Why Big Prostates Are Good

BY MARK SCHOLZ, MD

Whenever the prostate gets mentioned, excess enlargement is frequently mentioned, as if increased size is the root of all evils. So what follows may surprise you: Having a big prostate can be desirable. For example, studies show that as the prostate gets larger, prostate cancer grade tends to become lower. And the frequent urinary problems that are so often blamed on a big gland often result from other causes.

Sound strange?  The urinary tract is far too complex to simply blame everything on a big prostate gland.  For example, take the almost universal complaint of aging males who say that they go to the bathroom too often.  Or consider the companion complaint, urinary urgency, which results in getting up frequent urination at night. Clearly these common problems are not restricted only to men with big prostate glands. Men with normal sized and even small glands have the same problem.  Even women suffer these problems and they have no prostate at all.

In this short blog it’s impossible to address every possible reason for urinary frequency. However, a couple of rather obvious matters are often overlooked.  First, consider the common mantra that it’s healthy to drink eight glasses of water daily.  Come on people!  The body does not digest water.  All the water that enters the body must come out somewhere. Need I say more?

But completely separate from the fact that our culture slugs down huge amounts of water daily, older people also typically experience a strengthening urge to urinate as we get on in years.  Why is this?  Think about it.  Most urges and sensations grow weaker with age.  Eyesight dims, libido fails, hearing diminishes. What a mess we would be in if our urge to urinate faded away too. The progressively stronger urge to urinate is a built in protective measure to ensure continued healthy function of the urinary tract. If a man loses his urge to urinate he ends up with a chronically indwelling catheter to drain his nonfunctioning bladder.

This is not to say that the increasing urge to urinate is convenient.  And a variety of over-the-counter and pharmaceutical agents have been marketed to help temper the intensity of the urge. It’s just not accurate to place all the blame on prostate enlargement. Moreover, several studies show that larger glands tend to generate lower grade cancers. Studies also show that men with smaller prostate glands have more extra-capsular spread and higher cancer recurrence rates after surgery compared to men with big glands.

The cause for less aggressive disease in men with larger prostate glands is unknown. Some researchers have postulated that men with big prostate glands, since they run higher PSA levels, get subjected to biopsy more frequently, and thus are diagnosed with cancer at an earlier stage. However, studies of men who have been diagnosed by the detection of a palpable abnormality (a semi-advanced stage) rather than by PSA, show the same pattern of having a better grade when the prostate is enlarged.

Perhaps someday scientists will be able to explain these mysterious disease patterns.  And having a big gland is not always good; there are indeed some men with big glands who suffer urinary blockage symptoms. For now, however, men with big prostates can be thankful that their large gland has some sort of a protective influence over prostate cancer. 

Remember: In BPH, the “B” stands for “Benign”

BY RALPH BLUM

The prostate gland is the only organ in our body that keeps growing as we get older; all our other organs shrink and atrophy over time. A healthy prostate gland weighs around half an ounce (15 grams) in young men, and an ounce (30 grams) or more in men who are 50 or older. However, the prostate can weigh over 100 grams, in some cases causing problems with urination.

Although an enlarged prostate doesn’t inevitably lead to problems, one-third of all men older than 60 have benign prostatic hyperplasia (BPH) that causes urinary symptoms. The most common urinary symptoms are:
 
— Frequent urination.             
— A slow, weak stream of urine—there may be a lot of stopping and starting.
— A feeling of urgency when you feel like voiding.
— Painful, almost total blockage (this requires immediate medical treatment).

If you are having any of these urinary symptoms, in addition to a urine test to rule out a bladder infection, you will need an ultrasound scan to measure the size of your prostate gland, and to determine the nature and seriousness of the problem.

In most cases BPH can be treated with a category of medications, known as alpha blockers, that relax the prostate and make urinating easier. The best known of these is Flomax (generic name: tamsulosin). Another standard treatment is Proscar (generic name: finasteride) that works to shrink the size of the gland and, therefore, reverse the problem of slow urination from prostate enlargement.

However, if your symptoms are severe and/or multiple, you may require treatments using microwave, laser or electrical energy. Or if total blockage occurs, your urologist will perform transurethral resection of the prostate (TURP), a surgical procedure that removes the prostate tissue that is blocking the flow of urine.  This procedure is sometimes referred to as a “rotor-rooter job.”

BPH is the most common reason for urinary problems in older men. But equally important is the fact that an enlarged prostate causes a rise in PSA. The reason for this elevation is because the level of PSA measured in the blood is not only proportionate to the number of cancer cells in the prostate gland, but also to the size of the gland. If, therefore, the PSA level is appropriate for the size of the prostate, and if ultrasound imaging fails to reveal any sign of cancer, chances are the PSA elevation originates from BPH. In which case, active surveillance with regular PSA testing and occasional prostate imaging is, without a doubt, preferable to biopsy.

