Treating noncancerous growths
Every year, a gland the size of a walnut — a mysterious little organ tucked up under the bladder — goes bad and kills thousands of North American men. Millions of others suffer lesser wounds. Just why it runs amok has science, for the most part, baffled.
What is known is that the prostate, the male sex gland that produces the milky portion of semen, is the second leading cause of cancer deaths in men (after lung cancer). It can also fall victim to prostatitis — inflammation and/or infection, mostly in younger men — and enlargement, known as benign prostatic hyperplasia (BPH).
It’s estimated that half of all men over 50 and 80 per cent over 80 — some 1.2 million Canadians — have some degree of BPH. In fact, it’s the most common noncancerous growth in adult men after cataracts and the second most common reason for surgery.
The prostate is composed of glandular tissue, which secretes the seminal fluid, and smooth muscle, which contracts during sex, squeezing the fluid into the urethra, the tube that serves as a channel for urine and sperm. The prostate also effects changes on testosterone, a hormone produced by the testiclethat triggers physiological changes at puberty (body hair, deepening the voice, etc.), converting it to dihydrotestosterone, a potent hormone that affects the size of the prostate.
After puberty, the prostate remains relatively stable until about age 45, when it begins to grow again. If it grows too large, it causes problems, usually by constricting the urethra, which can cause urinary urgency and frequency, mild incontinence, a weak or interrupted stream and a feeling that the bladder hasn’t completely emptied. Urine that does remain in the bladder can cause urinary tract infections or kidney obstructions. In extreme cases, the urethra may become completely blocked, requiring emergency surgery.
In most men, BPH symptoms are mild to moderate, and they learn to live with them. They should, however, have an annual digital rectal examination, during which the physician inserts a gloved, lubricated finger into the rectum and feels the prostate for changes in size, or hard, lumpy areas, which could indicate cancerous growth. A urinalysis may be used to detect infections or tainted blood in the urine; a PSA test (see the story on page TK) may indicate early signs of cancer.
There are several anti-BPH medications, including finasteride (Proscar), to inhibit the rate of prostate growth, and alpha-blockers, which relax smooth muscle cells in the prostate and bladder neck, reducing pressure on the urethra. Finasteride may take six months to effect any change, but about three-quarters of patients experience moderate symptomatic improvement. Only two or three per cent suffer such temporary side effects as reduced sex drive, impotence and decreased fertility. Alpha-blockers improve symptoms by an average of 50 per cent within a month in up to 86 per cent of men, generally with few or only mild side effects.
A small proportion of men with BPH require surgery to reduce pressure on the urethra. There are three common procedures: TURP (transurethral resection of the prostate), TUIP (transurethral incision of the prostate) and traditional prostatectomy. TUIP is a relatively minor procedure, usually done on an outpatient basis, in which incisions are made in the prostate. With TURP, the most common method, part of the prostate is removed via a fibre-optic tube passed up the urethra. A traditional prostatectomy is more serious, requiring an abdominal incision to remove the inner part of the prostate.
A form of hyperplasia
BPH is a form of hyperplasia (uncontrolled cell division causing an excessive tissue growth, or tumor), but it’s benign and doesn’t spread to other parts of the body. Malignant hyperplasia — cancer — does. Cancer cells can invade and destroy neighboring tissue, or spread (metastasize) through the bloodstream and lymphatic system to form tumors elsewhere. The key is to catch the cancer before it metastasizes; once it does, it becomes extremely difficult to treat.
The problem is, early prostate cancer is often silent, with no obvious symptoms. When symptoms do occur, they may include frequent urination, especially at night (nocturia), difficulty starting urination, weak or interrupted flow, pain or a burning sensation during urination, painful ejaculation, blood in the urine or semen or frequent pain and stiffness in the lower back, hips and upper thighs. Such symptoms don’t necessarily indicate cancer, but a man who experiences them should see a doctor to identify the cause of the problem. If cancer is discovered, the physician will attempt to ascertain how advanced it is in the prostate, and whether it’s spread to other parts of the body.
Treatment will depend on the results of those tests, the patient’s age and relative health, as well as his feelings about individual treatments. The most common routes, though, are surgery, radiation therapy (or radiotherapy) and hormone therapy. Surgery for cancer of the prostate is called a radical prostectomy — removal of the entire organ, as well as the sevical vesicle, part of the vas deferens and nearby lymph nodes, which may harbor metastasized cancer cells. There are risks: In attempting to catch every trace of cancerous tissue, permanent injury can be done to the nerves that control erection (leading to impotence) and the opening of the bladder (causing incontinence), though improved surgical techniques have reduced such risks. For metastasized cancers, radiation therapy may be recommended as an adjunct to surgery.
Hormone therapy, the main treatment for advanced prostate cancer, is aimed at cutting off the male hormones that prostate cancer cells need for growth. Unlike standard surgery and radiation, hormone therapy is systemic: It works against cancer cells anywhere in the body. One approach, called orchiectomy, is a form of surgery involving removal of the testicles to shut down the body’s main source of testosterone. A less radical alternative uses LHRH (luteinizing hormone-releasing hormone), a synthetic form of the LHRH produced by the body, to inhibit testosterone production. Regular doses of the female hormone estrogen can have the same effect, though it’s not recommended for men with a history of heart problems.
All three methods can cause problems, including loss of sexual desire, impotence and hot flashes. If the cancer isn’t responding, doctors may try chemotherapy or biological therapy, despite their potential side effects — with chemotherapy, lower resistance to infection, loss of appetite, nausea, vomiting and mouth sores; with biological therapy, chills and fever, muscle aches, loss of appetite, nausea, vomiting and diarrhea.
None of this is easy to bear. Prostate cancer can inflict severe pain, discomfort and psychological stress. For many men, there’s a measure of relief to be found in support groups, such as Man to Man, which began in Toronto in late 1994. Such groups can provide information and understanding as well as firsthand experience to help patients make informed decisions about treatment. For more information, contact the Canadian Cancer Society.