Prostate is a gland that is part of the male reproductive system, and contributes some quantity of fluid that makes up the semen.  Prostate cancer occurs when there is abnormal growth of cells of the prostate gland.

It is different from Benign Prostatic Hyperplasia which is non-cancerous enlargement of the prostate gland. This cancer is the most common cancer in men, in at least 112 countries and also the main cause of cancer deaths in about 48 countries.¹

It commonly affects men aged 45 to 70 years though can rarely occur from 40years of age or beyond 70 years.Globally, prostate cancer is estimated to affect 1 in every 8 men,² with black men being mostly affected.³

This cancer accounts for about 14% of all cases of cancer diagnosis made in Sub-Saharan Africa, and 12% of all cancer-related death in this region.^4,5 There is however, global evidence that morbidity and mortality associated with prostate cancer is reducing as a result of increased screening exercises.⁶

In this article, we shall discuss the risk factors, symptoms, types, diagnosis, prevention, treatment, effects on sexuality/fertility, and myths about prostate cancer.

Prostrate Cancer Risk Factors^7-17

Exact cause of Prostate cancer is not known, but certain factors make it more likely for people to develop the disease. These factors include;

• Family history: About 5 – 10% of Prostate Cancer cases could be associated with history of father, siblings or a close relative having been diagnosed with the disease in the past
• Age: Chances of having Prostate cancer increases with age. Generally, men that are above 50 years of age and 40 years old black men/men with positive family history are more at risk.
• Race/Ethnicity: Lowest incidence of Prostate cancer is seen among Asians, followed by white men; while black men have more cases of the disease.
• Tobacco Smoking: In addition to being a risk factor for Prostate cancer, tobacco smoking is also implicated in causation of about thirteen other cancers
• Excessive alcohol consumption: Excessive intake of alcohol is not good for health. Some researchers have shown that in addition to being implicated in the development of prostate cancer, it is also a risk factor for many cancers and other non-communicable diseases such as hypertension and diabetes.
• Obesity: It is accumulation of excessive body fat resulting in somebody’s weight being above Body Mass Index of 30. Commonly caused by overeating and physical inactivity. Very well-known risk factor for Prostate cancer and other non-communicable disease.
• Unhealthy diet: Diet rich in saturated fat, excessive consumption of red meat and dairy products are implicated in prostate cancer. Adequate consumption of fruits, vegetables and diet rich in vitamins help in preventing prostate cancer. Tomatoes-based foods are particularly helpful. Healthy diet is key to preventing obesity too
• Physical inactivity. Sustained physical exercises are very helpful in preventing prostate cancer. Advised to start slowly and improve. This also helps to fight obesity, and prevent other non-communicable diseases

Family history, age, and race/ethnicity are non-modifiable risk factors; which means that the individual has no control over whether they would ultimately lead to prostate cancer or not.

On the other hand, tobacco smoking, alcohol consumption, obesity, unhealthy diet, and physical inactivity are modifiable risk factors; implying that adoption of healthy lifestyle could contribute to one’s ability to prevent prostate cancer disease.

Prostate Cancer Symptoms^2,7,18

It commonly does not present with any symptoms at early stage, hence the compelling need to make a diagnosis of the disease before it becomes symptomatic. Usual symptoms include;

• Difficulty in passing urine/urinary retention: The man has urge to urinate, but the urine is not coming out as usual, or simply not coming out at all
• Frequent urination: The patients go to urinate many times, but only able to pass very small quantity of urine
• Painful urination or ejaculation: Passing urine is associated with pain, and ejaculation during intercourse is also occasionally associated with pain
• Poor stream of urine: Urine flow is much reduced. In some situations, the urine could be dropping on the patient’s feet. The usual force used in voiding urine is significantly diminished
• Hesitancy: The patient goes to pass urine, but spends some time waiting for the urine to come out
• Terminal dribbling: Some quantity of urine remains after voiding, leading to continuing seepage of urine through the penis
• Blood in urine or semen: Occasionally, noticing blood in urine or semen after intercourse; might be the first abnormal occurrence noticed by a Prostate cancer patient. Some other health conditions could also lead to this
• Erectile dysfunction: Erectile Dysfunction (ED) occurs when a male is unable to achieve adequate erection of the penis during sexual intercourse. This commonly could be as a result of psychological problems, but could also be due to Prostate cancer. It is important to see a doctor for evaluation of the problem
• Low back pain: This symptom in Prostate cancer cases is usually a worrisome one, since it commonly indicates that the cancer cells have spread beyond the prostate gland, and attacked the pelvic bones

Types and Stages of Prostate cancer^2,8,9,19

Most cases of prostate cancer are Adenocarcinoma, arising from the secretory cells of the prostate gland. Other rare types are; Small cell carcinomas, Transitional cell carcinomas, Neuroendocrine tumors, and Sarcomas.

