Last partial update: July 2016 - Please read disclaimer before proceeding.

 

Prostate cancer in Australia

What is the prostate?

The prostate is a small gland, about the size of a wallnut, located at the base of the bladder. It surrounds the urethra (the tube that takes the urine from the bladder to the tip of the penis.) Its main function is to providethe fluid component of the semen. The sperm come from the testes.)

Prostate cancer incidence

Prostate cancer is the most common cancer in males. The natural history of the majority of cases of prostate cancer is an onset late in life followed by slow disease progression. This explains why most men with prostate cancer die never knowing they have the disease. (Early prostate cancer does not usually cause any symptoms and thus goes unnoticed in most cases.)

Statistics regarding actual prostate cancer illness, when combined with information gained from autopsies of men who died of other diseases and had no history of prostate cancer, reveal that while about 30 to 40 per cent of men over 50 years of age have prostate cancer, only about one quarter of these men will develop prostate cancer symptoms, and about one in 14 men diagnosed with prostate cancer will die from the disease. In Australia in 2010 it is estimated that about 20,000 new cases of prostate cancer will be diagnosed. This rate is increaseing for two reasons; firstly (and most importantly) there is increased testing for the cancer and secondly, the age of the population is increasing. Interestingly, the death rate is not changing or is slightly decreasing. (Possible reasons for this include better treatment, better diet and earlier diagnosis through screening that has allowed curative treatment.)

Overall in Australia about 19.3% of men will be diagnosed with prostate cancer but only 2.3% will die from the disease. The death rate is higher in younger men because the disease has more time to progress and there is less chance of the younger men dying from other causes. At present (2010) about 19,000 men are diagnosed with prostate cancer each year and 3,000 men die from the disease.

In some cases the disease presents earlier in life and these men have a much greater chance of dying prematurely (i.e. before 80) than men diagnosed later in life. In Australia, about 60 per cent of men diagnosed with prostate cancer at age 50 will die from the disease by age 80 compared with 50 per cent for men diagnosed at age 60 and 38 per cent of men diagnosed at age 70. This is due to the longer time the cancer has to progress and the fact that older men are more likely to die of other causes. Also, cancers in younger men often tend to progress more quickly. Interestingly, the disease is even relatively common in very young men, with about 20 per cent of men in their twenties having evidence of prostate cancer. Thus, in some men, prostate cancer can lay dormant for very long periods of time.

Prostate cancer diagnosis and death rates according to age in Australia

Age

Incidence of diagnosis

(per 1000 men)

Incidence of death

(per 1000 men)

Within the next 10 yrs
Within the next 20 yrs
Within the next 10 yrs
Within the next 20 yrs
40
4
33
0
1
50
30
109
1
4
60
82
172
4
19
70
98
176
15
69

Source: Australian Government: National Health and Medical Research Council (March 2014)


A good screening test / program for this common male cancer would be very beneficial to males in general and to men in their 50s and 60s in particular. Unfortunately, as shall be discussed shortly, the only available screening test is considerably less than perfect and there is much debate about whether the screening of patients without prostate symptoms provides any overall community benefit.

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Men with prostate cancer symptoms

As stated above, most men with early prostate cancer experience no symptoms at all due to the disease. Many men over the age of 50 years (i.e. the prostate cancer age group) experience urinary tract symptoms due to an enlargement of the prostate gland that occurs commonly with increasing age and is not due to cancer. However, they can be due to cancer when it is more advanced / and thus larger. The reason these symptoms occur is that the tube that takes urine from the bladder to the penis flows through the prostate gland and enlargement of the gland compresses the tube which disrupts normal urine flow. These symptoms include:

Men who experience the above symptoms should discuss them with their doctor and investigate them as appropriate. Investigation of these symptoms involves blood tests and feeling the prostate through performing a digital (by finger) rectal examination. This examination is not normally part of a routine medical examination and is usually only done if a patient’s symptoms suggest possible bowel or prostate problems.

Symptoms that are caused by larger, later stage prostate cancer (as well as other diseases) include:

Anyone with these symptoms needs to have them investigated and thus needs to see their doctor.

IMPORTANT: Passing blood in the urine is not a symptom of benigh disease and always needs immediate investigation to rule out cancer as a cause.

