What is the Prostate?

Male Genital Anatomy

Above is a diagram of male genital anatomy.  The prostate is the beige circular structure below the bladder in the purplish color.  The prostate produces fluid that assists in ejaculation because the semen contained in the seminal vesicle is a very small amount.  The fluid of the prostate nourishes the sperm, protects them during ejaculation and forms a clot-like glob that sticks to the cervix and aids in reproduction.

What is the PSA test?

PSA stands for prostate specific antigen.  It is a protein-like substance produced normally by the prostate. It was discovered in 1970 by prostate cancer researcher Dr. Richard J. Ablin Ph.D. PSA is measured for many different reasons, some useful and some questionable. It was publicity about PSA and Dr. Ablin that prompted this article. The testing of PSA in the blood to screen for prostate cancer has been controversial for many years.  Measurement of PSA after the diagnosis and treatment of prostate cancer (the most prevalent form of non-skin cancer in men) aids in following the post-treatment progression and effectiveness of the therapy provided. Dr. Ablin for many years has said PSA should not me relied upon as a screening tool in the general population. Urologists vocally disagree. What is our risk of prostate cancer (men only of course)? What can we do to lower our risk and detect cancer early?

Who should be screened?

Screening is controversial in all but a few instances. If you have had a male relative that had prostate cancer before age 65, you should be screened starting at age 45.  If you have more than one male relative with early prostate cancer, screening should begin at age 40. If you are a man of color, you should be screened at age 45. This may be due to low vitamin D levels as it is in women of color who have increased risk of breast and colon cancer because of habitually low Vitamin D 3 levels. So early in life, say high school, men of color should be screened for low Vitamin D3 levels. Perhaps They should just begin regular supplementation with 1000 IU per day then and save the money – about $40 for the 25 OH VitD levels.

It is not clear that other men should be screened at all and almost certainly not before age 50. A digital rectal exam (DRE)

The dreaded DRE!

and PSA should be done baseline and then again in 3-5 years. If these are both normal, then probably not again until age 65. PSA values are not the same at all ages as the linked chart from Sloan-Kettering reveals. Some specialty hospitals allow men 70-75 to have a PSA of 5 but most studies think screening anyone over 70 not productive or cost effective. Why?  The over all, lifetime risk of prostate cancer in all American men is about 17% but the chance of dying of prostate cancer is 3.4%.  It seems there are two different forms. Dr. Ablin describes them as either a Rabbit or Turtle in a box. The turtle represents slow movement and no risk of getting out of the box. The rabbit is certain to get out if we take the lid off. We do not have a test to distinguish which one a man might have.

What should you do?

If you are white, under 50, have no family history and healthy (not over-weight, no other cancer, none smoker your whole life, regular exercise, no prescribed medication) then no screening is needed until age 50 at the earliest.  After age 50, your heritage (family history of prostate cancer, African-American, obesity, smoker, history of other cancers) and your preference/understanding come into play.  I think it is bunk to put the hard decisions on patients. If you are 50 and have a PSA screen of 4.0 or more, you would likely get set to a urologist for biopsy. Your Gleason score (a judgement by the pathologist reading the tissue from the biopsy) is likely to be low but if you only consult your Urologist you are likely to get surgery. You can find a recent study at the Archives of Internal Medicine.

The study entitled “Physician Visits Prior to Treatment for Clinically Localized Prostate Cancer” looked at 85 088 men(over age 65) with this diagnosis. 50% were only seen by their Urologist, 44% by the Urologist and a Radiation Oncologist, 3% by Urologist and Medical Oncologist and 3% by all 3 specialists. Only 17% visited a primary care doctor (PCP) – the person who did the screening test that led to the biopsy diagnosis.

Within 9 months of diagnosis, 21% got a radical prostatectomy, 42% got radiation therapy, 17% received hormone therapy, 20% were just observed and most of these visited their PCP during the decision process. It appears from the study that what specialist you visit dictates the therapy recommended.  I have always said that the person with only a hammer to solve problems, sees every problem as a nail. This study bears this out. There is no evidence that any therapy for this problem is superior to watching, yet 18000 men got a major operation that carries the risk of impotence and incontinence.

The moral of the story here seems to be to find your self a primary doctor that is well trained and younger than you by about 10 years. Visit that person regularly and give them every piece of your medical history. Insist that any specialist consult with your Doctor prior to any treatment they recommend or talk to your doctor about how you can communicate with them to discuss therapeutic recommendations by specialists.  Don’t be pound foolish here. Pay the person for their time. If they charge you an office visit that costs you $50 as your copay, count it as an investment in your health.

Don’t expect anyone in medicine to be perfect or to know it all.  You will get a perfect doctor when they get a perfect patient.  When it comes to prostate cancer, the odds are in your favor if you don’t have special circumstances. I think some screening is OK if it is most likely to yield good results. PSA screening is iffy and so is treatment of localized prostate cancer.

The best course is to not smoke, drink plenty of water, eat a diet that has lots of fresh green vegetables and just enough protein (I favor animal protein). Avoid processed food, especially grains and eat just enough most days to keep you well and able to do some physical work, (either exercise or hard manual labor to strengthen your muscles). Get enough sleep! Also take some instruction in controlling your response to stress. You do not manage stress, just your response (the link will take you to the first of two videos – watch #1). There is evidence that pure Pomegranate juice can lower your risk of heart disease and slow prostate cancer tumor growth, so drink some regularly.

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