet and lifestyle, their risk of prostate cancer increases substantially. Clearly environment plays a strong role in the genesis of prostate cancer and it is not just a simple matter of genetics.
An artery-clogging Western diet high in animal fat and highly processed foods and low in fruits, vegetables, legumes and whole grains is associated with a higher incidence of many preventable chronic health problems including cancer.
Adopt a prostate-healthy, colon-healthy, heart-healthy lifestyle by:
A healthy diet and lifestyle also helps you heal better if you are diagnosed with prostate cancer. Good nutrition and exercise helps in part by inhibiting oxidation and inflammation, factors that contribute not only to prostate cancer but also to conditions such as heart disease and osteoarthritis.
The presence of precancerous conditions many years before the onset of prostate cancer, coupled with the increasing prevalence of prostate cancer with aging, suggest that the process of developing cancer takes place over a protracted interval. It is estimated that it takes often more than a decade from the initiation of the initial mutation to the time when prostate cancer becomes clinically manifest with either a PSA elevation or an abnormal digital rectal examination. In theory, this provides the opportunity for intervention before the establishment of a cancer and there are several medications available that can decrease one’s risk for prostate cancer.
Prostate cancer is very prevalent in men, involving one in six men in the USA. When picked up on a timely basis via screening with the digital rectal exam and blood PSA test, it is eminently treatable and has an excellent prognosis, with only 3% of deaths in the USA attributable to prostate cancer. Furthermore, not every patient with prostate cancer needs to be treated and many cases can be followed with careful monitoring.
There are both genetic and environmental factors at work in the genesis of prostate cancer. We are not in control of our genetics, but we are in command of our lifestyle. Maintaining a healthy lifestyle can help mitigate our chances of developing prostate cancer.
Andrew Siegel, M.D., Urologist, Cofounder of The Private Gym, and author of the highly acclaimed book, Male Pelvic Fitness, Optimizing Your Sexual and Urinary Health.
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