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Risk factors for prostate cancer

Increasing age and family history are the two main risk factors that have been identified, although geographical and racial differences in incidence indicate that other yet to be identified factors are likely to be present.

Prostate cancer is less common in Asian countries, especially Japan. (This reduced incidence is becoming less pronounced, probably because of the increased consumption of a western type diet that is higher in fat in these countries.) Asian men who live their whole lives in Australia and consume an Australian diet (and thus tend to become overweight) tend to have an incidence similiar the 'Australian average'. (The incidence of prostate cancer in the grandsons of immigrants to Australia is similar to the average Aiustralian incidence.) The incidence in African-Americans living in the USA is particularly high.

Family history of prostate cancer increases risk: The disease is inherited in about nine per cent of cases. However, this rate is much greater in young men. Forty-three per cent of cases occurring in males under the age of 55 are inherited. A male with a first-degree relative (father or sibling) with the disease at or after the age of 50yrs has two times the ‘normal’ risk of developing the disease and that risk is increased up to seven times if two first-degree relatives develop the disease. The risk is also greater if the relative developed the disease before 50 years of age.

There are racial differences in the incidence of prostate cancer. For example, afro-american men have a much higher incidence than Japanese men.

There is no evidence that having a vasectomy increases the risk of developing prostate cancer.

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Diet and prostate cancer prevention

There is no convincing evidence that any particular food causes or helps reduce the risk of prostate cancer. However, there is some evidence that the consumption of fish, especially fatty fish such as salmon, herring and mackerel, reduces the risk of prostate cancer. This is probably due to the effects of omega-3 fatty acids contained in these fish.

There is also evidence that a diet high in lycopenes, which are a group of anti-oxidant compounds mostly found in tomatoes and tomato products such as pastes etc, helps in reducing prostate cancer incidence and that lack of exercise and excessive dietary fat may increase the its incidence. Consuming soy products may also reduce prostate cancer risk.

Probably the best dietary defense against prostate cancer is to consume the above healthy foods and seven servings of vegetables and fruit per day.

There is no good evidence that dietary supplements such as vitamins tablets etc have any beneficial effect with respect to reducing prostate cancer.

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Screening for cancer - It should provide a significant community benefit.

Before discussing prostate cancer screening specifically, it is important to emphasise that all cancer screening programs involve doing medical procedures on WELL people that are intrusive, cost money and involve side effects. It is therefore important that a substantial overall benefit is demonstrated to exist for those being screened before a screening program is implemented. The following quote emphasizes what this implies for doctors recommending a screening procedure. 

“For decades, Australia has accepted the World Health Organization guidelines for evaluating the worth of screening. These guidelines, recently updated, state “. . . in screening there is an ethical responsibility to conduct programs that will be of overall benefit to those who are screened and will minimize harm and anxiety that will arise. It is not simply the offering of medical tests for people to accept or reject as they wish. This responsibility implies that if evidence is not available from valid studies on the effectiveness of screening, screening should not be offered.”

Strong K, Wald N, Miller A, Alwan A, on behalf of the WHO Consultation Group. Current concepts in screening for noncommunicable disease: World Health Organization Consultation Group report on methodology of noncommunicable disease screening. Journal of Medical Screening 2005; 12; pp12 - 19

It is unwise to presume that a medical intervention / test performed on a well person will be of benefit just because it exists to be done. It is safest to establish the evidence for benefit first.

 

Screening for prostate cancer by prostatic specific antigen (PSA) testing

How did screening for prostate cancer evolve?

The PSA test (the test used for prostate cancer screening) measures a compound called Prostatic Specific Antigen. It is normal for the level of this compound in the blood to rise gradually as men get older, mainly because their prostates gradually enlarge with age and the PSA level is proportional to the size of the prostate.

The PSA level has been found to be raised abnormally in men with several prostate conditions. By far the most common cause for a raised PSA is a benign enlargement of the prostate that commonly occurs from middle age in men. However, it is also raised in men with prostate cancer and the PSA test has been used for a long time to monitor the progression of men with diagnosed prostate cancer.

Quite reasonably, it was thought that this test might help in detecting early cases of prostate cancer, before symptoms occurred, thus allowing earlier treatment of existing prostate cancer; and it was hoped that this earlier treatment would help increase overall longevity and reduce overall disability in men undergoing the test. Unfortunately studies to provide good evidence that this was the case were not completed prior to the PSA test being offered by some doctors to well men as a screening test for prostate cancer and, at present, evidence demonstrating such a benefit still does not exist.

