Related Terms

• ABP, acute bacterial prostatitis, adrenal, androgen, antiandrogen, apoptosis, benign prostate hyperplasia, benign prostatic hypertrophy, bicalutamide, biologic therapy, biopsy, BPH, brachytherapy, CAP, Casodex®, catheter, chemotherapy, chronic bacterial prostatitis, chronic nonbacterial prostatitis, chronic pelvic pain syndrome, chronic prostatitis, cryosurgery, Davinci, digital rectal exam, enlarged prostate, erectile dysfunction, estrogen, flutamide, genitourinary, goserelin acetate, HIFU, hormonal, hormone, hyperplasia, hypogonadism, impotence, incontinence, laparoscopic prostatectomy, leuprolide acetate, Lupron, metastasis, metastasize, Nilandron, nilatamide, nocturia, obesity, oncologist, pelvic lympadenectomy, perineal prostatectomy, perineum, prostadynia, prostatectomy, prostate enlargement, prostate gland, prostate infection, prostate-specific antigen, prostatic acid phosphatase, prostatic hyperplasia, prostatitis, PSA, radical prostatectomy, resectoscope, retropubic prostatectomy, robotic prostatectomy, RRP, seminal fluid, testosterone, transperineal, transrectal, transrectal ultrasound, transurethral, transurethral microwave thermotherapy, TUMT, TURP, ultrasound, urologist, urology, vaccine, Zoladex®.

Background

• The prostate is part of a man's reproductive (genitourinary) system and is located in front of the rectum and under the bladder. It surrounds the urethra, the tube through which urine flows.

• A healthy prostate is about the size of a walnut. Male hormones (androgens, particularly testosterone) normally produced by the body stimulate the growth of the prostate. The testicles are the main source of male hormones, including testosterone. The prostate changes size very little from birth until puberty, but at puberty it increases in weight and doubles in size. In general, the size of the prostate remains constant after puberty for the next 30 or more years. In some men, in fact, the prostate never again increases in size. Unfortunately, however, this is not the case for most men, who will develop some form of non-cancerous enlargement of the prostate, medically known as benign prostatic hyperplasia or BPH. Half of all men in their 50s and 80% of men in their 80s have some symptoms of BPH.

• The prostate makes part of the seminal fluid. During ejaculation, seminal fluid helps carry sperm out of the man's body as part of semen. In the adult male, the glandular tissue of the prostate secretes a fluid that contributes 20-30% of the total volume of the seminal fluid released when a man ejaculates. This prostate fluid is continuously generated by the prostate but increases during sexual excitement. The combination of spermatozoa, seminal vesicle fluid, and prostatic fluid, in addition to a tiny amount of fluid from some minor glands, constitutes semen. The prostate gland fluid is a thin, milky substance that gives semen its characteristic color and odor.

• Some common prostate problems include prostatitis (inflammation of the prostate, usually caused by bacterial infection), benign prostatic hyperplasia or BPH (an enlarged prostate, which may cause dribbling after urination or a need to urinate often, especially at night), and prostate cancer (a common cancer that responds best to treatment when detected early).

Types and Causes of Prostate Conditions

• Prostatis: Prostatitis is inflammation of the prostate gland usually caused by an infection that often affects younger men. With treatment, prostatitis should generally be alleviated within several days to two weeks. Treatment of chronic (long-term) bacterial prostatitis usually involves antimicrobial medication for four to 12 weeks. This type of prostatitis is difficult to treat and recurrence is possible.

• Prostatitis usually results from blockage or irritation of some of the ducts within the prostate gland, and the cause may be mechanical (such as narrowing of the urethra) or infectious. The infectious causes may be viral or bacterial, including E. coli or sexually transmitted infections such as Chlamydia.

• There are four types of prostatitis: acute bacterial prostatitis (the least common of the four types, but the most common in men under 35); chronic bacterial (not very common, but affects mostly men between 40-70 years); asymptomatic inflammatory prostatitis (produces no outward symptoms and occurs mainly in men aged 60 and over); and chronic nonbacterial/prostadynia (most common type). Prostadynia, also known as chronic pelvic pain syndrome, is a condition associated with similar symptoms as chronic nonbacterial prostatitis, but which has no evidence of prostate inflammation.

• Benign prostatic hyperplasia (BPH): Benign prostatic hyperplasia (BPH) is a normal, gradual enlargement of the prostate caused by hormonal fluctuations, such as decreases in testosterone and increases in dihydrotestosterone (DHT) and estrogen in prostate tissue. BPH usually beings in middle age. BPH does not lead to cancer. BPH does not generally cause pain, but discomfort (a feeling of pressure) in the groin area is generally found.

• As the prostate enlarges, it presses against the urethra and interferes with urination. At the same time, the bladder wall becomes thicker and irritated and begins to contract, even when it contains small amounts of urine, which causes more frequent urination. And, as the bladder continues to weaken, it may not empty completely leaving some urine behind. Blocking or narrowing of the urethra by the prostate and partial emptying of the bladder cause many of the problems associated with BPH.

• BPH affects about half of men aged over 60 and 80% of men aged 80 or older; it is considered to be a condition related to aging. Almost every man over 45 has some prostate enlargement, but symptoms are rarely felt before the age of 60. BPH affects all men differently and therefore treatment varies.

• Prostate cancer: As men get older (after age 50), their risk of prostate cancer increases. Men above 50 years of age should be checked for prostate cancer routinely by their doctor, and men with risk factors for developing prostate cancer (including family history of prostate cancer, multiple family members with prostate cancer, and/or African heritage), should talk to their doctor about starting this screening at a younger age such as 40.

• Prostate cancer exhibits tremendous differences in incidence among populations worldwide. Asian men typically have a very low incidence of prostate cancer, with age-adjusted incidence rates ranging from 2-10 per 100,000 men. Higher incidence rates are generally observed in northern European countries. African men, however, have the highest incidence of prostate cancer in the world. In the United States, African American men have a 60% higher incidence rate compared with Caucasian men.

• Prostate cancer is the most common non-skin cancer in America, affecting one in six men. More than 218,000 men in the United States will be diagnosed with prostate cancer in 2007. Healthcare professionals recommend men 50 years of age and older get screened for prostate cancer.

• If an immediate family member such as a father or brother has prostate cancer, the risk of developing the disease is greater than that of the average American man. Between 5-10% of prostate cancer cases are believed to be due primarily to high-risk inherited genetic factors or prostate cancer susceptibility genes. The survival rate indicates the percentage of patients who live a specific number of years after the cancer is diagnosed. For prostate cancer, the 10-year survival rate is 93% and the 15-year survival rate is 77%.

