Carcinoma of the prostate is the most common malignancy in men in the U.S. With nearly 317,000 new cases diagnosed and 41,000 deaths per year, it is the second most common cause of cancer death in men over 55 years of age (3% of Caucasian male deaths and 4% of African-American male deaths) after lung cancer. Incidence rates increase dramatically with age, particularly with each decade after age 50. Racial differences in incidence and mortality have been noted. Japanese men have an incidence rate of 5 per 100,000 men; however, after immigrating to the U.S., incidence rates of offspring match Caucasian-Americans, which are 22 cases per 100,000 under age 65 and 84 cases per 100,000 after age 65. The incidence rate for African-Americans is 123 per 100,000. Ninety-five percent of prostate cancers are adenocarcinomas, and 5% include squamous cell carcinoma, transitional cell carcinoma, and sarcoma.

No etiologic agent has been identified, but environmental, nutritional, and genetic factors have been implicated. Because incidence increases among men who immigrate to the U.S. from areas with low incidence rates, diet high in saturated fat (e.g., red meat, milk products) may be a factor. In addition, workers exposed to cadmium, in tire and rubber manufacturing, in sheet metal, and farmers have high mortality rates from prostate cancer. Family clusters have been identified, making hereditary risk a possibility.

• Family history (first- or second-degree relative)
• Diet high in saturated fat
• Occupational exposures
• Age over 55 years
• African-American descent

Nonpalpable localized prostate cancer is often asymptomatic. Symptoms of outlet obstruction are associated with local extension and distant metastases.

With local extension:

• Urinary hesitancy and intermittency
• Urinary frequency and urgency
• Post-void dribbling
• Nocturia
• Decreased force of stream

With metastatic disease:

• Bone pain, particularly in axial and appendicular skeleton
• Pathologic fractures
• Cord compression with weakness or paraplegia
• Weight loss
• Anemia or pancytopenia
• Renal failure

• Acute and granulomatous prostatitis
• Prostatic calculus
• Benign prostatic hypertrophy
• Urinary tract infection
• Urolithiasis
• Urothelial tumor

Men with a family history and African-American men should undergo a digital rectal examination (DRE) and prostate specific antigen (PSA) measurement annually after age 40; all other men should have yearly DREs and PSA measurements beginning at age 45. The physician should note the size of the prostate gland and the presence of any nodules. Use of PSAs alone as a screening tool is not recommended; DRE and PSA should be performed together. The median age at diagnosis is 72 years. The Gleason score (2 to 10) measures histologic grade, the TNM system stages the tumor, and the combined scores determine clinical significance.

• PSA measurement is prostate specific but not cancer specific (0 to 4 ng/mL = normal; 4 to 10 ng/mL = moderately elevated; 10 ng/mL = elevated)
• Prostatic acid phosphatase (PAP) less specific than PSA

• Computed tomography (CT) scan to detect enlarged nodes, but unable to image prostate cancer
• Magnetic resonance imaging (MRI to detect extracapsular extension and metastases and for staging
• Radionuclide bone scan to determine extent of metastases

• Fine-needle biopsy
• Transrectal ultrasonography (TRUS)
• TRUS-guided transrectal needle biopsy (TRNB), using a biopsy gun

Treatment strategies depend on the tumor stage and grade, pretreatment PSA levels, and the desires of the patient. Prostatectomy with or without lymph node dissection is recommended for patients who are in good health, under age 70, with tumors confined to the prostate, and have a negative bone scan. Radiation therapy is recommended for patients whose cancer is confined to the prostate or is locally invasive and who have negative bone scans. Radiation therapy is also used for painful metastases or local urinary obstruction. Radioactive seed implantation is used for localized disease. Watchful waiting is recommended for asymptomatic patients over age 70 who have complicating illnesses or who have early stage, well-differentiated tumors confined to the prostate. Androgen ablation therapy is recommended for men with metastatic disease. Chemotherapy is recommended for hormone refractory prostate cancer.

• Estrogens (e.g, diethylstilbestrol, 3 mg/day; ethinyl estradiol; polyestradiol)
• Progestational agents (e.g., medroxyprogesterone acetate, megesterol acetate, cyproterone acetate)
• LH-RH agonists (e.g., leuprolide, 1 mg/day; goserelin, 3 mg/day)
• Antiandrogens (e.g., flutaminde, bicalutamide, 50-150 mg/day; nilutamide)
• Adrenal enzyme synthesis inhibitors (e.g., ketoconazole, 1,200 mg/day; aminoglutethimide)
• Chemotherapeutic agents (e.g., mitoxantrone, estramustine, vinblastine, suramin) for painful metastases
• Radioactive agents (e.g., strontium 89, samarium-53-lexidronam)

Radiation therapy:

• External-beam radiation
• Three-dimensional conformal radiation therapy (3D-CRT)

• Radical perineal and retropubic prostatectomy
• Laparoscopic or open pelvic lymph node dissection (PLND) to evaluate nodes for metastases
• Ultrasound-guided cryosurgery (under clinical evaluation)
• Transurethral resection of the prostate (TURP) to relieve obstructive symptoms (may be associated with tumor dissemination)
• Bilateral orchiectomy to lower testosterone levels

Nutrition and herbal therapies may be helpful in minimizing the disease process, enhancing conventional treatment, improving overall health, and reducing side effects. Mind/body practices, such as relaxation techniques, imagery, meditation, and yoga, may aid in improving response to treatment and increasing the sense of well-being.

