1. health and fitness
2. disease
3. cancer

Cancer Association of South Africa
(CANSA)
Fact Sheet
on
Prostate Cancer
Introduction
The prostate is part of the male reproductive
system. It is a round gland, about the size of a
pea at birth and has the size and shape of a
walnut in adult life. It lies in the pelvic cavity
immediately in front of the rectum. It surrounds
the commencement of the urethra (urinary tube)
at the base of the urinary bladder. It produces
seminal fluid that assists in transporting the
sperm during ejaculation.
Prostate cancer is one of the leading cancers in
males worldwide. It is the most prevalent cancer
among White South African males. However,
recent statistics indicate that Black males are at
increased risk of prostate cancer and often
develop an aggressive type of prostate cancer
(Men’s Health 4-men).
[Picture Credit – Male Pelvis]
Incidence of Prostate Cancer in South Africa
The following South African statistics regarding histologically diagnosed cases of prostate
cancer during 2007 are available from the National Cancer Register (2007):
The following South African statistics regarding prostate cancer are available from the
National Cancer Register (2007):
Group
All males
No of
Cases
4 345
Lifetime
Risk
1:24
The frequency of histologically diagnosed cases of prostate cancer in South Africa for 2007
was as follows (National Cancer Register, 2007):
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved for Distribution by Ms Elize Joubert, Acting Chief Executive Officer
May 2014
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Group
All males
0 – 19
Years
0
20 – 29
Years
2
30 – 39
Years
6
40 – 49
Years
95
50 – 59
Years
748
60 – 69
Years
1 626
70 – 79
Years
1 301
80+
Years
443
Prostate cancer is caused by changes in the DNA of a normal prostate cell. DNA makes up
the genes, which control how cells behave. DNA is inherited from our parents. A small
percentage (about 5 to 10%) of prostate cancers are linked to these inherited changes
(American Cancer Society).
Research shows that men with BRCA1/2 mutations were more likely than non-carriers to be
diagnosed with advanced-stage prostate cancer or cancer that had already spread.
Risk Factors
The following are the known risk factors for prostate cancer:
o
Age: it occurs more frequently in older men. Most men diagnosed with prostate
cancer are over 65 years of age. The disease is rare in men under 45 (National
Cancer Institute)
o
Family history: Prostate cancer seems to run in some families, and scientists have
found several inherited genes that seem to raise prostate cancer risk
Risk Group
Brother(s) with prostate cancer diagnosed at any age
Father with prostate cancer diagnosed at any age
One affected first-degree relative diagnosed at any age
Affected first-degree relatives diagnosed <65 years
Affected first-degree relatives diagnosed ≥65 years
Second-degree relatives diagnose at any age
Two or more affected first-degree relatives diagnosed at any age
Relative Risk for
Prostate Cancer
(95% Confidence
Index) *
3.14
2.35
2.48
2.87
1.92
2.52
4.39
(2.37 – 4.15)
(2.02 – 2.72)
(2.25 – 2.74)
(2.21 – 3.74)
(1.49 – 2.47)
(0.99 – 6.46)
(2.61 – 7.39)
(*) Adapted from Kiciński, at al (2011)
If there is a family history of the BRCA1 or BRCA2 gene mutation or a very strong
history of women with breast cancer, the risk for prostate cancer may be higher
o
Inheritance of prostate cancer risk: epidemiologic studies (case-control, cohort, twin,
and family) strongly suggest that prostate cancer susceptibility genes exist and play
an important role in the development of prostate cancer (National Cancer Institute;
Lichtenstein, et al., 2000)
o BRCA1 Gene Mutation: Men with a BRCA1 gene mutation has a 3.4-fold
increased risk for prostate cancer
o
BRCA2 Gene Mutation: Men with a BRCA2 gene mutation has an 8.6-fold
increased risk for prostate cancer
o
Lifestyle: high fat intake, high red meat intake, low consumption of vegetables,
obesity, lack of physical activity, and smoking are associated with prostate cancer
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved for Distribution by Ms Elize Joubert, Acting Chief Executive Officer
May 2014
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risk (Kolonel, 2001; Hickey, et al., 2001; Gong, et al., 2007; Kristal & Gong, 2007;
MedlinePlus)
o
High alcohol intake - usually stated as more than two (2) standard alcoholic drinks
per day (MedlinePlus)
o
A standard alcoholic drink is the equivalent of:
 340ml beer (average 5% alcohol by volume)
 120ml wine
 25ml liqueur
 50ml sherry
 25ml spirits (such as brandy, whiskey, gin, vodka and cane) (Life is Beautiful).
o
Race: Although most prevalent in White men, prostate cancer is becoming more
common among Black men (National Cancer Institute)
o
Men who took 400 international units (I.U.) of synthetic Vitamin E daily had more
prostate cancers compared to men who took a placebo (National Institutes for
Health)
o
Use of Anabolic Steroids:- The use of anabolic steroids may have the following side
effects (University of Northern Colorado):






Infertility (low sperm count)
Impotence
Testicular shrinkage
Baldness
Testicular/prostate cancer
Enlarged breast tissue
Having had a vasectomy does NOT increase the risk for prostate cancer (Stanford, et al,
1999)
In the past few years, we’ve learned that prostate cancer really is several diseases with
different causes. More aggressive and fatal cancers have different underlying causes than
slow-growing tumours.
For example, while smoking has not been thought to be a risk factor for low-risk prostate
cancer, it may be a risk factor for aggressive prostate cancer. Likewise, lack of vegetables in
the diet (especially broccoli-family vegetables) is linked to a higher risk of aggressive
prostate cancer, but not to low-risk prostate cancer.
Body mass index is a measure of obesity and should not be used as diagnosis of prostate
cancer although obese men are more likely to have aggressive prostate cancer.
PSA levels should also not be used diagnostically for prostate cancer in obese men as they
may have a relatively lower PSA than non-obese men due to dilution of the PSA in a larger
blood volume.
Other risk factors for aggressive prostate cancer include:
o Lack of exercise and a sedentary lifestyle
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved for Distribution by Ms Elize Joubert, Acting Chief Executive Officer
May 2014
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o
o
o
High calcium intake
Family history
Agent Orange exposure
Early Warning Signs of Prostate Cancer
Early warning signs of prostate cancer include:
o Difficulty in passing urine
o A slow stream, often with dribbling at the end
o Inability to start or stop the flow of urine
o Frequent need to pass urine, especially at night
o Swelling in legs
o Discomfort in pelvic area
(Prostate Cancer Warning Signs; Mayo Clinic).