• A high-fat diet and obesity may increase the risk of prostate cancer. Researchers theorize that fat increases production of the hormone testosterone, which may promote the development of prostate cancer cells. Obese men who are diagnosed with prostate cancer have more than two-and-a-half times the risk of dying from the disease as compared to men of normal weight at the time of diagnosis. Scientists believe that obesity increases the risk of prostate cancer by increasing inflammation and steroid hormones, such as testosterone.

• Because testosterone naturally stimulates the growth of the prostate gland, men who have high levels of testosterone and men who use testosterone (steroid) therapy are more likely to develop prostate cancer than are men who have lower levels of testosterone. Long-term testosterone treatment could cause prostate gland enlargement (benign prostatic hyperplasia or BPH). Also, doctors are concerned that testosterone therapy might fuel the growth of prostate cancer that is already present.

Signs and Symptoms

• Prostatitis:

• Symptoms of prostatitis may include painful, burning, or frequent urination, weak urine flow or incomplete emptying, fever and chills, lower abdominal pain or pressure, painful ejaculation, impotence, and low back pain.

• Acute bacterial prostatitis: Although the least common of all types of prostatitis, acute bacterial prostatitis occurs in men at any age and often with sudden onset and severe symptoms. Men may find urination difficult and extremely painful. Other symptoms of acute bacterial prostatitis include fever, chills, lower back pain, pain in the genital (between the legs) area, urinary frequency, burning during urination, and/or urinary urgency at night, coupled with aches and pains throughout the body.

• Chronic bacterial prostatitis: Although fairly uncommon, chronic bacterial prostatitis is a recurrent infection of the prostate gland that is difficult to treat. Symptoms of the infection are often similar to but less intense than acute bacterial prostatitis. However, symptoms of chronic bacterial prostatitis generally last longer and often fever is absent, unlike during an acute infection.

• Chronic prostatitis/chronic pelvic pain syndrome: Chronic prostatitis/chronic pelvic pain syndrome is likely the least understood form of prostatitis, but the most common form of the disease. Symptoms may resolve and then reappear without warning. The infection may be considered inflammatory, in which urine, semen, and other secretions are absent of a known infecting organism but do contain infection-fighting cells, or the infection may be considered non-inflammatory, in which inflammation and infection-fighting cells are both absent.

• Asymptomatic inflammatory prostatitis: Asymptomatic inflammatory prostatitis may be diagnosed when infection-fighting cells are present, but common symptoms of prostatitis, such as difficulty with urination, fever, and lower back and pelvic pain, are absent. A diagnosis of asymptomatic inflammatory prostatitis is made most often during an examination for other conditions, such as infertility or prostate cancer.

• Benign prostatic hyperplasia:

• Common symptoms of BPH include: having to wait for the urine stream to start; poor urinary flow and a variable flow rate; frequent urination; difficulty postponing urination (urgency); dribbling of urine at the end of urination; and having to wake at night to urinate multiple times (nocturia).

• Prostate cancer:

• Cancer of the prostate often grows slowly, especially in older men. Symptoms may be mild and occur over many years. Early symptoms of prostate cancer can mimic other prostate conditions, such as BPH and prostatitis. In later stages, prostate cancer cells may spread to the bones, causing pain in the back, hips, pelvis, and other bony areas.

Diagnosis

• Digital rectal exam (DRE): The digital rectal exam is a procedure commonly performed during routine physical examinations. During a DRE, a doctor feels the prostategland by passing a gloved finger into the individual's rectum tofind hard or lumpy areas of the gland, which may represent anabnormality. If there is suspicion of an abnormal prostate, the doctor may analyze urine and prostate fluid after massaging the prostate gland.

• The doctor may also assess the degree of pain or discomfort the individual experiences as he presses the muscles and ligaments of the pelvic floor and perineum. If a man has prostatitis, this examination may produce momentary pain or discomfort but it causes neither damage nor significant prolonged pain.

• Prostate-specific antigen (PSA) test: Prostate specific antigen (PSA) is an enzyme normally made by cells in the prostate gland that helps break down proteins in seminal fluid to aid with fertility. PSA levels can be measured by drawing blood from a vein, which is then sent for a PSA laboratory test. It is normal for the blood stream to contain some PSA. However, if the PSA level is found to be elevated, it may be an indication of prostate infection, inflammation, enlargement (BPH), or cancer. However, in the United States, a generally accepted standard PSA level is considered to be 4.0 nanograms per milliliter (ng/ml). If the PSA level is above 4.0, further evaluation will often be recommended, for example with an ultrasound and prostate biopsy by an urologist. Even if the PSA is less than 4.0, if the PSA has risen a concerning amount since a prior measurement, further evaluation may be recommended. PSA values tend to be lower in younger men, and it has been suggested that the PSA level at which to consider a biopsy should be lower for younger men than for older men.Even if the PSA is elevated, it does not necessarily mean that cancer is present, since there are other causes of PSA elevations. This is why further evaluation with a biopsy is often recommended.

• Using the PSA test to screen men for prostate cancer is controversial because it has not clearly been proven that this test actually saves lives. Moreover, it is not clear if the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments. For example, the PSA test may detect small cancers that would never become life threatening. This situation, called over diagnosis, might put men at risk for complications from unnecessary treatments such as surgery or radiation, although this is unproven. Regardless of these concerns, at this time, PSA screening is recommended by most professional organizations and is considered the standard of care.

• Prostate biopsy procedure: If the DRE and/or PSA blood test results are suspicious for a possible prostate cancer, a doctor may recommend a prostate biopsy. The patient will be prescribed antibiotics, usually a three day course, before the procedure. Most individuals receive local anesthesia, such as lidocaine (Xylocaine®). To do a biopsy, a doctor inserts a small, lubricated probe about the size and shape of a cigar into the rectum (called transrectal ultrasound). The probe uses sound waves that are converted to visual data in order to see a picture of the prostate gland, which is then analyzed for changes. If an abnormal area is seen on the transrectal ultrasound, the doctor will likely biopsy that area. Then a fine, hollow needle is aimed at these areas of the prostate. A spring propels the needle into the prostate gland and retrieves a very thin section of tissue. Biopsies are generally obtained from multiple areas of the prostate, and it is important that all relevant areas be included (this should be discussed with the urologist). Biopsies are often done with the guidance of a transrectal ultrasound (TRUS). Biopsies in general take 15-45 minutes to complete, depending upon the procedure. The procedure may cause side effects, including bleeding and infection. Approximately 55% of men report discomfort during the biopsy. Some men also experience pain in the rectal area or penis following biopsy, which should be reported to a doctor if it does not resolve. Biopsies can also be performed through the perineum area (between the anus and the scrotum, called transperineal biopsy), or through the urethra (canal that the urine travels through for elimination, called transurethral biopsy).