Staging gives information on whether, and where the cancer has spread outside the prostate gland. It is based on clinical assessment of the patient, investigations, and intra/postoperative findings. Two types of staging commonly in use are;

1. Clinical staging which is based on Direct Rectal Examination, PSA result, Gleason score. Findings from above will determine whether further investigations such as X-rays, ultrasound, CT scan, bone scan, and MRI would be helpful. Gleason score is graded from 6 to 10 over 10. Score of 6 over 10 is interpreted as low risk cancer, score of 7 over 10 is intermediate/moderate risk cancer, while scores of 8 – 10 are high risk cases. Clinical staging guides the doctor in planning the best management options for the patient.
2. Pathologic staging which is based on findings during surgery and postoperative histology result of the specimen removed.

Findings on the Tumour, lymph Nodes, and Metastasis are used in the staging system. The acronym TNM is used for this. (T) reports on the size of the primary tumor, and which part of the prostate gland it is located, (N) gives information on whether the lymph nodes have been affected and to what extent, while (M) reports on the spread of the cancer cells to other sites outside the prostate gland.

 Results from clinical and pathologic staging are used to categorize the disease into 4 stages viz;

• Stage I: Cancer localized only in the prostate gland, Gleason score of 6 and PSA result of not more than 10ng/mL
• Stage II: Cancer cells still within the prostate and Gleason score of 6 or 7, but with PSA result of between 10 and 20ng/mL.
• Stage III: Cancer has spread to nearby tissues such as seminal vesicles, but still no lymph nodes involvement, but high PSA value
• Stage IV: Cancer has spread to other parts of the body such as bones. Regional and distant lymph nodes are now involved.

The American Joint Committee on Cancer (AJCC) TNM staging system further broke down these 4 stages to sub-stages. Doctors use this staging system to decide on the best form of management for the prostate cancer patient.

Diagnosis of Prostate Cancer⁷

Definitive diagnosis of Prostate cancer is made through histological report of a biopsy specimen. This biopsy procedure is usually ultrasound-guided. The initial steps and investigations done prior to the ultrasound-guide biopsy are;

• Digital Rectal Examination (DRE), where the doctor inserts his/her gloved finger into the anus of the patient, to feel the size and consistency of the prostate gland
• Prostate Specific Antigen (PSA) assay to determine if it is above the upper limit of 4ng/mL. Values that are above 4ng/mL are not diagnostic of prostate cancer. Other conditions such as infection/inflammation of the prostate gland, and benign enlargement of the prostate (BPH) also could lead to elevated PSA value. The doctor will usually conduct further investigations to determine cause of the raised PSA value.
• Ultrasound examination to check the size and possible suspicious portions of the prostate gland
• In confirmed cases of prostate cancer, in addition to routine laboratory investigations; other investigations such as Computed Tomography (CT) scan, Magnetic Resonance Imaging (MRI), and Positron Emission Tomography (PET)-CT STUDY are conducted to determine the extent of spread of the cancer cells, and decide on the best treatment option.

Prevention of Prostate Cancer^7,18,19

Emphasis on Prostate cancer prevention is mainly on primary level and secondary level prevention activities.

1. Primary level prevention

This approach uses Health Promotion activities, such as Health Education to make people adopt behaviors that do not predispose them to developing cancer of the prostate.

Such behaviors include not smoking, not drinking alcohol excessively, not eating unhealthy diet, and being physically active through regular exercises. Mass media and social media can also be used for these health promotion activities.

2. Secondary level prevention

This is focused on identifying prostate cancer early, and commencing treatment immediately. This usually is done through Digital Rectal Examination as stated earlier, or Prostate-Specific Antigen (PSA) assessment.

It is recommended that every man gets screened for the first time not later than 50 years of age for white men, and Asians. But black men and persons who have positive family history should start as early as 40 years of age.