Should I look into prostate cancer screening further?

There is no doubt that the lives of some Australian men will be saved if they choose to have PSA screening for prostate cancer. (It is thought that for every 34 men diagnosed with prostate cancer following PSA screening, about one will have his life 'saved' (or more correctly, significantly prolonged.) There is also no doubt that some men who choose to not have PSA screening will by doing so delay the diagnosis of an existing prostate cancer.

However, there are real harms / problems as well as benefits associated with prostate cancer screening and insufficient evidence exists to demonstrate whether men who undertake prostate cancer screening, as a group overall, are likely to benefit or suffer harm from undertaking such screening. (For example, for each life 'saved', 33 men will suffer the psychologicsl problems associated with a diagnosis of cancer (a real problem!) and a considerable number will undergo unnecessary treatment for prostate cancer that causes significant side effects.)

For every 1000 low-risk*, 60-year-old men tested annually over a decade:

  • Two will avoid dying of prostate cancer before age 85. (The evidence for this benefit is somewhat inconsistent.)
  • PSA testing has "no discernible effect" on overall mortality. (Four major studies found PSA testing did not alter the overall death rate, indicating that any deaths from prostate cancer that were prevented were balanced out by deaths from other causes.)
  • Two will avoid metastatic prostate cancer before age 85. PSA testing does help detect prostae cancer earlier and thus the cancer is less likely to have spread at the time of diagnosis.
  • 87 will have a false-positive test leading to an unnecessary biopsy, and 28 will suffer side effects as a result that they consider to be a moderate or major problem. (One of these will require hospitalisation.)
  • 28 will be have prostate cancer diagnosed and many of these men would have never developed any symptoms from the disease during their life. (This means their cancers would never have metastasised (spread)). In other words, many are overdiagnosed.
  • 25 will choose to have treatment by either radiation or surgery due to uncertainty about which cancers require treatment. Many of these men would have done well with out any treatment i.e. overtreatment is a problem. Of these 25 men, 7-10 will develop persistent impotence or incontinence as a result of their treatment and some will develop bowel problems. (For every 2000 men tested, one will develop a serious cardiovascular event such as a heart attack due to treatment.)

*Low risk is a person who has no first degree relative with a history of prostate cancer.

Thus, if a man asks his doctor about whether he should have prostate cancer screening, the outcome is most likely going to be that the doctor cannot give a definite opinion and that it is for the man to decide once reading the pros and cons. (This is the view also of the Cancer Council of Australia.) This may seem like a bit of a 'cop out' by the medical profession, but if a doctor really does not know the answer to a question, then it is best that the patient is told this.

This makes it very difficult for men to make a decision regarding prostate cancer screening and, if a man is considering undertaking prostate cancer screening, it is worthwhile just stopping for a moment and asking whether this matter should be considered any further.

The stakes are high when dealing with cancer and the decision to do nothing is often the most difficult one to make, especially if the person’s family has been touched by prostate cancer in some way; and this is often that case as prostate cancer is a common disease. However, doing nothing is a real alternative in this situation; at least until more useful evidence is available. At present several major studies are nearing completion and the initial results of two major studies, The European Randomised Study of Screening for Prostate Cancer and The Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial on prostate-cancer mortality conducted in the USA, were actually published in 2009. The European study did show some benefit but the US study showed none and thus, overall, these results unfortunately did not clarify things one way or the other. Importantly, both studies reported harms attributable to screening and harms as well as benefits need to be considered in recommendations about population screening. Thus, these results did not change the Australian Cancer Council's view that PSA screening for prostate cancer in men (of any age) should not be recommended. (See boxed section below.)

The European Randomized Study of Screening for Prostate Cancer

This study looked at over 160,000 men (aged 55 to 70 years) who were randomly divided into two groups; one that was not offered screening and another that was. About 82% of the screening group were actually screened and on average they were screened 2.1 times. (The screening interval was every four years.) The incidence of prostate cancer found in the screened group was about 8.2%, compared with 4.8% in the unscreened group.

Overall, 126,462 PSA tests were done, with about 16% of tests (one in six) being positive (i.e. adnormal). Of these positive tests, 76% were found to be false positives (i.e. no cancer was found) This is a very high rate of overdiagnosis and all these asymptomatic men would have needed a prostate biopsy and would have had the worry of a possible cancer hanging over their heads.

