"Prostate cancer is the commonest cause of early death from cancer, after breast cancer in women and lung cancer in both sexes, but many people know little about it, and many don't realize that it can easily be treated.

The first part of this book is about diagnosis of prostate cancer, and so will be valuable for all men from middle age onwards who would like to know more about it, and how to spot it early enough for the treatment to be really effective.

The second part of the book describes the many treatments for cancer that will prolong life and alleviate symptoms. Men who have had to face this diagnosis, their partners, families and friends will see here that there is great cause for optimism. Men with prostate cancer can live successfully, happily and with fulfilment, and this book will help you and those around you see that there is real hope for the future.

Contents

Introduction

The Normal Prostate Gland

When the Prostate Goes Wrong — the Natural History of Prostate Cancer

The Science behind Prostate Cancer

Some Case Histories

Explaining the Symptoms

Staging and Assessing Your Tumour

Prostate Specific Antigen (PSA) — and Future Tumour Markers

Screening for Prostate Cancer

Investigating Prostate Cancer

The Decision to Treat

Treating Cancer Confined to the Prostate Gland — Surgery

Radiation Therapy

Other Treatments for Localized Prostate Cancer

Cancer Beyond the Prostate — 'Locally Advanced'

Cancer Beyond the Prostate — Metastatic Disease

Dealing with Androgen Independence

Coping with Sex

Hopes for the Future

Glossary

References

Index

Introduction

Who would want to read a book on prostate cancer? At first thought, cry few. Men who already know they have the disease, and their partners, are an obvious readership. Relatives of men who have had it, and who think they may get it themselves, are another. Yet another target group includes men who have had the odd problem with their ability to urinate and who may be wondering about their future, and are even frightened about it.

This book aims to help all these people, but it is for a much wider group than just them. It is for anyone with an interest in enjoying a healthy old age, regardless of whether or not they fear prostate cancer in particular. There are several reasons for this. Most important among them is the fact that prostate cancer has, until recently, been the 'hidden epidemic' among us. While breast, lung, and bowel cancers have hit the headlines time and again when a new treatment for them has been launched, the constant stream of good news about prostate cancer coming from the research institutes and hospitals has rarely seemed to excite the newspaper editors.

Partly that has been due to ignorance of the prostate gland and its importance. This ignorance exists just as much among many media people who write and broadcast about health matters as in the rest of society. Even some of the most prestigious newspaper, magazine, radio, and television journalists still persist in mis-spelling and mis-stating prostate as prostrate. I have had my own copy for health columns mis-corrected in this way many times by sub-editors: it makes me frustrated and angry. If people whose very job depends on their excellent knowledge of the English language get such things wrong, there is little chance that the rest of the public will be any better informed than they are.

That is sad, because in countries where huge efforts have been made to educate the public about prostate cancer, there is evidence that deaths from the disease have passed their peak and may even be declining. The hidden epidemic is no longer hidden in the United States. Better public awareness of prostate cancer there has led to earlier diagnosis and therefore to earlier and more successful treatment. Combine these pieces of good news with newer treatments that cure or give long-term relief from prostate cancers, and the war against them is beginning to be won. The American Cancer Society, using figures from the US National Cancer Institute, has shown that since the early 1990s deaths from prostate cancer have declined by around 7 per cent.

This welcome fall in deaths from prostate cancer has not been because there have been fewer cases. On the contrary, the number of cases of prostate cancer has been rising all over the developed world, the United States included. The rise is set to continue and become even steeper as the proportion of older men in each country rises further. In 1994, Drs R. and M. Kirby and Drs J. and A. Fitzpatrick predicted the increase in numbers of men over 60 years old in various countries by the year 2020. The United Kingdom's projected increase was the lowest, at 60 per cent. The figures for the United States, Japan, and Canada were 120, 160, and 210 per cent respectively. Writing now in 2001, they have been proved accurate so far.

What is the relevance of these population figures to prostate cancer? The answer is that men's risk of developing this type of cancer, more than any other, rises steeply as they grow older. This does not mean that everyone with prostate cancer is so old that there's not much point in treating them. Far from it. The rise in risk starts at age 50 to 54, with a death rate from prostate cancer of 8 per 1,000 men in the population of that age group. The figure rises to 23 by ages 55—59, 68 by 60—64, 140 by 65—69, and 260 by 70—74. In 1990 in England and Wales 12,423 men younger than 75 died from prostate cancer. This makes it number three in the causes of early death from cancer — after breast cancer in women, and lung cancer in both sexes.