PSA is the common screening test, and should be repeated every 2 years for persons with result that is below 2.5ng/mL, and every year for persons with result of 2.5ng/mL and above; but below 4.0ng/mL.

Persons with results above 4.0ng/mL MUST see an Urologist, who will further assess him.  Urologist is a surgeon that specialized on male reproductive system and urinary system generally. You may discontinue regular PSA screening at the age of 70 years if everything is OK, but continue to be watchful for symptoms.

3. Tertiary level prevention

This involves limiting the disability associated with prostate cancer disease, rehabilitating, and providing palliative care for persons who are already afflicted.

Successful implementation of primary and secondary levels of prevention is key to ensuring that people do not need the tertiary level of care.

Treatment of Prostate Cancer^2,7,19

Treatment usually depends on the type and stage of the cancer, among other factors. The patient and the doctor should discuss treatment options, and a plan agreed upon. Management and treatment options include;

• Active surveillance: This option may be used if the cancer has low Gleason score, and is slow-growing. Surveillance entails monitoring PSA level, conducting ultrasound and biopsy every one or two years. It could be used if the patient is still desirous of having children.
• Watchful waiting: It is used for old and frail patients, on whom the doctor may consider any active treatment option more hazardous. It concentrates on managing the symptoms of the patient and conducting less frequent investigations.
• Surgery: Prostate cancer surgery could be;
  • Radical Prostatectomy: This implies complete removal of the prostate gland and surrounding tissues including seminal vesicles and lymph nodes. In the past it was done through large abdominal incisions, but less invasive and more advanced technology surgery is now available, especially in developed countries and some middle-income countries. This is robotic radical prostatectomy done through small abdominal incisions. This robotic surgery is usually nerve sparing, thus enhancing return to sexual activities post-surgery, and preventing urinary incontinence post-surgery.
  • Orchidectomy, in which the testicles of the patient are removed. This is usually done for patients whose cancer has spread outside the prostate gland and surrounding tissues, and affected the bones. The aim is to grossly reduce the production of male hormones which are known to aid the growth and spread of the cancer. It is usually effective in guaranteeing 5 years survival rate for patients with low and moderate risk prostate cancer.
• Radiation therapy: This involves using radioactive substances to kill the cancer cells. This can be done through the use of;
  • Internal radiation, where the radioactive substance is placed within the prostate gland, thus limiting undesired effects on surrounding tissue. It is also known as Brachytherapy.
  • External radiation, where radioactive beams are directed at the cancer focus from outside the body. Special machine is used for this purpose.
• Chemotherapy: Some drugs are used in the treatment of prostate cancer, especially in cases where surgery might be delayed or the cancers cells have spread to other parts of the body. In cases where the cancer disease is advanced, and spread outside the pelvic region, the drugs are commonly given in cycles. These drugs can be given orally or through injections. They have different ways of action such as preventing the growth, and killing the cancer cells, androgen deprivation, or immunotherapy that helps restore the patient’s natural immune system to fight the disease.
• Focal therapy: This method targets only the portion of the prostate gland that is affected by cancer. It is a newer approach to treating prostate cancer. Examples of focal therapy are; cryotherapy, and laser ablation. In cryotherapy, extreme cold is used to destroy the cancer cells; while in laser ablation, very thin beam of light that produces high energies is used in removing cancer cells from the prostate gland.
• Palliative care: In situations where the prognosis is bad and it is clear that the patient does not have much time to live, the attending medical personnel ensure that the patient is as comfortable as is possible during his last days. The disease is usually associated with severe pains during this period, hence strong pain-relieving medications such as narcotic analgesics, and tranquilizers are used.

Effects of Prostate Cancer on Sexuality and Fertility^2,18,19

Prostate cancer disease and all the treatment options commonly, adversely affect sexuality and fertility; though these effects can be ameliorated. The prostate gland and associated seminal vesicles produce fluid that mix with sperm cells, and aid transportation into the female vagina during sexual intercourse.

Cancer reduces production of this fluid, and also could lead to inability to achieve and sustain adequate erection for sexual intercourse.

Erectile nerve which is responsible for achieving penile erection has contact with the prostate gland; hence it can be damaged in the course of treating the patient by use of drug, radiation or surgery.

Nerve sparing surgical procedure, such as Robotic Radical Prostatectomy is now advocated, in order to minimize erectile nerve damage during surgery, and enhance quick restoration of sexual function. Drugs used for chemotherapy, exert their action on the prostate gland, reducing its functionality.