These early symptoms may be related to other factors such as inflammation of the prostate
called prostatitis or enlargement of the prostate (benign prostate hyperplasia) or benign
prostatic hypertrophy which are non-cancerous.
Late Warning Signs of Prostate Cancer
Late warning signs of prostate cancer include:
o Inability to pass urine
o Lower back pain
o Blood in the urine or semen
o Painful ejaculation
o Erectile dysfunction
o Weight loss
o Bone pain
(Prostate Cancer Warning Signs; Mayo Clinic)
Types of Prostate Cancer
There are many types of prostate cancer and the condition is often present in many different
parts of the prostate. The precursor to prostate cancer is known as prostatic intraepithelial
neoplasia, this is also found in many different locations within the prostate.
Although there are many different kinds of prostate cancer the vast majority (around 95%)
are of the type known as adenocarcinoma. As this type of cancer is the most widespread
form of prostate cancer it has become synonymous with the term prostate cancer.
Adenocarcinoma - The most common site of origin of prostate cancer is in the peripheral
zone (the main glandular zone of the prostate). The term adenocarcinoma can be split up to
derive its meaning. ‘Adeno’ means ‘pertaining to a gland’, whilst ‘Carcinoma’ relates to a
cancer that develops in epithelial cells. The term ‘epithelial’ simply relates to cells that
surround body organs or glands and basal cell carcinoma
Small cell carcinoma - This kind of cancer is made up of small round cells and typically forms
at nerve cells. Small cell carcinoma is very aggressive in nature and as it does not lead to an
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved for Distribution by Ms Elize Joubert, Acting Chief Executive Officer
May 2014
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increase in prostate specific antigen (PSA) it can be somewhat harder to detect than
adenocarcinoma - this usually means that it has reached an advanced form upon detection.
Squamous cell carcinoma - This is a non-glandular cancer, like small cell carcinoma there is
no increase in prostate specific antigens (PSA) when this is present. Squamous cell
carcinoma is very aggressive in nature.
There are other, more rare, forms of prostate cancer. These include sarcomas and
transitional cell carcinoma; the latter rarely develop in the prostate but derives from primary
tumours present in the bladder or urethra.
(Prostate Cancer Guide).
Screening and Diagnosis of Prostate Cancer
Screening and diagnosis of prostate cancer includes:
o Digital rectal examination (DRE) by a
doctor where the doctor inserts a
lubricated, gloved finger into the rectum to
examine the prostate
o Urine test to check for the presence of
blood
o Measurement of Prostate Specific Antigen
(PSA) which is discussed in more detail
below. The prostate normally secretes
small amounts of PSA, A higher level may
indicate a problem with the prostate. It
may be cancer or merely an enlarged
prostate caused by infection.
(National Cancer Institute).
[Picture Credit – Digital Rectal Examination]
The above tests can only detect whether there is a problem in the prostate. They cannot
show whether the problem is cancer or a less serious condition.
The following examinations are done to determine the presence of cancer:
Transrectal ultrasound – a probe is inserted into the rectum to check the prostate for
abnormal areas. The probe sends out sound waves that cannot be heard. The waves
bounce off the prostate to create a picture called a sonogram.
Transrectal biopsy – a biopsy is the removal of tissue to look for cancer cells. It is the
only sure way to diagnose prostate cancer. The doctor inserts needles through the rectum
into the prostate. A small piece of tissue is removed from various areas of the prostate.
Transrectal ultrasound is usually used to guide the insertion of the needles. The tissue
samples are checked by a pathologist for the presence of cancer cells (National Cancer
Institute).
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved for Distribution by Ms Elize Joubert, Acting Chief Executive Officer
May 2014
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Prostate Specific Antigen
Prostate Specific Antigen (PSA) is a protein produced by both cancerous (malignant) and
non-cancerous (benign) prostate tissue. PSA helps to liquefy the semen. A small amount of
PSA normally enters the bloodstream. Cancer cells usually make more PSA than benign
cellsdo, causing PSA levels in the blood to rise. PSA can also be elevated in men with an
enlarged or inflamed prostate. Therefore, determining what a high PSA score means, can be
complicated (Mayo Clinic).
Prostate Specific Antigen (PSA) test is a blood test which is done to determine the presence
of prostate abnormalities including prostate cancer, however, PSA is not prostate cancer
specific.
PSA is the most widely used test for the possible detection of prostate cancer today and is
simple to do.
A small sample of blood is taken, usually from a vein in the arm, and is tested for the
presence of prostate specific antigen (PSA). PSA level determination can now also be done
by means of a finger-prick test with the result becoming available in a few minutes.
PSA levels can be elevated by a number of causes.
Causes of elevated PSA levels include:
o Prostate cancer – the presence of prostate cancer cells increases PSA levels.
o
Benign Prostatic Hyperplasia – this non-cancerous condition is simply an ‘enlarged
prostate’. It is common in older men and, unlike cancer, has to risk of spreading
throughout the body
o
Prostatitis – inflammation of the prostate due to bacterial infection. This is mostly an
acute condition, but some men may have chronic prostatitis
o
Infection of the bladder – this is called cystitis and should be treated prior to having a
PSA test done
o
Recent ejaculation – having ejaculated within the previous 24-48 hours prior to PSA
testing. To prevent this, the patient should be advised to avoid any sexual activity for
at least a couple of days before having a PSA test
o
Prostate biopsy – men who recently undergone a prostate biopsy will have an
artificially elevated PSA. After biopsy, one should wait a few weeks before having a
PSA level test
o
Digital Rectal Examination (DRE) – a digital rectal examination may also cause an
artificial increase in PSA levels, therefore, blood should be drawn for the PSA
determination prior to a DRE examination
Bicycle riding – there is insufficient evidence to substantiate claims that bicycle riding
has the potential to increase the PSA blood levels (Crawford, et al., 1996).
(Prostate Cancer Watchful Waiting; LabTestOnLine; Mayo Clinic).
o
Only about 1 in 4 men who have a positive (elevated) PSA test turns out to have prostate
cancer (Mayo Clinic).