The screened group achieved a 20% reduction in the rate of death from prostate cancer. (The actual reduction was about 27% if those in the screening group who did not comply i.e.did not have the PSA test, were excluded from the screened group.)

Overall the study found that 1,410 men needed to be screened and 48 additional cases of prostate cancer needed to be treated to prevent one cancer death. (The figure of 1410 would have been less if those alloated to the screened who did not actually have a PSA test done were excluded. Also, not all 48 prostate cancer cases needed to be treated with removal of the prostate.)

The Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial on prostate-cancer mortality conducted in the USA.

Initial results from this trial were published in 2009. Participants were again divided into two groups, those that had PSA screening for prostate cancer and those that did not. It was also a very large study with about 38,000 participants aged between 55 and 74 years in each group. After 7 to 10 years of follow-up, the rate of death from prostate cancer was very low and did not differ significantly between the two study groups. That is, there was no observed benefit from screening. For summary article see link to New England Journal of Medicine below. http://www.nejm.org/doi/full/10.1056/NEJMoa0810696#t=abstract

As stated above, the results of these trials did not change the overall view of cancer authorities regarding advice about prostate cancer screening .

(The follow up period for the initial results of the study was about 11 years. Further results looking at future study outcomes will be released at a later date.)

It is worthwhile just mentioning once again that screening means testing well people with no symptoms. A man who has symptoms of prostate cancer should report them to their doctor quickly. See above for prostate cancer symptoms.

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Screening using the PSA test.

The only screening method available for prostate cancer involves the measurement of Prostatic Specific Antigen (PSA) in men with no prostate symptoms. (This is a 'blood test'.) PSA is a chemical (a glycoporotein) secreted by the prostate; mostly into the semen but also into the blood. It is made by both normal and cancerous prostate cells. The PSA level is increased in a number of conditions that affect the prostate and as many as two thirds of men with a raised PSA will not actually have prostate cancer. (The number depends on the PSA level used as an abnormal cut off level.) PSA exists in the blood in a 'bound to blood protein' form and a 'free' form and both these can be measured. The 'total PSA' is the measurement of both these forms together. (Unless stated otherwise, in this section 'PSA test' refers to the' total PSA'.) The amount of the free form compared to the total (expressed as a percentage) can give an indication of whether prostate cancer is likely, with ratios of 15% or lower increasing the likelihood of cancer and ratios above 20% lessening the likelihood.

The prostates of all men release PSA and thus all men have a reading of some level. Unfortunately, even having a low (i.e. normal) level does not preclude prostate cancer being present. One recent study that biopsied the prostates of all men in the study irrespective of their PSA level found prostate cancer to be present in 15% of men with low PSA levels (less than 4ng/mL). This just means that some cancers don't produce much PSA; in some cases even when they grow to a reasonable size. (Prostate cancer cells often produce less PSA than normal prostate cells but they usually release more of it into the tissues and blood which causes the elevated levels; usually.)

The total PSA test can be raised by causes other than cancer, including needle biopsy of the prostate, ultrasound examination of the prostate, prostatitis (i.e. prostate infection), recent ejaculation and, most commonly, benign enlargement of the prostate. (This is a very common prostate abnormality.) Testing should be done at least 24 hours after sexual intercourse and should be delayed till at least six weeks after finishing treatment for prostatitis. To improve result consistency, testing that needs to be repeated is best done at the same laboratory where possible. (Examination of the prostate by digital (finger) examination of the prostate may also cause a transient rise in PSA and thus the PSA test should not be done immediately after such an examination.)

There is considerable individual variation in PSA levels and some studies suggest that up to 30 per cent of raised PSA tests will return to normal if the men were retested several weeks later.

As stated above, the PSA level varies with age. This is because PSA production is related to the size of the prostate and the size of the prostate increases with age in the vast majority of men. For this reason many specialists consider that the PSA cut-off level used for indicating that prostate cancer may exist should also vary with age. (Some suggest appropriate ‘cut-off’ levels should be 2.5micrograms/L of those under 49 yrs of age; increasing to 4.5micrograms/L for those aged 60 to 69. However, there is considerable controversy regarding this issue.) Generally speaking the PSA test is much better at monitoring a man’s response to treatment for prostate cancer than it is at diagnosing it.

