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What is Prostate Cancer?

Posted Aug 24 2008 1:49pm
PAUL MONIZ: I'm Paul Moniz. Thank you for joining us on this webcast. Today we are talking about prostate cancer, a subject every man needs to know about. It is the second leading cause of cancer death among American men, second only to lung cancer. And it does not discriminate.

Here to discuss what prostate cancer is, and how it is diagnosed, are two specialists in the field. To my left we have Doctor Daniel Shasha. He is an Assistant Professor of Radiation Oncology at the Albert Einstein College of Medicine, which is affiliated with the Beth Israel Medical Center. Thanks for joining us.


PAUL MONIZ: Next to him we have Doctor Robert Salant, who is an Associate Professor of Urology at the NYU School of Medicine.

Doctor Salant, let's begin with you. What is the prostate, first, for those in our audience who don't know.

ROBERT SALANT, MD: The prostate is an organ that every man has, that is located just below the urinary bladder. The function of the prostate is to supply some of the fluid material in the ejaculate, which is the semen that supports the sperm. This is required to give the sperm an energy source, as well as a proper environment in which to live until it fertilizes the egg.

When a man turns forty, the prostate begins to grow. When the prostate grows, it can do either of three things: grow and give no symptoms at all; grow and compress the tube called the urethra where the urine flows through, creating symptoms of blockage; or grow and become cancerous.

PAUL MONIZ: So, does it grow in every man? In other words, take me through even a healthy person, a healthy man, thirty; a healthy man, sixty. The sixty-year old is always going to have a larger prostate?

ROBERT SALANT, MD: In general, when a man turns forty the prostate will begin to grow. And it will grow in just about everybody. That does not mean everybody will experience symptoms related to the prostate growth. Here is a model of the prostate with the bladder, the urethra where the urine flows through and the prostate. As a man grows, the prostate expands and not only outwardly, but puts pressure on the tube, called the urethra, causing resistance to the urine flow and symptoms of urinary blockage. This is benign prostate growth.

The prostate may also develop cancer. Cancers, at least at the very early stages, tend not to have any symptoms whatsoever.

PAUL MONIZ: So, for people who are at home experiencing no symptoms, thinking that they probably shouldn't even worry about this, you would say what?

ROBERT SALANT, MD: I would have to tell them that if you're above the age of 40, you need to have your prostate examined at least once a year.

PAUL MONIZ: How common is this? Let's bring Doctor Shasha into this. How common is prostate cancer among men?

DANIEL SHASHA, MD: It's too common. It is a disease that I tell my patients, if you're lucky enough to be a man, or unlucky enough to be a man, and if you're lucky enough to live long enough, statistically, you're going to develop a prostate cancer.

Doctor Salant and you have both said that it is a silent developer, and that is the case. Where we are most commonly finding prostate cancers now is at the earliest stage, which we're very grateful to see, as our ability to cure cancers in the earlier, silent stages is much better than in later stages of the development of disease.

PAUL MONIZ: What causes prostate cancer? Do we know?

DANIEL SHASHA, MD: We don't really know. Several factors have been implicated. The most commonly implicated factor is just being a man. Testosterone and promotion of cancer cells. A cancer is simply the unchecked growth of a cell that has the potential to grow locally. But eventually a piece of that cancer, a seed of that cancer may break off and go elsewhere in the body and spread to grow in other parts of the body, causing damage and symptoms elsewhere. So, cancers can do two things: they can grow locally and progress within the prostate gland, as Doctor Salant just demonstrated, causing symptoms of obstruction; or they can spread elsewhere to the body in more advanced stages of the disease.

PAUL MONIZ: Doctor Salant, what about the role of heredity? If an uncle, a father, a brother, has had prostate cancer, does that make you more susceptible?

ROBERT SALANT, MD: There are certain known risk factors for developing prostate cancer, which would put a person in a higher-risk group. Number one, African-American men have a higher incidence of prostate cancer, as well as developing prostate cancer at a younger age.There's plenty of overlap between the white population and the African-American population, but, as a group, the cancer tends to be more virulent and also occurring at a younger age in the African-American population.

This is very important in terms of screening for prostate cancer and getting the message out to the African-American community. Certainly, by the age of 40, they should all be screened for prostate cancer.