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved for Distribution by Ms Elize Joubert, Acting Chief Executive Officer
May 2014
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PSA results show the level of PSA detected in the blood. The results are usually reported as
nanograms of PSA per millilitre (ng/ml) of blood. In the past a PSA level below 4.0ng/ml was
taken to be normal. There is, however, no normal or abnormal PSA level. In addition, as
indicated above, there are several causes of an increase in a man’s PSA level. It is also
common for PSA values to vary somewhat from laboratory to laboratory and also at differing
intervals. One ‘abnormal’ PSA test result does not necessarily indicate the need for a
prostate biopsy.
(National Cancer Institute).
The Prostate Health Index (PHI) Test
Prostate Health Index (phi), a more precise blood test, outperformed traditional PSA
screening in predicting clinically significant prostate cancer. There is no clear indication
when this test will be available in South Africa.
The Prostate Health Index (phi), a blood test used to evaluate the probability of prostate
cancer diagnosis, outperformed commonly used prostate-specific antigen (PSA) and
free/total prostate-specific antigen (%fPSA) tests in predicting the presence of clinically
significant prostate cancer and in improving prostate cancer detection, according to a new
study.
The phi combines measurements of %fPSA(percent of protein-attached and protein-free
PSA circulating in the bloodstream) and a subcategory of free PSA called pro-PSA, and is
estimated to be 2.5 times more specific in detecting prostate cancer in patients than a PSA
screening. The phi was approved by the US Food and Drug Administration (FDA) in June
2012 and has been available since late 2012. The study also found using a specific phi
benchmark level may help identify biopsy candidates and reduce over-detection of indolent
(slow-growing) prostate cancer.
“The phi can play a valuable role in determining whether an elevated PSA is likely due to
prostate cancer or benign changes,” said Brant Thrasher, MD, chair of Urology, University of
Kansas Medical Center, Kansas City, KS. “This option may prevent patients from potentially
undergoing unnecessary biopsies.”
Study Details - Researchers at several leading institutions in the United States and the
Netherlands, including Harvard Medical School and Johns Hopkins University, investigated
whether the use of phi, as compared to total PSA and %fPSA, can reduce unnecessary
biopsy and over-detection of indolent prostate cancer, while improving the detection of
aggressive prostate cancer.
The study consisted of 658 participants who were 50 years of age or older with a biopsyconfirmed prostate cancer diagnosis, a final PSA between 4-10 ng/mL and a benign rectal
examination. Study investigators evaluated prediction of clinically significant cancer
(aggressive histopathology per Epstein criteria or Gleason 7+) based on pre-biopsy
measures of pro-PSA, total PSA, fPSA, %fPSA and phi and evaluated prospects for
eliminating unnecessary biopsies based on results of phi prior to biopsy.
The researchers found:
o At 90 percent sensitivity, the specificity of phi was 31.1 percent, compared to 19.8
percent for %fPSA (p=0.024) and 10.8 percent for PSA (p<0.001).
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved for Distribution by Ms Elize Joubert, Acting Chief Executive Officer
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o
o
At a moderate to high phi range of 27 to 55, the probability of cancer varied from 9.8
to 50.1 percent and the probability of clinically significant cancer extended from 3.9 to
28.9 percent.
At a phi level of 27, which is the 90 percent sensitivity cut-point, 18.8 percent of men
could have been spared from undergoing prostate biopsy or over-diagnosis of nonaggressive disease.
Study investigators concluded phi outperformed PSA and %fPSA in predicting the presence
of clinically significant prostate cancer and for improving prostate cancer detection.
Additionally, using a phi level of 27 for selecting men for prostate cancer biopsy, when total
PSA is 4 to 10 ng/mL, can decrease unnecessary biopsies and reduce over-detection of
indolent prostate cancer.
(American Urological Association).
Staging of Prostate Cancer
Like other forms of cancer, the prognosis for prostate cancer depends on how far the cancer
has spread at the time it is diagnosed. A system of staging is used to describe prostate
cancer spread. Accurately identifying the prostate cancer stage is extremely important.
Prostate cancer staging helps to determine the optimal treatment as well as prognosis.
The TNM system for describing prostate cancer uses the letters ‘T’, ‘N’, and ‘M’ to signify
‘Tumour’, ‘Nodes’, and ‘Metastasis’.
The following is the breakdown of exactly what each category in this system means.
Primary tumour (T)
TX:
The primary tumour was not or could not be assessed.
T0:
There is no evidence of a primary tumour.
T1:
The tumour could not be found by examination or with the use of imaging (like
ultrasound or an MRI scan), but was incidentally found during a biopsy or surgery.
T1a: The tumour is found in 5% or less of the tissue that was taken.
T1b: The tumour is found in more than 5% of tissue that was taken.
T1c: The tumour was found by needle biopsy after an elevated PSA level.
T2:
The tumour is found only within the prostate itself.
T2a: The tumour is found in 50% or less of one lobe.
T2b: The tumour is found in more than 50% of one lobe.
T2c: The tumour is found in both lobes.
T3:
The tumour has extended through the capsule that surrounds the prostate.
T3a: The tumour has only gone through the capsule without invading the seminal vesicles.
T3b: The tumour has invaded the seminal vesicles.
T4:
The tumour has invaded structures or tissues near the prostate other than the
seminal vesicles. These include the bladder neck, the rectum, and the pelvic wall
along with other structures.
Nodes (N)
NX:
The lymph nodes were not or could not be assessed.
N0:
The nodes do not show evidence of cancer.
N1:
The nodes show evidence of cancer.
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved for Distribution by Ms Elize Joubert, Acting Chief Executive Officer
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Metastasis (M)
MX: The presence of metastases was not or could not be assessed.
M0:
There is no evidence of distant metastasis.
M1:
There is evidence of distant metastasis.
M1a: Cancer has been found in lymph nodes far from the prostate.
M1b: Cancer has been found in the bone.
M1c: Cancer has been found in another area of the body.
(About.Com Prostate Cancer; Cancer Research UK).
The following is the Number Staging Method:
Stage I
The prostate cancer is found in the prostate only. Stage I prostate cancer is microscopic; it
cannot be felt on a digital rectal examination (DRE) and it is not seen on imaging of the
prostate
Stage II
The tumour has grown inside the prostate but has not extended beyond the prostate
Stage III
The cancer has spread outside the prostate, but only barely. Prostate cancer in stage III may
involve nearby tissue like the seminal vesicles
Stage IV
The cancer has spread (metastasised) outside the prostate to other tissues. Stage IV
prostate cancer commonly spreads to lymph nodes, the bones, liver, or lungs
(WebMD).
