Prostate Cancer
Prostate cancer is second in mortality in men. It has really come on down past gastrointestinal malignancy as the second most significant malignancy in males. There are over 30,000 deaths a year from prostate cancer. About 47,000 with breast cancer. The incidence of death from prostate cancer, the mortality rate, actually has gone down a little bit last year for the first time. So again, this is a parallel to the breast cancer data. There has been a slight drop in mortality despite the rising incidence of this disease.
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We think that not everybody is at equal risk for prostate cancer. As in breast cancer, we have been able to elucidate some genetic and other factors that seem to be associated with an increased risk of disease. The most pertinent of these if family history. We know that if you have one first degree relative with prostate cancer it does increase your risk you certainly have screening in those patients. If you have more than one relative then you have an even bigger effect on risk. We also know that there are racial differences in prostate cancer. This might be due to diet or habits, or to other genetic factors. We know that the bottom line is that African-American men have a two-fold increased risk of prostate cancer compared to their Caucasian counterparts. We think that increased levels of androgens, particularly 5-alpha reductase, which converts testosterone to dihydrotestosterone is associated with increased risk. This may account for some of the racial differences. It does correlate with high fat diets as well. It forms the basis of a potential chemoprevention, in fact using 5-alpha reductase inhibitors. We know that patients who have decreased plasma retinol levels have higher incidence of prostate cancer. Finally, patients that have had vasectomies, for reasons that are unclear, are known to have a higher incidence of risk for this disease as well.
Now prostate cancer does not have, at this point, any prevention data, like the data I showed you from the P-1 trial for breast cancer. We will conclude by looking at some prevention opportunities but all we have right now is secondary prevention or screening for this disease. Again, as in breast cancer screening, I think this is an area that has become somewhat controversial. I think that it’s fair to say that the PSA determination is the most sensitive test that can be used. But the specificity of PSA, particularly in mild elevations, is not optimum because you will have mild elevations – at least in non-prostatic hypertrophy. Digital rectal examination should not be forgotten. Remember that the posterior lobes of the prostate are the lobes usually involved in cancer and these are quite amenable to palpation on rectal examination. Remember that about 10-15% of patients who have palpable lesions will have negative PSA or normal PSA levels. They are just very much like mammography and physical examination. They are complimentary procedures and both should be done if you are going to be screening someone.