• Prostate biopsy analysis: Prostate biopsy specimens are examined by pathologists using a microscope and chemical staining in order to make a diagnosis. The pathologist may determine that the prostate looks normal, or that there are pre-cancerous areas called high-grade prostatic intraepithelial neoplasia (PIN), or that there is prostate cancer present. If there is high-grade PIN, a repeat biopsy or close follow-up will usually be recommended. If there is prostate cancer present, the pathologist will assign Gleason grades to evaluate the aggressiveness of the cancer. For each biopsy core, two numbers will be assigned that are then added together for the total Gleason grade for that core. The first number represents the most common level of aggressiveness of cancer cells for that core, and the second number represents the second most common level of aggressiveness for that core. These individual numbers can range between 3 and 5, and therefore the total Gleason sums range between 6 and 10. For example, if there is a core with the most common cancer cell type being 3 and the second most common being 4, then the total Gleason grade for that core is 3+4=7. Each core gets its own grade. Sometimes, the pathologist will note the third most common level of aggressiveness for a core, and this is called the "tertiary" Gleason grade.

• Transrectal ultrasound (TRUS): If the doctor requires a closer look at the prostate gland or decides that a biopsy is necessary, he may order a TRUS, which allows him to visualize the prostate gland. A TRUS is a 5-15 minute outpatient procedure that uses sound waves to create a video image of the prostate gland. A small, lubricated probe placed into the rectum releases sound waves, which create echoes as they enter the prostate. Prostate tumors sometimes create echoes that are different from normal prostate tissue. The echoes that bounce back are sent to a computer that translates the pattern of echoes into a picture of the prostate. While the probe may be temporarily uncomfortable, TRUS is usually a painless procedure.

• Imaging: If prostate cancer is diagnosed with a biopsy, depending on the Gleason grade and PSA values, a physician may recommend a bone scan and computerized tomography (CT) scan of the abdomen and pelvis. The bone scan is to evaluate for potential spread of cancer to the bones. The CT scan should be done using intravenous contrast for eligible patients, and can evaluate the lymph nodes, liver, and, to a limited extent, the prostate area. Even if there is a very low chance of spreading, these scans can be helpful to get baseline images for later comparisons if necessary. Increasingly, magnetic resonance imagine (MRI) of the prostate is being used to obtain views of the prostate to plan treatment, with good supporting evidence. This is usually done with a thin probe that is placed into the rectum to get the best picture possible.

Complications

• Biopsy complications: Biopsy complications can include pain (which can persist after the biopsy), bleeding (which can appear in the stool or semen), and infection. Ongoing discomfort or bleeding should be evaluated by a clinician.

• Prostate cancer complications: Prostate cancer can metastasize (spread to areas of the body other than the prostate such as lymph nodes, bone, lung, or liver) and can be life-threatening. Metastasis can take months to years to occur, depending on the individual. Although early-stage prostate cancer typically is not painful, once it has spread to bones, it may produce pain, which can be intense. Local growth of prostate cancer or treatment of prostate cancer can lead to urinary incontinence (leakage), erectile dysfunction (impotence), and other serious complications.

Treatment

• Prostatitis:

• Pain relievers and several weeks of treatment with antibiotics are typically needed for category 1 and 2 prostatitis, which are bacterial infections. A variety of treatments as well as self-care measures also can provide relief. Treatment for category 3 prostatitis (nonbacterial) is less clear and mainly involves relieving symptoms. Category 4 prostatitis is usually found during examination for another reason and often does not require treatment.

• Acute bacterial prostatitis (infectious prostatitis) is treated with oral antibiotics for one to two weeks. The commonly used antibiotics include quinolones, such as norfloxacin (Noroxin®), ciprofloxacin (Cipro®), or levofloxacin (Levaquin®). In severe cases, treatment with intravenous (IV) antibiotics may be necessary. Chronic bacterial prostatitis is also treated with oral antibiotics for 4-12 weeks. Other medications used to treat infectious prostatitis include: stool softeners, such as docusate sodium (Colace®); anti-inflammatory medications, such as ibuprofen (Motrin®); analgesics or pain medications, such as hydrocodone (Vicodin®, Lortab®); alpha-blockers such as tamsulosin (Flomax®); and 5-alpha reductase inhibitors, such as finasteride (Proscar®) or dutasteride (Avodart®).

• If the individual has noninfectious prostatitis, he/she will not need antimicrobial medication. Treatment depends upon the symptoms that are present. If the condition responds to muscle relaxation, the individual may be given an alpha blocker, a drug that can relax the muscle tissue in the prostate and reduce the difficulty in urination.

• Asymptomatic inflammatory prostatitis and chronic prostatitis may respond to multidisciplinary approaches incorporating exercise, progressive relaxation, and counseling.

• Benign prostatic hyperplasia (BPH):

• Drug therapy: The U.S. Food and Drug Administration (FDA) has approved multiple drugs to relieve common symptoms associated with an enlarged prostate. Finasteride (Proscar®), FDA-approved in 1992, and dutasteride (Avodart®), FDA-approved in 2001, inhibit the production of the hormone dihydrotestosterone (DHT), which is involved with prostate enlargement. The use of either of these drugs can either prevent the progression of growth of the prostate or actually shrink the prostate in some men.

• The FDA also approved the drugs terazosin (Hytrin®) in 1993, doxazosin (Cardura®) in 1995, tamsulosin (Flomax®) in 1997, and alfuzosin (Uroxatral®) in 2003 for the treatment of BPH. All four drugs act by relaxing the smooth muscle of the prostate and bladder neck to improve urine flow and to reduce bladder outlet obstruction. The four drugs belong to the class known as alpha blockers. Terazosin and doxazosin were developed first to treat high blood pressure. Tamsulosin and alfuzosin were developed specifically to treat BPH.

• Because drug treatment is not effective in all cases, researchers in recent years have developed a number of procedures that relieve BPH symptoms, but are less invasive than surgery.