The Gleason Score
The Gleason score is used to help determine how quickly a tumour may grow or spread. It
may seem confusing because with the Gleason system (the most common system used),
there’s both a ‘grade’ and a ‘score’. The Gleason grade uses numbers 1 to 5. A number is
assigned to two of the areas of the prostate that have the most cancer (based on biopsy
core samples that are taken). This is because the cancer may look different in each of those
two areas. Once those two numbers are determined, they are added together to come up
with the Gleason score, which ranges from 2 to 10.
What the Gleason grades mean
Grade 1: The cells look almost like normal cells (called well differentiated) and are uniformly
spaced in a tight mass.
Grade 2: The cancer cells are still well differentiated, but are arranged more loosely, are
more irregular in shape, and some cells have spread to other prostatic tissue.
Grade 3: The cancer is moderately differentiated; cells vary in size from small to large; and
more cells have invaded other prostatic tissue.
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
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Grade 4: The cancer cells are irregular, distorted, and look
less like normal cells (called poorly differentiated), and there
is considerable spread (called invasion) to other prostatic
tissue.
Grade 5: The cancer cells do not look anything like normal
cells and have spread in haphazard ‘clumps’ of all different
shapes and sizes through the prostate.
[Picture Credit: Gleason Score]
What the Gleason scores mean:
o
o
o
If the score is less than 6, the cancer may be
considered to be well-differentiated or low-grade
cancer
A score of 7 may be considered to be moderately
differentiated or intermediate-grade cancer
A score of 8 to 10 may be considered to be poorly
differentiated or high-grade cancer
According to the American Urological Association, the lowest Gleason score that is usually
found after a biopsy is 5. The cancer is considered to be more aggressive as the score rises.
Scores of 8 to 10 are considered to be the most aggressive, which means that the cancer is
more likely to grow and spread more quickly.
The biopsy results (called the pathology report) will contain other important information that
helps to assess how aggressive the cancer may be.
This includes:
o How many biopsy core samples were positive for cancer
o How much cancer was in each core sample (this is given as a percentage)
o Whether cancer was found in just one side of the prostate gland or in both sides
(which is referred to as bilateral)
(Hisprostatecancer).
How Prostate Cancer Spreads
Prostate cancer most commonly spreads to the bones. It can spread to other organs though.
With prostate cancer, it is sometimes possible to have metastases (cancer spread) present
even when the prostate tumour is still very small. So even if the tumour appears to be very
small, when a bone scan shows that there is cancer in the bones, the prostate cancer is M1
stage. It will be treated as advanced, metastatic cancer. Advanced cancer can often be
controlled for several years with treatment.
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved for Distribution by Ms Elize Joubert, Acting Chief Executive Officer
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Recurrent Prostate Cancer
Prostate cancer may spread as indicated below:
Cancer Type:
Bladder
Breast
Colon
Colorectal
Kidney
Lung
Melanoma
Ovary
Pancreas
Prostate
Stomach
Thyroid
Uterus
Non-melanoma skin cancer
Main Sites of Metastasis (Spread)
Bone, liver, lung
Bone, brain, liver, lung
Liver, lung
Liver, lung, peritoneum (lining of abdomen)
Adrenal gland, bone, brain, liver, lung
Adrenal gland, bone, brain, liver, other lung
Bone, brain, liver, lung, skin, muscle
Liver, lung, peritoneum (lining of abdomen)
Liver lung, peritoneum (lining of abdomen)
Adrenal gland, bone, liver, lung
Liver, lung, peritoneum (lining of abdomen), ovaries
Bone, liver, lung
Bones, liver, lung, peritoneum (lining of abdomen), vagina
Very rare: lymph nodes, lung, bone (if in head/neck region)
(National Cancer Institute).
Treatment for Prostate Cancer
Treatment of prostate cancer can consist of:
Active Surveillance – active surveillance may be chosen if the risks and possible side effects
of treatment outweigh the possible benefits. A doctor may suggest active surveillance with
early-stage prostate cancer that seems to be slow growing. During active surveillance the
doctor will do check-ups every 3 to 6 months, at first. Active surveillance avoids or delays the
side effects of surgery and radiation therapy, but his choice may have risks for some men as
it may reduce the chance to control cancer before it spreads. It may also be more difficult to
cope with surgery or radiation therapy when older.
The concept of active surveillance, or watchful waiting, has increasingly emerged in recent
years as a viable option for men who decide not to undergo immediate surgery or radiation
therapy.
During active surveillance, prostate cancer is carefully monitored for signs of progression. A
PSA blood test and digital rectal exam (DRE) are usually administered periodically along
with a repeat biopsy of the prostate at one year and then at specific intervals thereafter. If
symptoms develop, or if tests indicate the cancer is growing, treatment might be warranted.
Current estimates indicate that many more men are aggressively treated for prostate cancer
than is necessary to save a life from the disease. The challenge has been to identify those
men who do not need immediate therapy, which is usually decided based on age, other
medical conditions, and cancer factors like the PSA, stage, amount of cancer in the biopsy,
and Gleason grade. Research is ongoing to develop biomarkers and additional tests that can
better stratify men at risk so that this decision is easier and more accurately informed.
Today, the man who is ideal for active surveillance has a low grade (Gleason 6 or under),
low-risk prostate cancer (low PSA - usually under 10 and low stage), that appears to be low
in volume (small amount of cancer found on biopsy, for example), and who is not eager to
undergo therapy right away due to concerns about potency preservation or urinary
symptoms.
Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved for Distribution by Ms Elize Joubert, Acting Chief Executive Officer
May 2014
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Active surveillance might also be a good choice for older men with limited life expectancy. In
addition, if a man is currently battling other serious disorders or diseases, such as heart
disease, long-standing high blood pressure, or poorly controlled diabetes, his doctors might
feel it is in his best interest to hold off on therapy and avoid its potential complications.
That is because many of the treatment options for prostate cancer can be difficult to endure,
and better outcomes are seen in men who are otherwise healthy.
Surgery – is an option for men with early (Stage I) prostate cancer. During surgery the whole
prostate, or only part of it, may be removed. There are several types of surgery for prostate
cancer:
Open surgery through the abdomen, called a radical retropubic prostatectomy. The surgeon
removes the entire prostate through a cut in the lower abdomen.
o
o
o
o
o
Open surgery between the scrotum and anus, called a radical perineal
prostatectomy. The surgeon removes the entire prostate through a cut
between the scrotum and the anus.
