With the graying of the baby boomers prostate health is looming large and concern for cancer has become an increasingly frequent topic of conversation. Unfortunately, the topic has also become increasingly complex. During more than a quarter century as a practicing pathologist, I have repeatedly been asked if, how and when to screen for prostate cancer and how to proceed if positive. As Hans Larsen and William Ware have indicated in The Prostate and Its Problems, these issues of screening, diagnosis and treatment are hotly debated and make prostate cancer more controversial than any other cancer. Do I request a PSA blood test and run the risk of chasing a false positive or perhaps worse, worrying about not chasing it? If the biopsy is positive, what should I do? What are my chances of ending up impotent and/or incontinent as a result of surgery or radiation? And of course, what if I don’t have any insurance? While there are no absolute answers, this comprehensive work provides the most recent relevant studies impacting these decisions. Indeed much of the material is directed toward maintaining a healthy prostate and minimizing the likelihood of ever having to embark on this treacherous and tortuous path.
For a small sampling of the controversy surrounding this cancer one need look no further than PSA. Over many years the screening triple play of transrectal ultrasound, digital rectal exam and PSA has been the cornerstone of medical dogma on prostate cancer. However, from the outset the value of PSA as a screening test for prostate cancer vs. BPH has been under constant assault and the test was even proclaimed dead in 2004 by eminent urologist Professor Thomas Stamey of Stanford University Medical School. This view was based on a large autopsy study that revealed that 8% of males in their twenties had prostate cancer with incidence increasing each decade until 80% had it in their seventies. Yet according to the National Cancer Institute, death due to prostate cancer in those over 65 years is only 226 per 100,000. However, it’s not just PSA anymore; refinements, such as per cent free PSA (the higher the better) and PSA density (how high is it relative to size of prostate) have been added. PSA velocity (how fast is it changing) is now very much in vogue and this book has a particularly elucidating discussion of this (Chapter 4).
Once you’ve been determined via screening to be at risk you must decide whether to undergo biopsy. Over the past few years I have seen the incidence of low-grade prostate cancer (Gleason score less than 7) decline and it is now seen very infrequently on biopsy specimens. Whether this is because pathologists tend to err on the side of caution for medicolegal reasons is hard to say, but in any case, it tends to push the decision regarding treatment (or not) firmly back into the laps of the patient and his physician. This means that if you decide on a biopsy you are likely to face the even more daunting dilemma of treatment or not. Given the conflicting data on efficacy of surgery vs. radiation vs. watchful waiting, whether or not to even embark on this slippery slope of screening and diagnosis has come into question. This book contains all the necessary data to make an informed decision at each juncture and, as it reiterates, to always have your biopsy slides reviewed by an independent pathologist before proceeding.
Mainstream medical journal articles on both BPH and prostate cancer, many of which are financed by large pharmaceutical companies and touted as evidence-based, often fall well short of the mark on objectivity. For example, this book describes how the North American medical community has failed to embrace the well documented, evidence-based studies demonstrating the beneficial effect of saw palmetto on BPH symptoms. Saw palmetto has long been accepted by mainstream medicine in Europe as a first-line treatment for BPH; however, in North America the focus has been on surgery and finasteride despite this drug’s already documented history of inducing sexual dysfunction.
The Prostate and Its Problems by Hans Larsen and William Ware tackles these thorny issues in a straightforward, easy to understand manner. The myriad questions are addressed via rigorous research translated into plain English. By sifting through all the medical literature they have presented a more balanced view, one that is both evidence-based and objective. Furthermore, unlike more traditional medical texts there is a strong emphasis on alternative, preventive strategies for avoiding inflammation, hyperplasia and cancer of the prostate. Neither author has received funding for this extraordinarily comprehensive work. Both are true scholars motivated purely by the sheer joy of learning and teaching others, and their total dedication to this goal is readily apparent in every page.
This book has appeal well beyond males. Life changing decisions on treatment for prostate cancer should be a joint decision. Oftentimes males are not prepared either emotionally or intellectually to undertake the requisite research to arrive at a well informed choice tailored to their specific situation. This then falls to their spouse. Furthermore, given that prostate and breast cancer are both hormone-dependent cancers and that men with a family history of breast cancer are more likely to get prostate cancer and women with a family history of prostate cancer are more likely to get breast cancer (Chapter 3), much of the presented preventive strategies may have equal gender appeal. Furthermore, antioxidant and anti-inflammatory strategies are of proven benefit for longevity, minimizing both cardiovascular disease and cancer in general.
If you are an informed consumer wishing to become more empowered in your healthcare decisions, then this book is for you. When made by others, many of these decisions are influenced by medicolegal and financial considerations of which you may not even be aware. Wouldn’t it be better to know the most recent data and to digest them for yourself rather than to have the decision made for you? Ultimately, it’s your life and your money. Hopefully, your PSA level will never become abnormal. However, if you want to become more prepared to deal with such an occurrence before the associated emotional cloud descends to color your thinking, then The Prostate and Its Problems by Hans Larsen and William Ware is highly recommended.
Patrick Chambers, MD
Patrick Chambers received his baccalaureate degree from Princeton University in Mathematics in 1971 followed shortly thereafter by completion of medical studies at the University of California at Davis. He completed his specialty training in pathology at the Los Angeles County/University of Southern California Medical Center. After more than 25 years as a practicing pathologist and laboratory director at Torrance Memorial Medical Center he recently retired to Kailua, Hawaii, where plentiful sunlight and high vitamin D levels hopefully keep his prostate healthy and cancer free. In an annual review of 4000 American acute care hospitals Torrance Memorial was the only non-teaching hospital of any size to be named a Top 100 Hospital three years in a row (1993, 1994, 1995).