Nutriton

• Avoid alcohol (especially beer), spicy foods, sugar, saturated fats (animal products, especially dairy and chicken), caffeine, nitrates, and additives. Eat only hormone-free, organic, unprocessed foods. Eat small, frequent meals for easy assimilation and blood sugar stabilization. Increase dietary fiber, legumes, soy, garlic and onions, sea vegetables, tomatoes, broccoli, brussels sprouts, and apricots. These foods aid in detoxification and provide antioxidant protection.
• Vitamin C (1,000 mg tid to qid), vitamin E (400 IU bid to tid), coenzyme Q10 (100 mg tid), and selenium (200 mcg bid) for antioxidant protection. Carotenoids, especially lycopene (100,000 IU bid to tid), provide antioxidant protection to the prostate.
• Eicosapentaenoic acid (EPA) and evening primrose oil (EPO) reduce thrombus formation and have an inhibitory effect on invasion and metastasis. Take 1,500 mg tid.
• Zinc (30 mg/day) is essential for prostate health and immune function.
• Glutathione (500 mg bid) for antioxidant protection and detoxification.
• Bromelain (250 to 500 mg between meals) is a proteolytic enzyme that has anticancer activities and may enhance chemotherapy.
• Melatonin (20 mg/day) may help overcome clinical resistance to LHRH analogs and improve treatment outcome.
• Modified citrus pectin (MCP) has an inhibitory effect on metastases.
• Shark and bovine cartilage have antiangiogenic properties (controversial).

Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or tinctures (alcohol extraction, unless otherwise noted). Dose is 1 heaping tsp. herb/cup water steeped for 10 minutes (roots need 20 minutes).

• Turmeric (Curcuma longa): 500 mg qid potentiates the effects of bromelain and has antitumor activities.
• Saw palmetto (Serenoa repens): 300 mg standardized extract tid is most effective in treating the symptoms associated with an enlarged prostate in stage I and II benign prostatic hyperplasia (BPH), and inhibits 5-alpha reductase and 3-ketosteroid reductase, and has antiandrogenic effects.

Combine the following herbs in equal parts. Take 30 to 60 drops tincture tid.

• Mistletoe (Viscum album) has cytotoxic properties.
• Gromwell (Lithospermum ruderale) decreases FSH.
• Fenugreek (Trigonella foenum-graecum) decreases FSH and estrogen levels.
• Chaste tree berry (Vitex agnus castus) decreases FSH and estrogen levels.
• Nettles (Urtica dioica) aids in detoxification.
• Poke root (Phytolacca americana) aids in detoxification.

Hoxsey Formula is traditionally used in cancer treatment and contains herbs with antitumor, antiangiogenic, and immune-stimulating properties. Commercial Hoxsey-like formulas or trifolium compounds include red clover (Trifolium pratense), burdock root (Arctium lappa), Oregon grape (Mahonia aquifolium), queen's delight (Stillingia sylvatica), barberry (Berberis vulgaris), licorice root (Glycyrrhiza glabra), poke root (Phytolacca americana), prickly ash bark (Xanthoxylum clava-herculis), and yellowdock (Rumex crispus). Take 60 drops bid to tid for six months or longer.

May aid in reducing side effects of conventional therapies, addressing symptomatic complaints, and improving overall sense of well-being. An experienced homeopath considers both the individual's symptoms and constitution.

May be beneficial in stimulating immune function, detoxification, and strengthening the individual's overall constitution.

All patients with prostate cancer should be monitored with PSA measurements.

• Complications largely result from treatment or advanced disease.
• Prostatectomy: urinary incontinence, urethral stricture, and impotence
• Radiation therapy: acute cystitis, proctitis, enteritis, and impotence
• Hormone therapy: loss of libido, impotence, hot flashes, and gynecomastia
• Prolonged use of estrogens: serious cardiac and vascular complications (e.g., myocardial infarction, cerebrovascular accident)
• Bilateral orchiectomy: impotence
• Some antiandrogens: diarrhea, breast tenderness, nausea, and liver toxicity

Prognostic factors include the extent and histologic grade of the tumor, age, concurrent medical illnesses, and PSA levels. Prostate cancer is curable if the cancer is confined to the prostate; the 15-year survival rate for men with organ-confined disease is similar to men who have never had prostate cancer. Locally advanced and distant metastatic disease are not often curable, but survival for five years or more can be expected as some prostate cancers follow a prolonged, indolent course; many patients die from other conditions.

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