The PSA test can be misleading

Unfortunately, as can be seen from the information provided below, the PSA test is often misleading, producing many false positive and false negative results. Results are classified as follows:

If PSA screening is to disclose the majority of curable cases of prostate cancer, it is necessary to investigate those with PSA levels in the inaccurate middle or ‘suspicious’ range. As stated above, the accuracy of the PSA test in predicting prostate cancer in this ‘suspicious ’ range can be improved by calculating the free to total PSA ratio. Using age-related upper limits of normal for (total) PSA can also reduce the rate of false positive tests. (Suggested upper limits for a normal total PSA test are less than 2.5ng/mL for age 40 to 49 years, less than 3.5ng/mL for age 50 to 59 years, and less than 4.5ng/mL for age 60 to 69 years.)

PSA as a screening test in Australia

Screening for prostate cancer in Australia is common. In 2005 it is estimated that about 700,000 PSA tests were performed to screen for prostate cancer.

As can be seen from the above, the PSA test is not perfect and understandably there are theoretical problems with its use as a screening test. (As stated above, there is no evidence that proves PSA screening is of overall benefit to those who have it.)

A screening program aimed at finding more cancers (which the PSA test will certainly do) is no help to the general community if it does not improve the overall health of that general community. There is no doubt that some individuals will benefit from and even have their life saved by having a PSA screening test. On the other hand, many more individuals will suffer from the inconvenience, complications and side effects associated with investigations and subsequent treatments without gaining any benefit. Where the balance lies, nobody at present knows.

PSA screening - Your choice

At present, the lack of evidence confirming an overall community benefit from PSA screening has meant that very few national health authorities are recommending community PSA screening and it is not recommended by Australian health authorities.

The position of the Cancer Council of NSW and Cancer Council Australia is:

Adequately informing men about the pros and cons of prostate cancer screening takes considerable time that is often not available in general practice and unfortunately it is thought that many of the men who consent to have a screening PSA test do so with inadequate information about:

When making a decision, please remember that most people have the underlying belief that doing something medically will always be of benefit. This, of course, is not necessarily the case.

The media and PSA screening

As prostate cancer is a major health issue, it is appropriate that the media is actively involved in promoting discussion about the disease. However, recent research presented in the Medical Journal of Australia points out that the media's overall presentation of PSA screening is misleading in that it is biased towards encouraging men to have PSA screening. The article's conclusion states;

'Despite near universal lack of support for prostate cancer screening of asymptomatic men by leading international and Australian cancer control agencies, Australians are exposed to an unbalanced stream of encouragement to seek testing. This coverage includes inaccurate information which ignores scientific evidence and the general lack of expert agency support.'

Ross MacKenzie, Simon Chapman, Alexandra Barratt and Simon Holding. “The news is [not] all good”: misrepresentations and inaccuracies in Australian news media reports on prostate cancer screening. MJA 2007; 187 (9): 507-510
http://www.mja.com.au/public/issues/187_09_051107/mac10505_fm.html

This reference is now 5 years old and thus somewhat dated. Certainly of recent times (2012), there has been a much better balance in the reporting regarding PSA testing. However, it is always good to remember that the media is not always on the side of truth and transparency, especially if it means forgoing a sales-increasing story.

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The case against PSA screening

The case against screening is based on the following facts;

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The case for limited PSA screening

The generaised screening of all men aged 50 to 70 years for prostate cancer is not supported by medical authorities in Australia. However, most doctors and health authorities do support a patient's right to elect to have a PSA test once they have been fully informed regarding both the possible benefits from having the test and the problems associated with the PSA screening test and subsequent necessary investigations and treatment.

Doctors who actively support screening do so because they believe that screening is the best way to minimize illness from this common cancer. (Many of these doctors deal every day with the illness and distress that this disease causes and really want to do everything they can to reduce its effect.) They also believe that the fall in prostate cancer death rates that have occurred over the past 15 years may be due to increased PSA screening levels. It is certainly true that PSA screening will save the lives of some men and that this is more likely to be the case when the cancer is found in younger men.

Doctors who support screening generally suggest it should be done in men without prostate symptoms between the ages of 50 and 70 unless they have a life expectancy of less than 10 years; especially if they have a family history of prostate cancer. A younger starting age of 40 is suggested by some doctors for those men with a family history of prostate cancer.

