The Prostate Cancer Dilemma
Roughly the size of a walnut and weighing about an ounce, the prostate gland is an unlikely candidate to create a major medical controversy. The prostate is located in front of the rectum and below the bladder and wraps around the urethra (the tube carrying urine out through the penis). Its primary function is to produce fluid for semen, the liquid that transports sperm. In half of all men over age 60, the prostate tends to enlarge, which may produce such symptoms as difficulty in urinating and frequent nighttime urination.
Enlargement of the prostate can happen for three main reasons: prostatitis (an inflammation of the prostate that is usually caused by an infection), benign prostatic hyperplasia (BPH), and prostate cancer. BPH is a noncancerous enlargement of the prostate that affects the innermost part of the prostate first. This often results in urination problems as the prostate gradually squeezes the urethra, but it does not affect sexual functioning. Prostate cancer often begins on the outer portion of the prostate, which seldom causes symptoms in the early stages. Each year, more than 200,000 men in the United States are diagnosed with prostate cancer; 35,000 die. For reasons we do not yet understand, African American men such as Moses have a 40% higher chance of getting prostate cancer. In addition, a genetic link is clear: A man whose brother has prostate cancer is four times more likely to get prostate cancer than a man with no brothers having the disease.
Part of the controversy surrounding prostate cancer relates to whether early detection reduces mortality from the disease. The American Cancer Society (2008e), the National Comprehensive Cancer Network (NCCN, 2007), and other groups have conducted aggressive campaigns to encourage men over age 50 (age 40-45 in high — risk groups) to undergo two diagnostic tests annually: the digital rectal examination (DRE, in which a physician examines the prostate by touch) and the prostate-specific antigen (PSA) blood test. In sharp contrast to clear evidence that early detection of breast cancer in women reduces mortality by at least 30% among older women, no similar statistics exist for prostate cancer. This lack of data led the U. S. Preventive Services Task Force, the Canadian Task Force on the Periodic Health Examination, and others to recommend abandoning routine prostate cancer screening because of the cost and the uncertain benefits associated with it.
The American Cancer Society and the National Comprehensive Cancer Network jointly created a guide to prostate cancer screening and treatment to help men negotiate the confusing
state of affairs (Version VI, completed in 2007, is available at http://www. nccn. org/patients/ patient_gls/_english/pdf/ NCCN%20Prostate%20Guidelines. pdf). Although not a replacement for physician input, the screening and treatment charts and decision tools can be very useful in sorting through the various options.
The sharp division among medical experts highlights the relation between carefully conducted research and public health policy. At present, there has been no systematic comparison of various treatment options (which include surgery, radiation, hormones, and drugs), nor do we fully understand the natural course of prostate cancer in terms of which types of tumors spread to other organs and which ones do not (American Cancer Society & National Comprehensive Cancer Network, 2007). Given that some of the side effects of surgery include urinary incontinence and impotence, and that some of the other therapies may produce other unpleasant effects, there is debate on whether the disease should be treated at all in most patients (American Cancer Society & National Comprehensive Cancer Network,
2007) .
At present, men who experience prostate-related symptoms are left to decide for themselves what to do.
Many men opt for immediate
132 CHAPTER 4
treatment and learn how to live with the subsequent side effects. Support groups for men with prostate cancer are becoming more common, and many encourage the patient’s partner to participate. The controversy
surrounding early screening and detection of prostate cancer is unlikely to subside soon because the necessary research concerning effective treatment and survival will take years to conduct. Until then, if you or
someone you know is over 50 or is in a high-risk group, the decision still must be made.
Talk at length with a physician who is up-to-date on the topic and educate yourself about the alternatives.
flow. This may occur when a person coughs, sneezes, or lifts a heavy object. Urge incontinence usually is caused by a central nervous system problem after a CVA or urinary tract infection. People feel the urge to urinate but cannot get to a toilet quickly enough. Overflow incontinence results from improper contraction of the kidneys, causing the bladder to become overdistended. Certain drugs, tumors, and prostate enlargement are common causes of overflow incontinence. Functional or environmental incontinence occurs when the urinary tract is intact but because of physical disability or cognitive impairment the person is unaware of the need to urinate. Iatrogenic incontinence usually is caused by medication side effects. Changing the dosage often solves the problem.
Most types of incontinence can be alleviated with interventions. Among the most effective are behavioral interventions, which include diet changes, relearning to recognize the need to toilet, and pelvic floor muscle training for stress incontinence (Zahariou, Karamouti, & Papaioannou, 2008). Certain medications and surgical intervention may be needed in some cases. Numerous products such as protective undergarments and padding also are available to help absorb leaks. All these options help alleviate the psychological and social effects of incontinence and help people live better lives (Burgio et al., 2001).