Laparoscopic prostatectomy – the surgeon removes the entire prostate
through small cuts, rather than a single long cut in the abdomen. A thin,
lighted tube (a laparoscope) helps the surgeon remove the prostate.
Robotic laparoscopic surgery – the surgeon removes the entire prostate
through small cuts. A laparoscope and a robot are used to help remove the
prostate. The surgeon used handles below a computer display to control the
robot’s arms.
Cryosurgery – the surgeon inserts a tool through a small cut between the
scrotum and anus. The tool freezes and kills prostate tissue. Cryosurgery is
currently under study.
Transurethral Resection of the Prostate (TURP) – the surgeon inserts a long,
thin scope through the urethra. A cutting tool at the end of the scope removes
tissue from the inside of the prostate. TURP may not remove all of the cancer,
but it can remove tissue that blocks the flow of urine (National Cancer
Institute).
External radiation therapy (also called radiotherapy) – is usually an option for men with any
stage of prostate cancer. It may also be used after surgery to destroy any cancer cells that
remain in the area. In later stages of prostate4 cancer, radiation treatment may be used to
help relieve pain. It uses high-energy rays to kill cancer cells. It affects cells only in the
treated area. The radiation comes from a large external source and focusses on the area
where the cancer has been diagnosed. Treatments are usually 5 days a week for several
weeks.
Internal radiation therapy (brachytherapy) – the radiation comes from radioactive material
usually contained in very small implants called seeds. Dozens of seeds are placed inside
needles, and the needles are inserted into the prostate. The needles are removed, leaving
the seeds behind. The seeds give off radiation for months. The seeds do not need to be
removed.
The doctor implants the radioactive seeds in your prostate using a needle guided by
ultrasound images. Men who have small, early stage prostate cancers may be considered
Researched and Authored by Prof Michael C Herbst
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for permanent prostate brachytherapy. The treatment may be used alone or in combination
with radiation given outside the body or hormone therapies. Permanent prostate
brachytherapy is minimally invasive and allows patients to resume most normal physical
activities within days.
Permanent prostate brachytherapy uses low-energy radioactive sources. The majority of the
radiation that seeds emit is delivered within 2,5cm of the seed.
Once the seeds are in place, the radiation emitted to tissues around the prostate and to
other people is minimal. People who have received permanent prostate brachytherapy,
however, should follow several radiation safety precautions, including:
o
Limit prolonged close contact (less than 2 metres) for two months after the
implant with children and women who are or may be pregnant
o
Avoid letting children sit on the recipient's lap for prolonged periods (for two
months after the implant)
o
Flush down the toilet any seeds that are passed during urination within the
first few weeks after the implant
o
Avoid sexual intercourse for two weeks after the implant. A seed may be
passed during ejaculation
o The man should wear a condom during sex for two months after the implant
(Mayo Clinic).
Hormone therapy - called anti-androgen therapy that consists of steroidal anti-androgens or
non-steroidal anti-androgens. Testosterone is the most abundant androgen that can cause
the prostate gland to grow and the hormonal therapy blocks this action.
Hormone therapy is treatment to stop your body from producing the male hormone
testosterone. Prostate cancer cells rely on testosterone to help them grow. Cutting off the
supply of hormones may cause cancer cells to die or to grow more slowly.
Hormone therapy options include:
Hormone therapy is used in men with advanced prostate cancer to shrink the cancer and
slow the growth of tumours. In men with early-stage prostate cancer, hormone therapy may
be used to shrink tumours before radiation therapy. This can make it more likely that
radiation therapy will be successful. Hormone therapy is sometimes used after surgery or
radiation therapy to slow the growth of any cancer cells left behind.
Side effects of hormone therapy may include erectile dysfunction, hot flashes, loss of bone
mass, reduced sex drive and weight gain. Hormone therapy also increases the risk of heart
disease and heart attack. (Mayo Clinic)
A man with prostate cancer may have hormone therapy before, during or after radiation
therapy. Hormone therapy is also used alone for prostate cancer that has returned after
treatment.
Male hormones (androgens) can cause prostate cancer to grow. Hormone therapy keeps
prostate cancer cells from getting the male hormones they need to grow. The testicles are
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the body’s main source of the male hormone testosterone. The adrenal gland makes other
male hormones and a small amount of testosterone.
Hormone therapy employs drugs or surgery.
Drugs used in hormone therapy include:
- Luteinising hormone-releasing hormone (LH-RH) agonists: these drugs canprevent the
testicles from making testosterone. . Drugs typically used in this type of hormone therapy
include leuprolide (Lupron, Eligard), goserelin (Zoladex), triptorelin (Trelstar) and histrelin
(Vantas).
- Anti-androgens: these drugs can block the action of male hormones. Examples include
bicalutamide (Casodex), flutamide and nilutamide (Nilandron). These drugs typically are
given along with an LH-RH agonist or given before taking an LH-RH agonist.
- Other drugs: some drugs can prevent the adrenal gland from making testosterone, e.g.
ketoconazole and aminoglutethimide.
Surgery to remove the testicles called an orchidectomy
After an orchidectomy or treatment with an LH-RH agonist, the body no longer gets
testosterone from the testicles.
Androgen Blockage -Because the adrenal gland makes small amounts of male hormones,
the patient may receive an anti-androgen to block the action of the male hormones that
remain. This combination of treatments is known as total androgen blockage.
Chemotherapy - may also be given in advanced stage prostate gland cancer not responding
to hormone therapy (hormone refractory or resistant prostate cancer). Chemotherapy uses
drugs to kill cancer cells. The drugs for prostate cancer are usually given through a vein. The
side effects depend mainly on the drug used. Chemotherapy drugs kill fast-growing cancer
cells, but can also harm normal cells that divide rapidly:
- Blood cells: when chemotherapy lowers the levels of healthy blood cells, infection becomes
a problem. The patient may bruise easily and feel very weak and tired. Regular blood counts
are usually done.
- Cells in hair roots: chemotherapy may cause hair loss. If hair is lost, it will grow back, but it
may change in colour and texture.
- Cells that line the digestive tract: chemotherapy can cause a poor appetite, nausea and
vomiting, or diarrhoea.
- Other side effects may include shortness of breath and oedema. Chemotherapy may also
cause a skin rash, tingling or numbness in the hands and feet, and watery eyes. These side
effects usually dissipate when treatment ends.