• Transurethral resection of the prostate (TURP): This is a surgical procedure to remove tissue from the prostate that may be blocking urine flow using a resectoscope (a thin, lighted tube with a cutting tool) inserted through the urethra. This surgery is sometimes performed to relieve symptoms caused by benign (non-cancerous) tumors. Transurethral resection of the prostate may also be done in men who cannot have a radical prostatectomy because of age or illness.

• Transurethral microwave procedures: In May 1996, the U.S. Food and Drug Administration (FDA) approved the Prostatron™, a device that uses microwave generated heat to destroy excess prostate tissue. In the procedure, called transurethral microwave thermotherapy (TUMT), the Prostatron™ sends computer-regulated microwaves through a catheter to heat selected portions of the prostate to at least 111 degrees Fahrenheit. The temperature becomes high enough inside the prostate to kill some of the tissue. As this part of the prostate heals, it shrinks, reducing the blockage of urine flow. A cooling system protects the urinary tract during the procedure.

• A similar microwave device, the Targis System™, received FDA approval in September 1997. Like the Prostatron™, the Targis System™ delivers microwaves to destroy selected portions of the prostate and uses a cooling system to protect the urethra. A heat-sensing device inserted in the rectum helps monitor the therapy.

• Both procedures take about one hour and can be performed on an outpatient basis without general anesthesia. Neither procedure has been reported to lead to impotence or incontinence.

• While microwave therapy does not cure BPH, it reduces urinary frequency, urgency, straining, and intermittent flow. It does not correct the problem of incomplete emptying of the bladder. Ongoing research will determine any long-term effects of microwave therapy and who might benefit most from this therapy.

• Transurethral needle ablation: In October 1996, the U.S. Food and Drug Administration (FDA) approved the minimally invasive Transurethral Needle Ablation (TUNA) System for the treatment of benign prostate hyperplasia (BPH). The TUNA System delivers low-level radiofrequency energy through twin needles to burn away a well-defined region of the enlarged prostate. Shields protect the urethra from heat damage. The TUNA System improves urine flow and relieves symptoms with fewer side effects compared with transurethral resection of the prostate (TURP, see below). No incontinence or impotence has been observed.

• Prostate cancer:

• Overview of management options: When prostate cancer is localized (not spread beyond the prostate), most practitioners will discuss options with patients that include surgical removal of the prostate (prostatectomy), radiation treatment, or active surveillance (also called watchful waiting or observation). The goal of prostatectomy or radiation treatment is to cure the patient by eradicating the cancer. There are other, less well-established approaches including cryotherapy and high-intensity focused ultrasound (HIFU), for which there is less scientific evidence available compared to prostatectomy or radiation therapy.

• Prostatectomy: Radical prostatectomy is a surgical procedure to remove the prostate, surrounding tissue, seminal vesicles, and pelvic lymph nodes. Prostatectomy is performed by a urologist. The traditional open surgery is also called "radical retropubic prostatectomy," during which a 3-4 inch incision is made below the belly button, through which the prostate and nearby lymph nodes are removed. Less common is the perineal prostatectomy, which is an open surgical procedure to remove the prostate and nearby lymph nodes through an incision made in the perineum (area between the scrotum and anus). More recently, laparoscopic prostatectomy and robotic laparoscopic prostatectomy approaches have become more common. For these procedures, several small incisions are made in the abdomen, through which instruments are inserted to perform the surgery. For non-robotic prostatectomy, the surgeon operates these instruments by hand, while in robotic prostatectomy the surgeon operates controls that move a robotic arm to perform the surgery. Most likely, these approaches are all equivalent in terms of effectiveness and side effects, although the least scientific evidence is available on robotic prostatectomy as it is a recently developed technique. Most scientific evidence suggests that the most important factor when selecting a surgical approach is the experience of the surgeon, not the specific surgical technique. Several studies show that the more prostatectomies a surgeon does each year, the better the outcomes for patients. Therefore, patients are advised to undergo surgery with a physician with a lot of experience removing prostates.

• Surgery complications: Surgery for prostate cancer can cause problems such as erectile dysfunction (impotence) and leakage of urine from the bladder (incontinence). Levels of severity are highly variable. In many cases, doctors may use a technique known as nerve-sparing surgery to save the nerves that control erection. These surgeries are performed under general anesthesia, which may also cause complications. The risk of complications should be discussed with the surgeon during initial meetings. Pre-operative clearance by an internal medicine physician or cardiologist should be considered and discussed with the surgeon.

• Radiation therapy: Radiation therapy is a cancer treatment that uses high-energy radiation to kill cancer cells and shrink tumors. It is performed by a radiation oncologist. There are two main types of radiation therapy. External beam radiation therapy (EBRT) uses a machine outside the body to send radiation toward the cancer. Most commonly, EBRT is performed using "conformal" approaches that customize the radiation to the shape of each patient's prostate and location of tumor, and particularly "intensity modulated radiation therapy" (IMRT). Internal radiation therapy (or "brachytherapy") involves surgically implanting tiny, radioactive capsules (called "seeds") into the cancerous prostate gland. The seeds emit radiation that kills the malignant tumor. The type of radiation therapy used depends on the type and stage of the cancer being treated. For some prostate tumors, a combination of EBRT and seeds may be considered by the radiation oncologist. For cancers that are higher-risk (higher Gleason grades, higher PSA scores, and/or greater amounts of cancer in the prostate or surrounding area), hormone therapy may be recommended by the radiation oncologist to be given during treatment and for a period of time after the radiation is completed. Recently, proton beam therapy has been suggested for localized prostate cancer, but evidence is limited and this approach is generally reserved for other types of cancers, such as small tumors in children.

• Radiation complications: Side effects during radiation treatment can include diarrhea, skin burns, sexual dysfunction, and urinary discomfort or urgency. Normal tissue can be damaged by radiation. Like prostatectomy, possible long-term complications include urinary incontinence (leakage) and erectile dysfunction (impotence). There is also a very small chance of long-term blood in the stool due to radiation damage to the lining of the rectum (radiation proctitis). New developments in radiation delivery have decreased the chances of these complications. The risks of these complications should be discussed with the radiation oncologist during an initial meeting.

• Active surveillance, watchful waiting, observation: For selected patients with low-grade cancers (Gleason 3+3=6 in few cores with low prostate specific antigen or PSA), active surveillance may be appropriate. Surveillance is usually under the supervision of a urologist and involves regular follow-up of the PSA, digital rectal exam, periodic re-biopsy, and consideration of periodic imaging with MRI or CAT scans. If concerning changes occur suggesting that the cancer is progressing, then proceeding with prostatectomy or radiation treatment will be considered. For older patients with limited life-expectancy (less than 5-10 years) and low-grade cancers, observation may be considered if the potential risks of treatment are felt to outweigh potential benefits.