So a major aim of this book is to help reduce these figures. The best way to do this is to persuade more men to seek early diagnosis of any minor symptoms related to passing urine. Only a small proportion of such symptoms turn out to be due to prostate cancer, but it is vital to sort them out from all the other, more minor, causes. That is because the earlier that prostate cancers are diagnosed, the more likely it is that they can be completely cured — for even now, by the time of diagnosis, around half of all prostate cancers have already spread outside the boundaries of the gland. By definition they cannot be completely removed at this stage. This book describes the many new treatments for this stage of cancer that prolong life and alleviate the symptoms, but cure for it is still some years away. It would be far better if many more prostate cancers could be 'caught' earlier, at a stage when cure is feasible. And it has to be said that the pattern of progression of most prostate cancers, which is usually slow and predictable, makes cure a real probability in most people for whom the diagnosis has been made in the earlier stages.

There is another group of men, however, whose prostate cancers can be diagnosed at an earlier stage still, when they have no symptoms at all. These are the men who, because of heredity, have a higher risk than others of developing the disease. A father, brother, or uncle has had the disease, usually at a younger age than most, say in their fifties. If they can go back further in their family tree they may find more men who have died early from the disease. There is a very strong case for them to be 'screened' for prostate disease using blood tests. Tests for detecting the earliest stages of prostate cancer are improving rapidly, and a chapter of this book has been devoted to them.

However, applying such screening for early prostate cancer to the general population with no history of the disease in the family, and no symptoms of early prostate cancer, is still controversial. It is argued, fairly, that many small prostate cancers that are found on screening will never progress in the man's expected lifetime to a stage where they will cause symptoms, far less death, from the disease itself. Finding these cancers would be a disadvantage, as it would add unnecessary stress and fear to individuals' lives. So the section of this book that deals with screening also looks at ways in which prostate cancers that are likely to be the ones that truly need treatment can be distinguished from those that can be left alone. We doctors are still not very good at making this vital distinction, but we are improving.

The first part of this book is therefore about diagnosis of prostate cancer. It is for men who have heard of it and would like to know more about it — so it should be of interest to any man in middle age and beyond. The second part is about the treatment of prostate cancer. Here most readers will be men who have had to face the diagnosis, along with their concerned partners, relatives, and friends. This is where the good news starts. Even now, in the twenty-first century, the word 'cancer' is commonly associated with imminent death. That view is firmly dispelled by the book's section on treatment. There is optimism on all fronts among the people who wage the war on this disease. Surgeons have found better ways to remove diseased prostate glands, while preserving sexual function and feelings (a real drawback in the past). Physicians have found better drugs to slow and even arrest the spread of the disease. And there is great optimism for the future, particularly with the ever- expanding knowledge of the mechanisms by which prostate cancers are initiated and then spread within the body. Molecular biologists and geneticists are combining their knowledge to produce ways of reversing the underlying causes of prostate cancer, and these will eventually reach the clinic.

Details of the genetics and molecular biology of prostate cancer are outside the scope of this book, but it would not be complete without giving you a flavour of what is happening in these areas, because they offer such hope for the future. So my chapter on them is an optimistic one.

Men with prostate cancer can live successfully, happily, and with fulfilment. This is the book's overall message. If you or a partner, relative, or friend have the illness, then please read it. It aims to support and lighten the burden, and not to depress.

Here I must pay a debt to several doctors without whom this book could not have been written. First to Dr Jonathan Waxman, of London, with whom I worked some years ago. He guided me, and first fired my special interest in this disease. Also, my thanks go to two other Londoners, Roger Kirby and Timothy Christmas, and their colleague Michael Brawer, of Seattle. Together these three men wrote Prostate Cancer, the definitive book for doctors on this disease. As a general practitioner, I obviously do not have their personal experience of research and of the specialist treatments in which they are so expert. So I have had to draw on their book for many of my facts. Any reader, medical or not, who would like to know much more about prostate disease could not do better than read their book. It is beautifully written and illustrated, though it will hardly be used as a coffee table ornament!

About the author

Dr Tom Smith has been writing full time since 1977, after spending six years in general practice and seven years in medical research. He writes regularly for medical journals and magazines and has a weekly column in the Bradford Telegraph and Argus. He also broadcasts regularly for BBC Radio Scotland. His other books for Sheldon Press include Heart Attacks: Prevent and Survive, Living with High Blood Pressure and Living with Alzheimer's Disease.