Biological therapy - This treatment works with the body's immune system to help it fight
cancer or to control side effects from other cancer treatments. Side effects are how the body
reacts to drugs or other treatments. Biological therapy is different from chemotherapy, which
attacks cancer cells directly.
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High-intensity focused ultrasound - This therapy directs high-energy sound waves
(ultrasound) at the cancer to kill cancer cells.
(Mayo Clinic; National Cancer Institute; Centers for Disease Control and Prevention).
When prostate cancer is at a very early stage or not expected to progress or not suspected
to cause symptoms, the doctor may ‘watch and wait’ (expectant therapy) and monitor the
cancer short term.
(Fred Hutchinson Cancer Research Center).
Prostate Cancer Survival Rates
In the United States of America (USA) the overall 5-year survival rate for prostate cancer is
100%. The 10-year survival rate is 92% and the 15-year survival rate is 70%. These high
prostate cancer survival rates are primarily based on the fact that nearly 91% of cases in the
USA are detected while the cancer is still contained within the prostate or in nearby areas.
For men whose cancer has already spread to distant parts of the body (metastasised), the 5year survival rate is only 32%.
Follow-up Care
Follow-up care is very important. The doctor will check for the return of cancer. Even when
the cancer seems to have been completely removed or destroyed, the disease sometimes
returns because undetected cancer cells may remain somewhere in the body after
treatment.
Check-ups may include a digital rectal examination and a PSA test. The doctor may also
order a biopsy, a bone scan, Computerised Tomography (CT scan) and Magnetic
Resonance Imaging (MRI scan) or other tests.
(National Cancer Institute).
Living with Prostate Cancer
Some treatments for prostate cancer can affect one’s sex life. Many men continue to enjoy
sex throughout their lives and well into old age and may be worried about how treatment for
prostate cancer will affect them.
Treatments can affect:
o ability to get an erection (erectile dysfunction)
o desire to have sex (libido)
o ability to ejaculate and have an orgasm
o fertility
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Living with Prostate Cancer - Frequently Asked Questions about Prostate Cancer and
Sex
Will the person be able to have sex or masturbate after treatment
This will depend on what type of treatment the patient has had and how he feels. Some men
will have problems with their erections (erectile dysfunction) and some may never get back
the ability to achieve or maintain an erection without the help of treatment.
Can cancer be passed on to one’s partner through ejaculation?
Some men worry that cancer can be transmitted when having sex. It is not possible to pass
cancer through intercourse. Having sex will not affect one’s cancer or the success of the
treatment.
What are the effects of cancer treatment and erectile dysfunction (ED)
Erectile dysfunction (ED) is when the person has difficulty getting or keeping an erection. It is
also known as impotence. It is more likely to occur as men get older. It can have many
possible causes, including treatment for prostate cancer.
Surgery, external beam radiotherapy, brachytherapy, high intensity focused ultrasound
(HIFU) and cryotherapy can all damage the nerves and blood vessels that are needed for an
erection. Hormone therapy reduces levels of the hormone testosterone, which is needed for
sexual desire and erections.
Medical conditions such as diabetes, hypertension, stress and anxiety can also cause ED.
There are a number of treatments available for ED including lifestyle changes, tablets,
injections, pellets and vacuum pumps.
How can prostate cancer treatment affect one’s desire for sex (libido)?
Hormone therapy - Hormone therapy for prostate can reduce, or cause one to lose one’s
desire for sex. This is as a result of the decrease in testosterone, which is the hormone
responsible for giving one 'sex drive'. A study suggested that about 50 per cent of men
taking a type of hormone therapy called LHRH agonists or who have had surgery to remove
their testicles (orchidectomy) will lose their interest in sex.
'Intermittent hormone therapy' can be discussed with one’s doctor or counsellor. For some
men desire for sex may return after hormone treatment is stopped, but this varies. It can take
three to nine months or sometimes longer for side effects of hormone therapy to wear off.
Physical and emotional impact - Testosterone is not the only factor that can affect one’s sex
drive. Both physical and psychological factors can also affect how one feels about sex.
Will prostate cancer treatment affect the ability for orgasm and to ejaculate?
If a person has had surgery (radical prostatectomy) he will not be able to ejaculate
afterwards. This is because the prostate and seminal vesicles, which store and transport
semen, are removed during the operation. Instead the person may experience what is
sometimes called a 'dry orgasm' where he feels the sensations of orgasm but do not release
any semen from the tip of the penis. This may feel different to the orgasms the person has
been used to. Occasionally, some men will find that a small amount of liquid comes out from
the tip of the penis during orgasm, which may be fluid from glands lining the urethra.
If the person has had radiotherapy or brachytherapy he may notice that he produces less
semen after completion of treatment. Such individuals should still be able to have an orgasm
but may find that it feels different than before treatment. Some men find that they have less
intense orgasms when they are having hormone therapy
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Will prostate cancer treatment affect the appearance of one’s penis?
Some studies have shown that around 50 per cent of men will find that their penis is shorter
after treatment with surgery (radical prostatectomy). This happens because of changes to
the tissue inside the penis. Men may be less likely to experience these changes if the
surgeon has tried to save the nerves that control erections during surgery (nerve sparing
surgery). Some studies have shown that encouraging blood flow to the penis after surgery
may help you get erections and prevent the penis becoming smaller.
Other types of prostate cancer treatment such as radiotherapy and hormone therapy may
also cause changes to the size of the penis. There is not as much research into this but it
may be less common than changes to men's penis size after surgery.
Changes to one’s body and one’s penis can feel difficult to cope with. Talking to someone
about this might be helpful.
Will prostate cancer treatment affect one’s fertility?
Treatment for prostate cancer can affect one’s ability to produce sperm or ejaculate and lead
to infertility. It may be possible for someone to store some sperm before treatment so that
they can be used later to fertilise an egg. Other infertility treatment options may also be
available.
If the patient is planning to have children he should seek further information from his doctor
or other health professional. The person’s partner should also be included in talks about
plans for having children and what this would involve.
(Prostate Cancer UK).
Masturbation and Prostate Cancer
Masturbation is the deliberate self-stimulation of the genitals to achieve sexual arousal
usually to the point of orgasm (sexual climax). It is commonly done by touching, stroking, or
massaging the penis until an orgasm is achieved.