• Cryosurgery: Cryosurgery is a treatment that uses an instrument to freeze and destroy prostate cancer cells. This type of treatment is also called cryotherapy. There is less scientific evidence available to support this therapy than there is for prostatectomy or radiation. It is sometimes used for cancer that has recurred after radiation or surgery, but it is associated with high levels of incontinence.

• High-intensity focused ultrasound (HIFU): High-intensity focused ultrasound is a new treatment that uses ultrasound (high-energy sound waves) to destroy cancer cells. To treat prostate cancer, an endorectal (inside the rectum) probe is used to make the sound waves. Scientific evidence supporting this approach is limited.

• Choosing a management approach: Selecting between the available options for localized prostate cancer can be very difficult, especially because for many men there may be no clear advantage of one approach over another. The choice of treatment should be made after discussion with physicians and reading about the different options. Regardless of the approach selected, it should be under the care of a physician with experience treating prostate cancer.

• Metastaticprostate cancer:

• Overview of management options: When prostate cancer has spread beyond the prostate, it is said to be "metastatic" or to have metastasized. The most common areas of metastasis are the bones (especially ribs, spine, skull, and pelvis) and lymph nodes, and less commonly the lungs and liver. Once the cancer spreads to the bones, liver, or lungs, it cannot be cured, and treatments are aimed at controlling the growth of the cancer for as long as possible. The standard initial treatment for metastatic prostate cancer is hormonal therapy. Chemotherapy is generally not given unless the cancer becomes resistant to the effects of hormonal therapy. Generally, the prostate area itself is not treated if the cancer has metastasized, although in some cases if there is a lot of cancer in the prostate area, radiation may be given for "local control" to avoid complications from the cancer growing too large in the pelvis area.

• Hormonal therapy: "Hormone therapy" is a potentially confusing term, as the goal of this treatment approach is actually to block the effects of the normal male hormone, testosterone, on prostate cancers. This is because testosterone stimulates the growth of prostate cancer cells. There are several stages of hormone therapy that can be used as the cancer becomes resistant to each prior stage.

• Castration (surgical or with medications): The initial stage of hormonal therapy involves blocking most of the body's production of testosterone ("castration"). This can either be done by surgical castration (surgical removal of the testicles) or with injected medications ("pharmacologic" or "chemical" castration). The medications are called luteinizing hormone-releasing hormone (LHRH) agonists or gonadotropin releasing hormone (GnRH) antagonists and include leuprolide (Eligard®, Lupron®, Lupron Depot®, Viadur®), goserelin (Zoladex®), and buserelin (Suprefact®). Side effects most commonly include hot flashes, erectile dysfunction (impotence), loss of sexual desire, weight gain, and fatigue. Less commonly men may experience diminished concentration and skin changes. Bone loss occurs and therefore a baseline bone mineral density test should be conducted, treatment with calcium and vitamin D should be started, and a bone-strengthening medicine such as a bisphosphonate should be considered. Recently, hormonal therapy has been linked to a possible increased risk of diabetes or heart disease, although further studies are necessary to determine if a link truly exists. Therefore, people with increased risk of these conditions should discuss the risks vs. potential benefits of this therapy with a doctor. Patients who begin hormone therapy may experience an increase in prostate cancer symptoms for approximately two weeks after starting this treatment due to a temporary increase in testosterone levels, and therefore 2-4 weeks of a different medication (antiandrogen) may be given initially to mute this effect.

• Antiandrogens: Antiandrogens are pills that block the action of testosterone on prostate cells. Examples are bicalutamide (Casodex®), nilutamide (Nilandron®, Anadron®), and flutamide (Eulexin®). They are often added when a prostate cancer becomes resistant to castration treatment alone. Breast enlargement and tenderness can occur, and to prevent breast enlargement, some patients undergo a single radiation treatment to the breast area (which should be given before starting the antiandrogen). Patients taking antiandrogens should undergo periodic liver function tests and should report symptoms such as nausea, vomiting, stomach pain, fatigue, appetite loss, dark urine, or yellowing of the eyes to a physician immediately. Diabetic patients should follow blood sugars closely when beginning therapy. If a cancer progresses during treatment with an antiandrogen, withdrawal of the antiandrogen should be done to see if the action of taking away the antiandrogen shrinks the cancer. If the cancer grows again, then a different antiandrogen may be considered.

• Adrenal agents: Drugs that can prevent the adrenal glands from making androgens (male sex hormones) include ketoconazole. An adrenal agent can be considered if a cancer progresses despite treatment with castration plus an antiandrogen. The adrenal agent should be started at a low dose and gradually increased by the treating physician as appropriate. At higher doses, a steroid pill such as hydrocortisone should be given with the adrenal therapy. Side effects can include drowsiness, dizziness, headache, weakness, nausea, or loss of appetite especially during the first few weeks of treatment. If these symptoms are severe, a physician should be contacted immediately. Liver function tests should be monitored during this treatment.

• Estrogens: Estrogens (hormones that promote female sex characteristics) were previously used to treat prostate cancer, but are seldom used today because of the risk of serious side effects, including blood clots.

• Chemotherapy: Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Chemotherapy is often used to treat advanced prostate cancers that are resistant to hormonal treatments. A medical oncologist (cancer specialist) will usually recommend a single drug or a combination of drugs. As of 2008, the only U.S. Food and Drug Administration (FDA)-approved chemotherapy for prostate cancer shown to lengthen life and improve quality of life is docetaxel (Taxotere®). Mitoxantrone (Novantrone®) has also been approved by the FDA for prostate cancer, but has not been shown to lengthen life and is only beneficial in a small percent of patients. Other chemotherapy medications sometimes used to treat prostate cancer include paclitaxel (Taxol®), carboplatin, and, less commonly, doxorubicin (Adriamycin®) or oral etoposide. For rare cases of "small cell" or neuroendocrine prostate cancer, intravenous etoposide and a platinum agent may be used. Side effects of chemotherapy depend on the type of drug used, dosage, and length of treatment. The most common side effects are fatigue, nausea and vomiting, diarrhea, hair loss, anemia, and increased susceptibility to infection due to lowered white blood cell counts. Radiopharmaceuticals such as samarium (Quadramet®) may be used as a palliative measure to treat bone pain.