In terms of heredity, if somebody has a father or an uncle who has had prostate cancer, they too are in a higher-risk group for prostate cancer, and must be extra-careful about screening for prostate cancer and have a rectal examination done at least once a year, starting at the age of 40, in addition to blood testing for prostate cancer.

PAUL MONIZ: So, it's crucial that they begin the process early.

ROBERT SALANT, MD: Absolutely.

PAUL MONIZ: Men would generally think that the higher their testosterone level is the more virile they are, the more of a man they are. But in this particular instance, it may not be so, in terms of it being healthy.

DANIEL SHASHA, MD: As it relates to prostate cancer, there may be a detrimental effect.

PAUL MONIZ: What percentage of men are in this high category, Doctor Salant, in terms of their testosterone?

ROBERT SALANT, MD: It has never really been documented that a higher testosterone level leads to a higher level of development of prostate cancer. These are theoretical considerations. So, having a high testosterone, in and of itself, will not necessarily lead to a higher risk of development of prostate cancer.

We do know, however, that the presence of testosterone does, "fuel the fire" and allow a prostate to continue to develop.

PAUL MONIZ: Doctor Salant, case scenario: a patient comes in, has no idea what a prostate is, calls it a "prostrate." What do you say to this patient? You have some models there. What do you show them about the prostate? What do you tell them?

ROBERT SALANT, MD: Well, depending upon the patient's age, if the patient is above the age of 40, the first thing I will do while obtaining a history is to talk a little bit about what a prostate is, and what its use is in the body, and then what can go wrong with the prostate once the age of 40 is reached. We do have some models here. I showed an earlier model of a normal-appearing prostate and its relationship to the urinary bladder and the urethra.

PAUL MONIZ: Now, we should point out, this is a cross-sectional view. Is that right? It's basically split in half.

ROBERT SALANT, MD: This is actually a longitudinal view.


ROBERT SALANT, MD: What you see here in this prostate model is a focus of cancer here on the right side and another focus on the left side. But what's of real interest is, if we were to turn the model around and look at the back of the prostate, this is the portion of the prostate that is felt with a digital rectal examination. And what you notice, in the area where those cancers are located, there's a bump on this side in the left lobe and another bump here in the right lobe.

Part of the screening test for prostate cancer is a digital rectal examination. And when this exam is done, one of the things that the physician is evaluating for is an abnormality in the shape of the prostate, which often goes along with prostate cancer.

PAUL MONIZ: That's one of the diagnostic tests. Also, a PSA. Can you briefly tell us what that is?

ROBERT SALANT, MD: PSA is prostate-specific antigen. It is a chemical that is produced by prostate cells, both normal and abnormal cells. When the prostate grows, the PSA may rise. Prostate cancers produce a higher level of PSA than do normal prostates. Therefore, a measurement of the PSA may indicate an abnormal process going on in the prostate gland itself. The most worrisome, and the one you are most concerned about, would be prostate cancer.

PAUL MONIZ: If someone has a high PSAof greater than 20, you suspect that this cancer may be metastasizing. What does that look like in the advanced stages? You have a model all the way to the right that shows us the advanced stage?

ROBERT SALANT, MD: This model shows, again, the bladder and the prostate. If you notice, on this side of the prostate, almost the entire portion on this side is involved in tumor. Not only is it growing in the prostate, but it is actually extending into the urinary bladder itself. If we turn the model around, there is a huge abnormality in the left lobe of the prostate, which would be easily felt by the examining physician.

PAUL MONIZ: How long would it take someone to get to that point?

ROBERT SALANT, MD: Most likely, on the order of several years.This is not something that would have developed over the course of a couple of weeks to a couple of months.

PAUL MONIZ: All right. Some very good information. I appreciate it. Doctor Daniel Shasha, I appreciate your time. And Doctor Robert Salant, as well.

Thank you for joining us on this webcast. It is important to understand that screening is crucial, especially if you are forty in a risk group, or fifty if you are not in a risk group. As some of the doctors have mentioned here, these cancers can be detected early, but some 40,000 American men die each year because in many cases their cancers have spread.

I'm Paul Moniz, thanks for joining us.

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