Why Men Masturbate - in addition to feeling good, masturbation is a good way of relieving
the sexual tension that can build up over time, especially for people without partners or
whose partners are not willing or available for sex. Masturbation also is a safe sexual
alternative for people who wish to avoid pregnancy and the dangers of sexually transmitted
infections. It also is necessary when a man must give a semen sample for infertility testing or
for sperm donation. When sexual dysfunction is present in an adult male, masturbation may
be prescribed by a sex therapist to allow that person to experience an orgasm or to delay its
arrival (WebMD).
The truth about masturbation - throughout history there have been many myths regarding
masturbation. Practically all these myths are false. There is no medical basis for any of
them. Below is the TRUTH about masturbation:
o
o
o
o
o
It does NOT stunt growth
It does NOT cause blindness
It does NOT cause deafness
It does NOT cause one to grow hair on the palms of one’s hands
It does NOT cause stuttering
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o
o
o
o
o
It does NOT cause pimples
It does NOT mean one will be promiscuous as an adult
It will NOT drive one crazy
One CANNOT die from it
It is perfectly healthy as long as it does not interfere with relationships with a spouse,
friends and family, or with doing other activities
(University of Michigan Health System; Dr Chakravarthy; Planned Parenthood).
Ejaculation frequency and subsequent risk for prostate cancer - sexual activity has been
hypothesised to play a role in the development of prostate cancer, but epidemiological data
are virtually limited to case-control studies, which may be prone to bias because recall
among individuals with prostate cancer could be distorted as a consequence of prostate
malignancy or ongoing therapy.
Leitzmann, et al. (2004), conducted a study to examine the association between ejaculation
frequency, which includes sexual intercourse, nocturnal emission, and masturbation and risk
of prostate cancer. In their study, using follow-up data from the Health Professionals Followup Study (February 1, 1992, through January 31, 2000) of 29 342 US men aged 46 to 81
years, who provided information on history of ejaculation frequency on a self-administered
questionnaire in 1992 and responded to follow-up questionnaires every 2 years to 2000.
Ejaculation frequency was assessed by asking participants to report the average number of
ejaculations they had per month during the ages of 20 to 29 years, 40 to 49 years, and
during the past year (1991).
During 222 426 person-years of follow-up, there were 1 449 new cases of total prostate
cancer, 953 organ-confined cases, and 147 advanced cases of prostate cancer. Most
categories of ejaculation frequency were unrelated to risk of prostate cancer. However, high
ejaculation frequency was related to decreased risk of total prostate cancer. The multivariate
relative risks for men reporting 21 or more ejaculations per month compared with men
reporting 4 to 7 ejaculations per month at ages 20 to 29 years were 0.89 (95% confidence
interval [CI], 0.73-1.10); ages 40 to 49 years, 0.68 (95% CI, 0.53-0.86); previous year, 0.49
(95% CI, 0.27-0.88); and averaged across a lifetime, 0.67 (95% CI, 0.51-0.89). Similar
associations were observed for organ-confined prostate cancer. Ejaculation frequency was
not statistically significantly associated with risk of advanced prostate cancer. Their results
suggest that ejaculation frequency is not related to increased risk of prostate cancer
(Leitzmann, et al. 2004; Bartlik, et al. 2005; Cornog, M. 2003).
Masturbation and zinc depletion - frequent ejaculation prevents prostate problems in the
future. Frequent sex can have the same effect as masturbation.
Semen comprises of:
o
o
o
o
o
o
o
fructose
ascorbic acid
zinc
cholesterol
protein
calcium
chlorine
o
o
o
o
o
o
blood group
antigens
citric acid
DNA
Magnesium
vitamin B12
phosphorus
o
o
o
o
o
o
sodium
potassium
uric acid
lactic acid
nitrogen
some other
nutrients
(Mandal, A.; NFSTC).
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Sperm does NOT contain a lot of Zinc - semen has some Zinc in it but it does not take a
large quantity of it out of the body. That is an old wives tale. Semen also does not have a lot
of protein, calcium, nutrients etcetera in it. Ejaculating frequently cleans out the prostate
preventing semen from sitting in the prostate for long periods of time which can lead to future
problems (MCRH.Org).
In summary, it can be said that there are many positive benefits to male masturbation such
as reducing stress, helping infertile couples have a child through sperm donation and
stimulating the immune system.
o
o
Masturbation benefits the immune system
Masturbation keeps one in good health – it prevents the build-up of ‘stale’ prostatic
fluids remaining in the prostate
o Masturbation releases tension and stress – masturbation can lower blood pressure in
stressful situations
o Masturbation releases sexual tension without any performance anxiety
o Masturbation fights depression - masturbation releases the mood-enhancing
substances serotonin and dopamine
o Masturbation is essential for infertility testing
o Masturbation is essential for sperm donation - sperm donation can help couples who
are struggling with infertility to start a family
o Masturbation is the ultimate practice of safe sex – there is no chance of a sexually
transmitted infection or unwanted pregnancy
(Human Reproduction; Leitzmann, et al.; Denison, et al.; dba Fertility Center of California).
Living with Prostate Cancer – Possible Urinary Problems after Prostate Cancer
Treatment
Some treatments for prostate cancer can cause problems passing urine. These can include:
o
leaking urine (incontinence) which can range from leaking a few drops to leaking a lot
during the day and night
o
leaking or dribbling urine when one sneezes, coughs or exercises (stress
incontinence)
o
passing urine more often than usual (more than eight times a day)
o
getting up a lot at night to pass urine (nocturia)
o
needing to go to the toilet urgently (urgency) and sometimes leaking before getting
there (urge incontinence)
o
a weaker or slower flow of urine, or
o
problems emptying the bladder (urine retention)
Urinary problems can also be caused by an enlarged prostate, also called benign prostatic
enlargement or BPE. Urinary tract infections can cause symptoms such as needing to pass
urine more often and without much warning, a burning feeling and cloudy, dark or strong
smelling urine.
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Lowering the Risk for Prostate Cancer
It is recommended that men with an average risk of prostate cancer make choices that
benefit their overall health if they are keen on prostate cancer risk prevention as research is
very diverse and controversial in this regard.