• Clinical trials: Many new drugs including "targeted" agents, vaccine-type therapies, and new chemotherapies are in development. A treating oncologist may offer enrollment in a trial to patients with prostate cancer. An "informed consent" document will be given to a patient that explains the potential risks and benefits of the trial. Information from clinical trials is used to improve therapies for future patients and is an opportunity to receive a new treatment approach that is not otherwise available.

• Hospice and end-of-life care: When a patient has not responded to treatment methods, is too frail to receive further therapy, or the prognosis is not good, palliative care can be started with a goal of comfort and to provide symptomatic relief and dignity. Hospice services are available as inpatient facilities or in the home with hospice nurses visiting as necessary. Hospice options can be discussed with an oncologist's office.

Integrative Therapies

• Strong scientific evidence:

• Pygeum: Pygeum (P. africanum bark extract) has been observed to moderately improve urinary symptoms associated with enlargement of the prostate gland or prostate inflammation. Numerous human studies report that pygeum significantly reduces urinary hesitancy, urinary frequency, the number of times patients need to wake up at night to urinate, and pain with urination in men who experience mild-to-moderate symptoms. However, pygeum does not appear to reduce the size of the prostate gland or reverse the process of benign prostatic hypertrophy. Avoid if allergic or hypersensitive to pygeum.

• Saw palmetto: Numerous human trials report that saw palmetto (Serenoa repens) improves symptoms of benign prostatic hypertrophy such as nighttime urination, urinary flow, and overall quality of life, although it may not greatly reduce the size of the prostate. Although the quality of these studies has been variable, overall they suggest effectiveness.

• Avoid if allergic or hypersensitive to saw palmetto. Use cautiously with a history of health conditions involving the stomach, liver, heart, or lungs; hormone-sensitive conditions; or bleeding disorders. Use cautiously with drugs that thin the blood or hormonal drugs.

• Good scientific evidence:

• Beta-sitosterol: Beta-sitosterol and beta-sitosterol glucoside have been used to treat symptoms of benign prostatic hypertrophy. Additional clinical study is needed before a firm conclusion can be made.

• Avoid if allergic or hypersensitive to beta-sitosterol, beta-sitosterol glucoside, or pine. Use cautiously with asthma or breathing disorders, diabetes, primary biliary cirrhosis (destruction of the small bile duct in the liver), ileostomy, neurodegenerative disorders (such as Parkinson's disease or Alzheimer's disease), bulging of the colon, short bowel syndrome, celiac disease, or sitosterolemia. Use cautiously with a history of gallstones.

• Selenium: Selenium is a trace mineral found in soil, water, and some foods. It is an essential element in several metabolic pathways. There is some evidence that low selenium levels are associated with an increased risk of prostate cancer. In human studies, initial evidence has suggested that selenium supplementation reduces the risk of developing prostate cancer in men with normal baseline PSA (prostate specific antigen) levels, and low selenium blood levels. Selenium deficiency may be diagnosed by measuring the selenium in the blood where the normal level is 70 nanograms per milliliter or ng/ml in blood plasma (liquid component) or 90 ng/ml in red blood cells, where the normal values are indicated. Laboratory studies have reported several potential mechanisms for selenium's beneficial effects in prostate cancer prevention, including a decrease in androgen receptors and PSA production, angiogenesis (growth of new blood vessels in tumors) inhibition, and increased antioxidant effects including cancer cell apoptosis (cell death).

• Avoid if allergic or sensitive to products containing selenium. Avoid with a history of nonmelanoma skin cancer.

• Unclear or conflicting scientific evidence:

• Acupuncture: Acupuncture, or the use of needles to manipulate the "chi" or body energy, originated in China over 5,000 years ago. While limited evidence suggests benefit may be possible, there is insufficient available evidence to recommend either for or against the use of acupuncture in prostatitis.

• Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, or neurological disorders. Avoid on areas that have received radiation therapy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.

• African wild potato: African wild potato has been studied as a possible treatment option for benign prostatic hyperplasia. Additional research is needed to make a conclusion.

• Avoid if allergic or hypersensitive to African wild potato or any species of the Hypoxidaceae family. Use cautiously with diabetes, liver disease or damage, HIV/AIDS, and kidney disease or damage.

• Calcium: Calcium is the most abundant mineral in the human body. There is currently a lack of agreement among studies on the relationship between calcium and prostate cancer risk. Until this is clarified, it is reasonable for men to consume recommended intakes as per the Food and Nutrition Board of the Institute of Medicine. Treatment of prostate cancer should only be done under the supervision of a qualified healthcare professional.

• Avoid if allergic or hypersensitive to calcium or lactose. High doses taken by mouth may cause kidney stones. Avoid with high levels of calcium in the blood, high levels of calcium in urine, hyperparathyroidism (overgrowth of the parathyroid glands), bone tumors, digitalis toxicity, ventricular fibrillation (rapid, irregular twitching of heart muscle), kidney stones, kidney disease, or sarcoidosis (inflammatory disease). Calcium supplements made from dolomite, oyster shells, or bone meal may contain unacceptable levels of lead. Use cautiously with achlorhydria or irregular heartbeat.

• Coenzyme Q10: Limited available study using a combination that included CoQ10 did not find a significant effect on PSA levels in patients with prostate cancer. Although PSA levels may be an indicator of cancer, it is unclear whether CoQ10 would have any effect on cancer treatment of prevention. More study is needed in this area.

• Allergy associated with Coenzyme Q10 supplements has not been reported, although rash and itching have been reported rarely. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Use caution with a history of blood clots, diabetes, high blood pressure, heart attack, or stroke, or with anticoagulants (blood thinners) or antiplatelet drugs (like aspirin, warfarin, clopidogrel (like Plavix®), or blood pressure, blood sugar, cholesterol or thyroid drugs.

• Danshen: Danshen (Salvia miltiorrhiza) is widely used in traditional Chinese medicine (TCM), often in combination with other herbs. Early studies have found that danshen in combination with routine western medicine was not as effective as warming needle moxibustion for prostatitis. More studies are warranted in this area.

• Avoid if allergic or hypersensitive to danshen. Use cautiously if taking sedatives, hypolipidemics, cardiac glycosides, CYP-metabolized agents, nitrate ester, steroidal agents, or some anti-inflammatories (e.g. ibuprofen). Use cautiously with altered immune states, arrhythmia, compromised liver function, or a history of glaucoma, stroke, or ulcers. Stop use two weeks before and immediately after surgery/dental/diagnostic procedures with bleeding risks. Use cautiously if driving or operating heavy machinery. Avoid if taking blood thinners (anticoagulants), digoxin, or hypotensives, including ACE inhibitors (e.g. captopril), or Sophora subprostrata root or herba serissae. Avoid use after cerebral ischemia.