All screenings should be done as a combination of a PSA test and a digital (finger) examination of the prostate via the anus / rectum, and, to be of maximum benefit, should really be done each year.

Men over 70 years of age should not be screened because most men in this age group who are diagnosed with prostate cancer would die of another disease.

Recently the Urological Society of Australia and New Zealand has advocated that men aged between 40 to 54 years should also be offered a PSA test as it has been shown that a PSA reading above the median in this age group (0.7ng/mL for a man aged 40-49, and 0.9ng/mL for a man aged 50-59) indicates a three and a half fold increased risk of developing prostate cancer over the next 25 years compared with men with levels below the median. This would allow these men to be watched more closely for the disease. The down side of course is that half the men tested will have a test in this upper 50% range and this large group of men will have the worry of being labelled as having an increased risk of cancer; and most will gain no benefit.

As stated above, there are several large studies into screening for prostate cancer being undertaken at present and hopefully they will help clarify this issue.  

The potential benefits of limited PSA screening include:

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PSA testing

As stated previously, PSA testing is simple and only involves having a blood sample taken.

To avoid an inaccurately raised test result, PSA testing should not be done when if the man has:

What to do if a PSA test is abnormal?

Firstly, do not panic. It may well be that the PSA level was temporarily elevated due to another cause, such as recent sexual activity, recent examination of the prostate, or a prostate or other urinary tract infection. If the urine examination suggests infection, then the infection should be treated. It can take three months for a PSA level to drop to normal after treatment of a prostate infection. (The PSA test should not be repeated for at least six weeks after treatment of the infection.)

An initial test that is abnormal, whether due to the above causes or not, should be repeated. If the test is still abnormal, then the man should be referred to a specialist urologist for further investigation. This will normally require a biopsy of the prostate. Ultrasound investigation of the prostate is of no benefit as it does not assist in the diagnosis of cancer. Recently (2014), it has been suggested that MRI investigations can be useful in the further invstigation of positive PSA tests. Further research needs to be done to confirm the benefit of these expensive investigations.

It is timely to also remember that most men with a persistently raised PSA have a benign enlargement of the prostate, not prostate cancer.

Finally, a negative biopsy following a positive PSA test may not be the end of the story. Biopsies are not perfect and a raised PSA will require further follow up to ensure that a cancer has not been missed. (About 15 per cent of men with a raised PSA and a negative biopsy will have cancer found at subsequent biopsy. As stated before, a similar number of men with a normal PSA have early prostate cancer.)

Prostate biopsy (Trans rectal ultrasound guided prostate biopsy)

Men who have a positive PSA test will require a prostate biopsy to determine whether prostate cancer is present or not. (Biopsy tissue can also help determine the agressiveness of any cancer found which in turn helps decide on appropriate treatment.) Generally about 12 biopsies are taken using an 18 gauge needle. The procedure is almost always done by an instrument that is inserted into the rectum and can be done under a local anaaesthetic block, sedation or a genereal anaesthetic. Side effects that can occur include:

Treatment following a biopsy that confirms cancer is present will vary according to the stage of the cancer (how far it has spread) and the grade* of the cancer. (Prostate cancers vary in their severity and prostate cancers biopsies are graded according to their aggressiveness). Treatment options include:

Further discussion of the treatment of prostate cancer is beyond the scope of this prevention oriented web site.

*Grading prostate cancer

Prostate cancer is currently graded according to the Gleeson scale. This scale theoretically goes from 2 to 10 (with 2 being the best case and 10 being the worst). However, in actual practice, the best grade that a man with prostate cancer can be given is a 6 and this person would have a good prognosis. This is an odd system for patient to understand and unfortunately it means that a man who got the best score possible (a six) doesn't feel great about this as it looks like having a 2 could have been an option. For this reason, the Gleeson system is currently being reviewed, with a system that grades prostate cancers from 1 to 5 being proposed (with all being used). The assessment of the cancers is basically done the same way pathologically. The approximate cure rates with each grade in the new system are as follows. Grade 1 means that person has a 97% cure rate, Grade 2 infers a 88% cure rate, Grade 3 infers a 55% cure rate, Grade 4 infers a 50% cure rate and a Greade 5 infers a 25% cure rate.

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