The following have been recognised as playing an important role in assisting to reduce the
risk for prostate cancer:
o
Choose a healthy diet – there is evidence that choosing a healthy diet plays an
important role in prostate cancer prevention
 Choose a low-fat diet – limit saturated fat intake to 2% and transfat intake to
1% of total fat intake
 Reduce the amount of fat added to foods during preparation
 Limit the intake of saturated fats (mostly found in animal fats and processed
meats)
 Eat more fat obtained from plants rather than from animals, for instance
rather cook with canola oil than butter or lard
o
Increase the daily intake of fresh vegetables and fruit (in season) – eat at least five
portions of fresh fruit and vegetables daily
o
Eat fish – such as salmon, sardines, tuna and trout. It also contains a fatty acid called
omega-3 that has been linked to a reduced risk for prostate cancer
o
Restrict or avoid alcohol intake – if you decide to drink alcohol, this means not
drinking more than two (2) standard alcoholic drinks per day. A standard alcoholic
drink is equal to:
 340ml beer (average 5% alcohol by volume)
 120ml wine
 25ml liqueur
 50ml sherry
 25ml spirits (such as brandy, whiskey, gin, vodka and cane)
o
Maintain a healthy weight – men who have a body mass index (BMI) of 30 or higher
are considered to be obese. Being obese increases the risk of prostate cancer
Exercise most days of the week – research has shown that men who regularly
exercise may have a reduced risk of prostate cancer
(Mayo Clinic; National Cancer Institute; Life is Beautiful).
o
Clinical Trials
Clinical trials are research studies that involve people. They are the final step in a long
process that begins with research in a lab. Most treatments used today are the results of
past clinical trials.
Cancer clinical trials are designed to test new ways to:
o
o
o
o
Treat cancer
Find and diagnose cancer
Prevent cancer
Manage symptoms of cancer or side effects from its treatment
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Every trial has a person in charge, usually a doctor, who is called the principal investigator.
The principal investigator prepares a plan for the trial, called a protocol. The protocol
explains what will be done during the trial. It also contains information that helps the doctor
decide if this treatment is right for a particular patient.
The protocol includes information about:
o
o
o
o
o
o
The reason for doing the trial
Who can join the trial (called “eligibility requirements”)
How many people are needed for the trial
Any drugs that will be given, how they will be given, the dose, and how often
What medical tests will be done and how often
What types of information will be collected about the people taking part
For some patients, taking part in a clinical trial may be the best treatment choice. Clinical
trials are part of the cancer research process. Many of today's standard treatments for
cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive
the standard treatment or be among the first to receive a new treatment.
Patients who take part in clinical trials also help improve the way cancer will be treated in the
future. Even when clinical trials do not lead to effective new treatments, they often answer
important questions and help move research forward. Patients can enter clinical trials before,
during, or after starting their cancer treatment.
Some clinical trials only include patients who have not yet received treatment. Other trials
test treatments for patients whose cancer has not gotten better. There are also clinical trials
that test new ways to stop cancer from recurring (coming back) or reduce the side effects of
cancer treatment (National Cancer Institute).
Medical Disclaimer
This Fact Sheet is intended to provide general information only and, as such, should not be
considered as a substitute for advice, medically or otherwise, covering any specific situation.
Users should seek appropriate advice before taking or refraining from taking any action in
reliance on any information contained in this Fact Sheet. So far as permissible by law, the
Cancer Association of South Africa (CANSA) does not accept any liability to any person (or
his/her dependants/estate/heirs) relating to the use of any information contained in this Fact
Sheet.
Whilst the Cancer Association of South Africa (CANSA) has taken every precaution in
compiling this Fact Sheet, neither it, nor any contributor(s) to this Fact Sheet can be held
responsible for any action (or the lack thereof) taken by any person or organisation wherever
they shall be based, as a result, direct or otherwise, of information contained in, or accessed
through, this Fact Sheet.
Support
Cancer Association of South Africa (CANSA): www.cansa.org.za
Toll free line (08:00 to 16:30 on weekdays): 0800 22 66 22
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Other Support
The Prostate Cancer Foundation: www.prostatecancerfoundation.co.za
Prostate Cancer Foundation
982 Louis Trichardt Street 0084 RIETFONTEIN
GEO: -25.700520, 28.231360 Phone: +27 12 342 9432/3 Fax: +27 12 342 9434
The Urological Association of South Africa: www.uronsa.co.za
PO Box 13392, Cascades, Durban, 3202
Tel: +27 (0)33 345 7872
Fax: +27 (0)33 342 7142
Website: www.urosa.co.za/default.asp
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American Cancer Society. Prostate cancer.
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American Urological Association
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Digital Rectal Examination
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Fred Hutchinson Cancer Research Center.
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Gleason Score
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Researched and Authored by Prof Michael C Herbst
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Hisprostatecancer
http://www.hisprostatecancer.com/gleason-score.html
Kiciński, M., Vangronsveld, J. & Nawrot, T.S. 2011. An epidemiological reappraisal of the
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Lab Tests Online. Prostate Cancer.
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Male Pelvis
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http://www.mayoclinic.com/health/prostate-cancer/DS00043/DSECTION=symptoms
http://www.mayoclinic.com/health/prostate-cancer-prevention/MC00027
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Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved for Distribution by Ms Elize Joubert, Acting Chief Executive Officer
May 2014
Page 24
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http://www.cancer.gov/cancertopics/wyntk/prostate/page8
http://www.cancer.gov/cancertopics/wyntk/prostate/page9
http://www.cancer.gov/cancertopics/wyntk/prostate/page10
http://www.cancer.gov/cancertopics/wyntk/prostate/page11
http://www.cancer.gov/cancertopics/screening/prostate
http://www.cancer.gov/cancertopics/factsheet/Detection/PSA
http://www.cancer.gov/cancertopics/factsheet/Sites-Types/metastatic
http://www.cancer.gov/cancertopics/pdq/screening/prostate/Patient/page3
http://www.cancer.gov/cancertopics/prevention-genetics-causes/prostate
http://www.cancer.gov/dictionary?cdrid=45696
http://www.cancer.gov/clinicaltrials/learningabout/what-are-clinical-trials
http://www.cancer.gov/cancertopics.factsheet.Sites-Types/metastatic
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NFSTC
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Prostate Cancer Canada. Prostate Cancer.
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Prostate Cancer Foundation
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Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved for Distribution by Ms Elize Joubert, Acting Chief Executive Officer
May 2014
Page 25
University of Northern Colorado
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Researched and Authored by Prof Michael C Herbst
[D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health]
Approved for Distribution by Ms Elize Joubert, Acting Chief Executive Officer
May 2014
Page 26