• Flaxseed and flaxseed oil: Flaxseed (Linum usitatissimum) and its derivative flaxseed oil/linseed oil are rich sources of the essential fatty acid alpha-linolenic acid, which is a biologic precursor to omega-3 fatty acids such as eicosapentaenoic acid. There is limited high quality research of the effects of flaxseed or alpha-linolenic acid (which is in flaxseed) on prostate cancer risk. This area remains controversial as there is some data reporting possible increased risk of prostate cancer with alpha linolenic acid. Prostate cancer should be treated by a medical oncologist.

• Flaxseed has been well-tolerated in studies for up to four months. Avoid if allergic to flaxseed, flaxseed oil or other plants of the Linaceae family. Avoid large amounts of flaxseed by mouth and mix with plenty of water or liquid. Avoid flaxseed (not flaxseed oil) with history of esophageal stricture, ileus, gastrointestinal stricture or bowel obstruction. Avoid with history of acute or chronic diarrhea, irritable bowel syndrome, diverticulitis, or inflammatory bowel disease. Avoid topical flaxseed with open wounds or abraded skin surfaces. Use cautiously with history of a bleeding disorder or with drugs that cause bleeding (like anticoagulants and non-steroidal anti-inflammatories (like aspirin, warfarin, Advil®)), high triglyceride levels, diabetes, mania, seizures or asthma. Avoid ingestion of immature flaxseed pods.

• Lycopene: High levels of lycopene are found in tomatoes and in tomato-based products. Tomatoes are also sources of other nutrients such as vitamin C, folate, and potassium. Early studies examining tomato-based products and blood lycopene levels suggest that lycopene may be associated with a lower risk of developing cancer and may help stimulate the immune system. Laboratory studies have reported that lycopene inhibits the growth of prostate cancer cells. Patients diagnosed with benign prostatic hypertrophy or enlarged prostate may be at an increased risk of developing prostate cancer and may benefit from taking lycopene supplements. Further studies are necessary before lycopene may be recommended. Avoid if allergic to tomatoes or to lycopene.

• Modified citrus pectin: Pectins are gel-forming polysaccharides from plant cell walls, especially apple and citrus fruits. Modified citrus pectin may reduce the metastasis (spread to other areas of the body) of certain types of cancers, including lung, prostate, and breast cancer. More research is needed in this area, especially with other types of cancer and with other criteria for prostate cancer progression.

• Avoid if allergic or hypersensitive to modified citrus pectin. MCP may cause gastrointestinal discomfort in patients allergic or sensitive to MCP. Use cautiously if taking chelating medications or if under treatment for cancer. Use cautiously if taking oral drugs, herbs, or supplements as MCP may reduce or slow their absorption. Use cautiously in geriatric patients or patients with gastrointestinal disorders.

• PC-SPES: Studies of PC-SPES® have reported improvements in patients with prostate cancer. Overall, these studies found prostate-specificantigen (PSA) levels to fall by greater than 50% in most patients, improvements in bone scans and x-rays, reductions in pain scores, and improvements in quality of life. In addition, PC-SPES® extracts were reported to cause cell death (apoptosis) or to slow the growth of cancer cell lines. Because of these complicated circumstances, and the fact that PC-SPES® has never been compared to placebo or standard cancer treatments in a well-reported study, the question of effectiveness remains unclear.

• Note: PC-SPES ® has been recalled from the U.S. market and should not be used. Based on safety concerns associated with PC-SPES®, no dosage is recommended.

• Physical therapy: The goal of physical therapy, or physiotherapy, is to improve mobility, restore function, reduce pain, and prevent further injury. There is currently insufficient available evidence to support the use of physical therapy for chronic prostatitis. Additional studies are needed before a conclusion can be made.

• Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with their qualified healthcare professionals before beginning any treatments. Based on the available literature, physical therapy appears generally safe when practiced by a qualified physical therapist; however, complications are possible. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the physical therapy literature, although causality is unclear. Erectile dysfunction has also been reported.

• Pomegranate: Consumption of pomegranate juice may be beneficial to patients with prostate cancer. Although early study is promising, more study is needed to a make a conclusion.

• Avoid if allergic or hypersensitive to pomegranate. Avoid with diarrhea or high or low blood pressure. Avoid taking pomegranate fruit husk with oil or fats to treat parasites. Pomegranate root/stem bark should only be used under supervision of a qualified healthcare professional. Use cautiously with liver damage or disease.

• Quercetin: Quercetin is one of the almost 4,000 bioflavonoids (antioxidants) that occur in foods of plant origin, such as red wine, onions, green tea, apples, berries, and brassica vegetables (cabbage, broccoli, cauliflower, turnips). There is some evidence that quercetin may be useful for the treatment of chronic prostatitis.

• Quercetin is generally considered safe when taken at doses normally found in foods. Avoid if allergic or hypersensitive to quercetin. Possible eye, skin, gastrointestinal and/or respiratory tract infection can occur.

• Red clover: Red clover is a legume that has plant-based chemicals that are similar to estrogen. Red clover isoflavones may have estrogen-like properties in the body, and have been proposed as a possible therapy in prostate cancer. Well designed human research is lacking in this area. There is also only limited study of red clover for benign prostatic hypertrophy. More research is needed before a firm conclusion can be made.

• Avoid if allergic to red clover or other isoflavones. Use cautiously if taking hormone replacement therapy (HRT). Use cautiously with a history of a bleeding disorder or if taking drugs that thin the blood.

• Saw palmetto: There is not enough scientific evidence to recommend the product PC-SPES® (which contains saw palmetto) for prostate cancer. PC-SPES® also contains seven other herbs (Chrysanthemum morifolium, Isatis indigotica, Glycyrrhiza glabra, Ganoderma lucidum, Panax pseudo-ginseng, Rabdosia rubescens, and Scutellaria baicalensis). It has been a popular treatment for prostate cancer, but the U.S. Food and Drug Administration (FDA) has issued a warning not to use PC-SPES® because it contains the anticoagulant chemical warfarin and may cause bleeding.

• A prospective, randomized, open label, one-year study was designed to assess the safety and efficacy of saw palmetto and finasteride in the treatment of men diagnosed with category III prostatitis/chronic pelvic pain (CP/CPPS). CP/CPPS treated with saw palmetto had no appreciable long-term improvement. In contrast, patients treated with finasteride had significant and durable improvement in multiple parameters except for voiding.

