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Prostate cancer and men’s dilemmas  

Prostate cancer develops in the walnut-sized gland underneath the male bladder. It is the most common cancer, other than skin cancer and is the second leading cause of cancer-related death in men.
 
The disease, which often develops slowly, is different to most other cancers because small areas of cancer within the prostate are common, especially in older men and may not grow or cause any problems. This presents men diagnosed with prostate cancer with some extremely difficult choices.
 
The statistics
Prostate cancer is the second most frequently diagnosed cancer in men and the fifth most common cancer overall. One in six men will be diagnosed with the disease in their lifetime and the overwhelming majority of cases occur in wealthy countries.
 
Each year, about 37,000 men in the UK and some 210,000 men in the US are diagnosed with prostate cancer and more than 10,000 and 28,000 respectively die each year of the disease. In the US there are over two million men living with the disease and African American men have a higher incidence of prostate cancer and double the mortality rate compared with other racial and ethnic groups. In the US about US$10 billion is spent annually on treatments for the disease. 
 
Standard treatments
Traditional treatments to stop the spread of prostate cancer involve surgery and radiotherapy, which has significant side effects. Following such treatments 50% of patients experience impotence, up to 20% suffer incontinence and between one and five percent who receive radiotherapy experience pain and bleeding.  
The standard PSA test is imperfect 
In the UK there is currently no national screening programme for prostate cancer. However, in 2002 the Prostate Cancer Risk Management Programme was introduced in response to a demand for the prostate specific antigen (PSA) test among men worried about prostate cancer. The Programme provides information to men about the benefits and risks of the PSA test, which is available, free of charge, to men over 50.
 
PSA is a protein produced by normal cells in the prostate and also by prostate cancer cells. All men have a small amount of PSA in their blood and elevated PSA suggests prostate problems, but not necessarily prostate cancer.
 
The test is imperfect and is not good at detecting prostate cancer early. In some cases, it completely misses cancers while in others it reports cancer when it is not present. This can lead to some difficult choices for men.
 
A 2013 study in Radiation Oncology supports earlier findings and suggests that men over 70 are better avoiding the PSA test since men with high risk prostate cancer are more likely to die of causes other than the disease.
 
The imperfections in PSA testing led, in 2011, to the US changing its guidelines on prostate cancer screening to suggest that healthy men should not take the test because of the risk of over diagnosing. Despite efforts to improve the PSA test, it is still recognised as the best non invasive prostate cancer test available.
 
Some good news for sufferers  
A promising new therapy to treat prostate cancer is high-intensity focused ultrasound (HIFU). HIFU therapy is a treatment modality of ultrasound involving minimally invasive or non-invasive methods to accurately destroy tumours by effectively heating them while doing far less damage to surrounding tissue and avoiding significant side effects. 
 
A 2012 clinical study reported in The Lancet suggests that HIFU therapy offers prostate cancer patients a significantly better treatment option than traditional methods and can be completed in a matter of hours during an outpatient visit to a hospital.
 
Clinical HIFU procedures are typically performed in conjunction with an imaging procedure to enable treatment planning and targeting before applying the therapeutic levels of ultrasound energy. MRI guided Focused Ultrasound Surgery (MRgFUS) combines a HIFU beam that non-invasively heats and destroys targeted tissue with MRI scanning that visualizes a patient’s anatomy and controls the treatment by continuously monitoring the tissue effect. 
Some other encouraging new therapies for prostate cancer
Recently, a new drug, enzalutamide (Xtandi), developed by the prestigious American prostate research centre in UCLA, has recently been licensed for use in the UK for patients with an advanced form of the disease and who have run out of treatment options.  
 
Also, there are some new FDA approved vaccines. One is sipuleucel-T (Provenge), which is designed to boost the body’s immune response to the prostate cancer cells. Another is PROSTVAC-VF, which uses a genetically modified virus containing PSA to trigger a response in a patient’s immune system to recognise and destroy cancer cells containing PSA.
 
Nutrition and Lifestyle
According to the World Health Organization, wealthy countries with the high meat and dairy consumption have the highest prostate cancer rates. This has encouraged scientists to examine foods and substances in them that may reduce the risk of prostate cancer.
 
Researchers suggest that lifestyle changes might affect the rate at which prostate cancer develops. One study reports that the level of PSA may be lowered by a vegan diet, regular exercise and yoga. Another suggests that a daily intake of flaxseed slows the rate at which prostate cancer cells multiply. Also, scientists suggest that lycopenes and isolflavones, found in tomatoes and soybeans respectively might help prevent prostate cancer.
 
Difficult choices for men
Given that patients decide about their treatment options and given that there are several treatment modalities for prostate cancer each with specific costs and risks; men diagnosed with prostate cancer face some difficult choices.
 
One challenge arises because genes linked to prostate cancer do not show which cancers are likely to remain within the prostate, which is normal for older men and which are more likely to grow and spread.
 
For example, researchers have found that the gene EZH2 is more frequent in advanced stages of prostate cancer, but this does not indicate how aggressive the cancer is. So, knowing of the genes presence does not help a patient make the important decision between immediate treatments or continued monitoring.
 
 
Christopher Anderson
Consultant Urologist, Clinical Lead of the Robotic Surgery Unit and Lead Cancer Clinician at St George's Hospital, London.
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