Q:  Why has prostate cancer suddenly become so prevalent?

Dr. Green: Primarily because of better education of physicians, allied health care professionals, and the population in general about the malignant potential of the prostate, the development of the prostate cancer screening blood test Prostate Specific Antigen (PSA), and the aging population.

Q:  What causes prostate cancer?

Dr. Green:  We do not know what causes prostate cancer.  What we do know is that the potential for prostate cancer increases with age, that it occurs more frequently in African-American men, that it occurs in families, and that it can kill.  We also know that if detected early it can be cured.

Q:  What is the role of PSA in prostate cancer detection?

Dr. Green:  PSA is currently primarily a marker for prostate cancer.  PSA is prostate specific and not cancer specific.  PSA can be elevated from an enlarged prostate, prostate infection or inflammation, urethral catheterization, cystoscopy, or prostate cancer but not from digital rectal examination (DRE).

Q:  Is it enough to have a yearly PSA test only to screen for prostate cancer?

Dr. Green:  No.  The greatest yield in detecting prostate cancer is with PSA and DRE.  If either one is abnormal then transrectal ultrasound with needle biopsy of the prostate should be done.

Q:  What does a high PSA level mean?

Dr. Green:  PSA levels, prior to any treatment as measured with the Hybritech technique, are considered normal from 0.0 - 4.0 nanogram per milliliter.  In general, the higher the level (barring infection, inflammation, instrumentation, etc.) the more suggestive of cancer outside of the prostate.  However, there is a significant overlap of PSA such that one cannot completely rely on it for staging of prostate cancer.  Again, no absolute criteria exist and marked overlap in serum values from stage to stage is common.  It should be noted that prostate volume and grade can alter the staging criteria.  For example, men with prostate cancer and a large prostate can have high serum PSA without cancer extending beyond the prostate and those with a high grade (deranged cell structure) may not have an elevated PSA.  We have seen prostate cancer in men with normal PSAs and men with elevated PSAs that have no evidence of cancer in their prostates.

Q:  What other ways do you use PSA?

Dr. Green:  The least controversial aspect of PSA is its utility for monitoring treatment, i.e., its use as a "marker" of tumor presence or growth.  For example, post surgery, radiation, or hormonal treatment for prostate cancer.

Q:  I heard that prostate cancer grows slowly and that I should ignore it... is that true?

Dr. Green:  There are multiple factors that influence prostate growth.  We presently do not know all of them.  There are some prostate cancers that are "latent" (slow growing), and may or may not affect your lifespan if left untreated.  There is risk in this group of patients because at present we are unable to predict with certainty which of these cancers are truly latent and which are not.  Obviously, treating latent cancer is unnecessary; however, missing a curable cancer could lead to death from withholding treatment.  What we do know is that in general the larger the cancer the worse it is, the higher the grade (cell disorganization) the worse it is, and if it extends beyond the prostate it is worse.  In general, an elderly male 75 years or older with a low grade, prostate-confined tumor probably has a "latent cancer."  A young male 40 years of age, or less, with a high grade cancer of high volume, probably has an "active, aggressive cancer."  However, none of this is absolute and thus prostate cancer is "no chip and easy putt".  While some prostate cancers may be as meek as a lamb, others can buck like a bull.

Q:  What is PSA velocity and density?

Dr. Green:  Recent data suggest that a serial rise in serum PSA (PSA velocity) greater than 0.75 ng/ml/year is predictive of prostate cancer several years in advance of clinical disease.  PSA density (PSA/volume) has been utilized to differentiate benign prostate enlargement (BPH) and cancer of the prostate from those with BPH only.  However, this test has not been consistently reliable.

Q:  How do you treat prostate cancer?

Dr. Green:  This is a decision that is jointly reached by the patient, the patient's family, and myself after clinical staging has been done (determine the extent of the cancer, i.e., whether it is confined to the prostate or whether it is outside of the prostate).  In general, if a patient has prostate-confined cancer and is physically fit as determined by his referring physician and/or consulting physician, he is offered surgery or radiation.  If the cancer is outside of the prostate then he is offered hormonal therapy either via removal of testes or monthly parenteral shots of hormone manipulating medicines (LH-RH agonist) and oral anti-androgens.  If the cancer does not respond to the above, chemotherapy is considered.

Q:  What does the future hold for prostate cancer?

Dr. Green: In order to more effectively treat clinically significant prostate cancer we need to fully know its natural history, and we need more specific and accurate detection tools and clinically effective treatment at minimal medical risk to the patient.  Due to the fact that our aging population is living longer and healthier, we need to restudy the actuarial survival rates for healthy 70-year-old males and not arbitrarily deny them curative prostate cancer treatment when appropriate.  Life expectancy actuarial tables suggest that a healthy seventy-year-old man can be expected to live approximately eleven years, i.e., until age 81.

Q:  Who's at risk?

Dr. Green:   About one man in 11 men suffers from prostate cancer.  It recently overtook lung cancer as American men's most commonly diagnosed cancer.  For unknown reasons, African-American men have the highest rate of prostate cancer in the world.  Because the causes of prostate cancer are not well understood, prevention is difficult.  However, two factors are known to increase risk:

• Age.  The rate increases as men age.  About 80 percent of all prostate cancers are diagnosed in men over 65.
   
• Race.  African-Americans have the highest rate in the world.

Suspected factors but not proven:

• Family history.  It's unclear whether this is due to genetic or environmental factors.
   
• Diet.  Dietary fat may play a role.
   
• Environment.  Men who work with cadmium are at slightly higher risk.
   
• Sexual partners.  Increased numbers of sexual partners and a high occurrence of venereal disease have been identified.

Q:  How does one diagnose prostate cancer?

Dr. Green:  A combination of a digital rectal examination (DRE) of the prostate and a simple blood test called prostate specific antigen (PSA).  If the rectal exam or the PSA is abnormal, then one should undergo a transrectal ultrasound (TRUS) of the prostate with needle biopsy of areas suspicious for cancer.  A biopsy is the only sure way to tell if cancer is present.

Q:  Is there a critical time period to diagnose cancer of the prostate?

Dr. Green: Early detection is crucial.  If cancer spreads to nearby lymph nodes, the spinal cord, or other organs, it may be too late to treat successfully.  All men over age 50 should have a DRE and PSA to screen for cancer of the prostate.  The majority of prostate cancers are silent, without symptoms.  There are some free prostate cancer screening clinics throughout most major cities conducted yearly, usually in the September-October time frame... look for them.

Q:  What are the symptoms of prostate cancer?

Dr. Green: Very often there are no symptoms in the earlier stages of prostate cancer.  When symptoms do occur they include some of the following:

• Frequent urination, especially at night.
   
• Difficulty starting urination or holding back urine.
   
• Inability to urinate.
   
• Weak or interrupted flow of urine.
   
• Painful or burning urination.

Q:  What treatments are used for prostate cancer?