Ability to achieve conception is reduced for prostate cancer patients, especially after surgery and the other forms of treatment. The current remedy includes banking sperm before radical prostatectomy and directly harvesting sperm cells from the testicles for artificial insemination.

Some medications that enhance penile erection are available, though the affected individual achieves orgasm, he usually does not ejaculate semen. Vacuum devices, independent or in combination with medication can also be used to achieve penile erection.

With nicely performed nerve sparing robotic radical prostatectomy, good erectile function could be restored within two years if the man practices penile rehabilitation exercises such as the use of vacuum devices. Exercises and good nutrition also assist in restoring erectile function.

In addition to the reproductive health complications associated with radical prostatectomy, urinary incontinence commonly follows. This however resolves quickly or after about six to twelve months, if nerve sparing surgery was used.

Myths and Misconception about Prostate Cancer^20-24

There are certain myths and misconceptions that ultimately lead to increased morbidity and mortality associated with prostate cancer disease. This misinformation is untrue and should be discountenanced.

• Runs only in families: Only about 5 – 10% of Prostate cancer cases are linked with previous close member of the family having had the disease. Other risk factors such as lifestyle certainly play more significant role in the causation of Prostate cancer
• Affects only old men: Though the prevalence is more, among men aged 60 to 70 years, the disease can affect men as young as 40 years of age, and those that are 75 years and beyond.
• Must be symptomatic: In many cases, prostate cancer symptom is an indication of advanced disease. Chances for cure and survival are higher if the disease is detected before it becomes symptomatic.
• Always slow growing: There are different grades and stages of prostate cancer. The rate of growth depends on the type of the prostate cancer. Diseases with Gleason’s score of 8 to 10 are high risk types, and could be very aggressive.
• Surgery usually ends one’s sex life: Recovery of sexual function by radical prostatectomy patients depends on whether the surgery was done through nerve-sparing surgery (Robotic Radical Prostatectomy), or manual open abdominal radical prostatectomy. Sexual function could return completely within two to three years post-surgery, if it was nerve-sparing operation. The patient is usually encouraged to embark on penile rehabilitation post-surgery, by using vacuum devices, and certain drugs. However, sexual function return in cases of open abdominal surgery is usually slower. Penile rehabilitation exercises are also recommended.
• Can be sexually transmitted: Prostate cancer disease is a non-communicable disease, and cannot be transmitted through sexual intercourse.
• Persons who ejaculate 21 times in a month can never have Prostate cancer: Some researchers have suggested that increased sexual activities and ejaculation help in preventing prostate cancer disease. A study that involved about 32,000 men in 2016 showed that men who ejaculated 21 times or more every month had about 20% lower chance of developing low-grade prostate cancer, when compared with men who had less than 4 to 7 ejaculations per month. Another study a year later did not find strong evidence to prove this. It is important for men to screen for prostate cancer disease as recommended, irrespective of their ejaculatory frequency.
• Frequent sexual activity can cause prostate cancer: Some researchers have found frequent sexual activity beneficial to prostate health. It has not been shown to be a risk factor in prostate cancer causation.
• Prostate cancer biopsy may cause spread of the disease: Prostate cancer biopsy in trained hands does not cause spread of the disease. It is usually ultrasound-guided, with small bites of prostate tissue taken from suspicious sites
• Prostate biopsy negatively affects sexual life: Prostate biopsy usually does not affect the erectile nerve, and hence does not affect sexual life directly. Any Erectile Dysfunction following biopsy can only be psychological
• Surgery leads to the spread of the disease and hastens the patient’s death: In trained hands, surgery does not lead to the spread of the disease. The aim of radical prostatectomy is to remove the cancerous prostate gland before the disease spreads to other parts of the body. Orchidectomy (removal of the testicles) is a palliative surgery that aims to reducing the quantity of male hormone in circulation, hence reducing the growth of the cancer cells.

Message From The Community Positive Health Attitude Initiative Team

Prostate cancer is preventable, and completely curable if detected early.   We love you, and your family/friends love you too. You still have so much to contribute to the happiness and wellbeing of your loved ones and humanity generally.

Please go now, and get screened for Prostate Cancer. It is currently ravaging the male folk. Do not say “IT IS NOT MY PORTION”. It certainly can be anybody’s portion!

References

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Prof Eddy Ndibuagu

edndibus@gmail.com      

+2348032618211