• Avoid if allergic or hypersensitive to saw palmetto. Use cautiously with a history of health conditions involving the stomach, liver, heart, or lungs; hormone-sensitive conditions; or bleeding disorders. Use cautiously with drugs that thin the blood or hormonal drugs.

• Soy: Early research has tested the effects of dietary soy intake on prostate cancer development in humans, but the results have not been conclusive. Better research is needed before a recommendation can be made for prostate cancer prevention.

• Caution is advised when taking soy supplements, as numerous adverse effects including an increased risk of drug interactions are possible.

• Stinging nettle: Stinging nettle is used rather frequently in Europe in the treatment of symptoms associated with benign prostatic hyperplasia. Early evidence suggests an improvement in symptoms, such as the alleviation of lower urinary tract symptoms associated with stage I or II BPH, as a result of nettle therapy. Additional study is warranted in this area.

• Avoid if allergic or hypersensitive to nettle, members of the Urticaceae family, or any ingredient of nettle products. Use cautiously with diabetes, bleeding disorders, low sodium levels in the blood). Use cautiously with diuretics and anti-inflammatory drugs. The elderly should also use nettle cautiously.

• Vitamin C (ascorbic acid): Dietary intake of fruits and vegetables high in vitamin C has been associated with a reduced risk of various types of cancer in population studies. However, it is not clear that it is specifically the vitamin C in these foods that is beneficial, and vitamin C supplements have not been found to be associated with this protective effect. Experts have recommended increasing dietary consumption of fruits and vegetables high in vitamin C, such as apples, asparagus, berries, broccoli, cabbage, melon (cantaloupe, honeydew, watermelon), cauliflower, citrus fruits (lemons, oranges), fortified breads/grains/cereal, kale, kiwi, potatoes, spinach, and tomatoes. Vitamin C has a long history of adjunctive use in cancer therapy, and although there have not been any definitive studies using intravenous (or oral) vitamin C, there is evidence that it has benefit in some cases. Vitamin C has been used in prostate cancer, however, there is currently a lack of evidence to determine its specific effect in this condition.

• Avoid if allergic or sensitive to vitamin C product ingredients. Vitamin C is generally considered safe in amounts found in foods. Vitamin C supplements are also generally considered safe in most individuals if taken in recommended doses. Large doses (greater than 2 grams) may cause diarrhea and gastrointestinal upset. Avoid high doses of vitamin C with glucose 6-phosphate dehydrogenase deficiency, kidney disorders or stones, cirrhosis (inflammation of the liver), gout, or paroxysmal nocturnal hemoglobinuria (bleeding disorder).

• Vitamin E: The role of vitamin E supplementation for prostate cancer prevention is controversial. There are numerous laboratory studies that support possible anti-cancer properties. However, the results of population research and human research have been mixed, with some studies reporting benefits and others finding no effects. Vitamin E succinate (one specific form of vitamin E) has been reported in laboratory studies to inhibit the growth of human prostate cancer cells.

• Caution is merited in people undergoing chemotherapy or radiation, because it has been proposed that the use of high-dose antioxidants may actually reduce the anti-cancer effects of these therapies. This remains an area of controversy and studies have produced variable results. Patients interested in using high-dose antioxidants such as vitamin E during chemotherapy or radiation should discuss this decision with their medical oncologist or radiation oncologist. Caution is advised when taking vitamin E supplements, as numerous adverse effects including an increased risk of bleeding and drug interactions are possible. Avoid if allergic or hypersensitive to vitamin E. Avoid with retinitis pigmentosa (loss of peripheral vision). Use cautiously with bleeding disorders or if taking blood thinners.

• Zinc: Early studies suggest that zinc supplements taken with antibiotics may be more effective than antibiotics alone for reducing pain, urinary symptoms, quality of life, and maximum urethra closure pressure for patients with chronic prostatitis (CP). Further research is needed to confirm these results.

• Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness.

• Fair negative scientific evidence:

• Vitamin D: There is preliminary evidence suggesting that high-dose vitamin D may be beneficial in the treatment of prostate cancer. This area is under active investigation, but clear evidence of benefit is not yet available.

• Avoid if allergic or hypersensitive to vitamin D or any of its components. Vitamin D is generally well-tolerated in recommended doses; doses higher than recommended may cause toxic effects. Use cautiously with hyperparathyroidism (overactive thyroid), kidney disease, sarcoidosis, tuberculosis, and histoplasmosis.

Prevention

• Generally, benign prostatic hyperplasia (BPH) and prostatitis cannot be prevented. Proper nutrition is important, such as eating plenty of fresh vegetables and decreasing the amounts of refined carbohydrates, such as sugars and white breads.

• Prostate screening: The American Urological Association (AUA) encourages men who are in good health to have annual prostate specific antigen (PSA) testing starting at age 50, or at age 40 if they're in high-risk groups, such as African American men or those with a father, brother, or son with BPH.

• Vaccine: A new vaccine, although not FDA-approved, has been developed to help extend survival for patients with deadly metastatic prostate cancer. The FDA has requested additional clinical data before the vaccine, called Provenge®, can be approved. The vaccine is targeted at individuals with prostate cancer who have ceased responding to hormone therapy and have cancer that has spread to other organs and tissues. Reported side effects include fever, chills, and fatigue (tiredness).

• Lifestyle changes: Diets should include less high-fat dairy products, such as cheese, sour cream, and ice cream. High fat dairy products and the calcium contained in dairy may increase the risks of developing prostate cancer.

• Cruciferous vegetables (such as broccoli, cabbage, and cauliflower) have been reported to contain cancer-fighting phytochemicals that may decrease the chances of developing prostate cancer. Antioxidant containing foods, including fruits (such as berries, grapes, and tomatoes) and vegetables (such as peppers and carrots) may help prevent the development of prostate cancer.

• Dietary consumption of red meat and/or processed meats may increase the risks of developing cancer of the colon, rectum, stomach, pancreas, bladder, ovaries, prostate, breasts, and lungs and other diseases such as heart disease, rheumatoid arthritis, type 2 diabetes, and Alzheimer's disease.

• Exercise (at least 30 minutes daily for five days a week), smoking cessation, and relaxation all may contribute to decreasing the risk of developing prostate cancer.

Author Information

• This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

1. American Academy of Family Physicians. http://familydoctor.org.

2. American Cancer Society. www.cancer.org.

3. American Urological Association. www.auanet.org.

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9. Prostate Cancer Foundation. www.prostatecancerfoundation.org.

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