September is the official Prostate Cancer Awareness month, however November has become equally if not more effective in driving the message home thanks to the Movember movement. Millions of men worldwide (known as 
Mo Bros) will start the month clean-shaven and then grow a mustache to raise awareness, fund research and combat men’s health related issues including prostate and testis cancer.
Prostate cancer is the second most common cancer diagnosed in American men after skin cancer. This year, the American Cancer Society estimates 238,000 cases will be diagnosed in the United States with about 30,000 deaths related to the disease. About 1 in 6 men have the risk of being diagnosed in their lifetime.
The prostate is a walnut-sized gland located between the bladder and rectum that produces seminal fluid to protect sperm and is needed for fertility purposes. Contrary to a common misconception, the prostate is not required for the production of male hormones such as testosterone. It isn’t entirely known what causes prostate cancer. Some prostate cancers may be inherited and caused by DNA mutations while others may be related to hormones, environment, or diet. The older a man is, the higher his risk of prostate cancer. African-American men have higher incidences of the disease than American men of other ethnicities. Rates for getting prostate cancer increase if a person’s father or brother has the disease. In addition, some researchers have linked the cancer to a high-fat diet.
Prostate cancer develops slowly and may cause few, if any, symptoms. Most urinary symptoms related to prostate growth are due to benign enlargement occluding the flow of urine and not cancer per se but if a tumor does enlarge rapidly it could also cause difficulty with voiding. Other symptoms include painful ejaculation, and low appetite/weight loss. When prostate cancer spreads outside the prostate, there can also be continual bone pain due to the spread of cancer to areas outside the prostate such as bone or lymph nodes.
Prostate cancer is diagnosed through a biopsy, or the extraction of tissue with a needle. They are indicated if a man has an elevated blood test for prostate specific antigen (PSA) or an abnormal digital rectal exam (DRE). There has been great controversy on the utility of PSA and DRE utilized in population based screening because of conflicting results in the pivotal trials studying their effectiveness in reducing death. What is known for sure is that thanks to the efforts of early screening, in more than two-thirds of men diagnosed with the disease, the cancer is confined to the prostate. Furthermore, Prostate cancers found through common screening tests are, on average, smaller and more contained than cancers discovered when the patient notices symptoms.
We believe that men should be well informed of the risk for having prostate cancer and the associated potential side effects from work-up and treatment. Through a informed decision making process we recommend annual PSA tests for men starting at age 50 (or at age 40 if any of his close relatives have had prostate cancer or if they are of African American descent). Since it may take many years to see the benefits of screening and treatment of prostate cancers, we usually do not recommend screening for men who have a life expectancy of less than 12-15 years.
The treatment (if any) depends on many factors including their age, life expectancy, extent of disease, other health conditions, and the patient’s expectations from therapy. Although there are numerous options, the mainstay of therapy for disease that is confined to the prostate includes active surveillance, surgery and radiation while therapy for more advanced disease involves hormones to block the body’s testosterone and/or chemotherapy. In the area of active surveillance, we now utilize updated MRI technologies and molecular markers analyzing genetic changes in the biopsy to better decide who is an ideal candidate for continued surveillance versus proceeding with definitive treatment. Advancements in radiation therapy utilizing shorter courses/image guided therapy and the use of minimally invasive robotic assisted surgery have both lead to significant reduction and prevention of some of the side effects associated with conventional treatment including incontinence (loss of urine control) and impotence. While the challenges for us as physicians taking care of patients with this cancer remain how to accurately identify and cure aggressive disease while avoiding over-treatment of indolent or non-significant disease, the continued advancements in research and the advent of new technologies have certainly lead to great reduction in morbidity and overtreatment associated with this disease.
David Josephson, MD FACS
Robotic Surgeon and Urologic Oncologist
Tower Urology Institute of Minimally Invasive Surgery
Cedars Sinai Medical Office Towers