 

But the overwhelming concern of most doctors is that they might miss cancer in their patients. That concern, plus our own fear of the disease, far too often makes us jump to an immediate, unnecessary biopsy. And here’s a fact to tape to your shaving mirror:

 

--More than half the prostate biopsies performed annually

in the U.S. are done for evaluation of an elevated PSA

caused by Benign Prostatic Hyperplasia.

 

Isn’t it time we got smarter and started acting out of knowledge, instead of out of panic? And to remember what the “Benign” in BPH stands for?

 

VIDEO: Learn more about High PSA, Multiparametric MRI and random biopsies  http://youtu.be/6QgcfVBzFNs

 

 

Aspirin Lowers Prostate Cancer Mortality Rates

BY MARK SCHOLZ, MD

If a man wants to tilt his odds in favor of a longer life, he wears a seat belt, eats a good diet, gets an annual medical checkup, exercises and gets married. Yes you heard me right, he gets married.  The November 2013 issue of the Journal of Clinical Oncology reports that the risk of dying from prostate cancer was 25% lower in married compared to single men.

Yet one intervention that also has merit and that often gets overlooked is the lowly aspirin pill. Aspirin is well-established as a beneficial agent for reducing cardiac risk.  It cuts the risk of heart attacks by about 30%, a rate of reduction similar to common statin medications like Lipitor and Crestor.  A risk reduction of this degree is notable considering that heart disease is the most common cause of death in men, especially in men with prostate cancer since most of them are over age 50.

I bring the issue of aspirin to light in this blog because I want to emphasize that there are further benefits of aspirin beyond the cardiac benefits. Specifically I want to cite another article published in the Journal of Clinical Oncology in October 2012, which reports that aspirin reduces prostate cancer mortality rates. Let me paraphrase the main take home message from the article: The difference in prostate cancer specific mortality between the men with prostate cancer on aspirin compared to the men with prostate not taking aspirin was most prominent in patients with high-risk disease.  The ten year prostate cancer specific mortality was only 4% in the men taking aspirin compared to 19% in the men who were not.  For men in the intermediate-risk group mortality was reduced from 6% down to 3% by taking aspirin.

So, in addition to the known cardiac benefits, aspirin also has a potent anticancer benefit.  Incidentally, other studies have shown that aspirin has an anticancer benefit for other types of cancer besides prostate cancer.

Aspirin is not totally risk free.  For example, one out of 200 can get a bleeding stomach ulcer.  People taking aspirin who develop black stools or heart burn should stop and get further medical evaluation. Despite these risks, aspirin can clearly be beneficial in a large number of people.  Just because it is cheap and readily accessible don’t be fooled into discounting its undeniable value.

Finding a Skilled Specialist

BY RALPH BLUM

Your number one priority when you have an elevated PSA and prostate cancer is suspected, is to take the time to find the very best urologist in your area. What you need now is an experienced urologist who specializes in treating prostate cancer, a urologist who is up on all the latest medical knowledge and surgical techniques, and who will thoroughly discuss all viable treatment options with you in an even-handed manner.

Your options might include nerve-sparing prostatectomy, radiation (IMRT and seed implants), cryosurgery, proton beam therapy, hormone therapy, and Active Surveillance. All prostate cancer treatments have their risks and benefits, and sometimes your best decision is no immediate treatment. I strongly suggest that you take the time to do some Internet research so that when you see the urologist you have some knowledge of the various treatments and their side effects, and know what questions to ask.

Before making any treatment decision you should also talk with a medical oncologist.  Urologists are surgeons, so if the cancer is contained within the gland, it’s not surprising that their treatment of choice would be surgery. But if you have done your homework, you will know that a prostatectomy is a complex procedure that can leave you with considerable collateral damage. Similarly, radiation therapists will likely recommend one of the targeted radiation options. However, a medical oncologist has no vested interest in either approach and is familiar with all the treatment options, so he is uniquely qualified to help you decide which treatment to select.

Your primary care doctor usually knows the names of the best local urologists and oncologists in your area. But you may want to go beyond your local area to find a specialist, in which case you can network--ask your friends if they know of any good doctors for treating prostate cancer. Search prostate cancer Web sites. Ask any doctors you have ever consulted who they would see if they had the disease. And most states have prostate cancer support groups that provide excellent advice.

Before making a final treatment decision, it is critically important to get a second opinion, preferably from a highly trained urologist, medical oncologist or radiation oncologist at one of the major cancer centers. Second opinion consultations are standard procedure; your doctor makes such referrals all the time, and a second opinion is reimbursed by most insurance programs. One other thing, be sure to take a complete transcript of your medical records with you.

Above all, don’t rush to make any pivotal decision that could influence the rest of your life while you are still in shock from the diagnosis. You have plenty of time to make sure you are selecting an experienced doctor, and one with whom you feel comfortable, and who gives you confidence.