Dr. Alireza Ahmadi
specialist in blood diseases and adult oncology, speeches about breast cancer.
Statements of Dr. Alireza Ahmadi, specialist in hematology and oncology, explanation about prostate cancer.
The text of Dr. Ahmadi’s speech
In the name of God. Greetings to the esteemed viewers and listeners. I am Dr. Alireza Ahmadi, a subspecialist in oncology and blood diseases. I’m eager to share some points about prostate cancer with you today. Prostate cancer, as you’ve heard, is one of the cancers with a high prevalence. The second leading cause of death after skin cancer is related to prostate cancer. Of course, these statistics are for Western societies. The first cancer on a global scale is skin cancer in societies worldwide. And after that, the cancer with the highest prevalence is prostate cancer. But it’s also the second leading cause of death in our country. So, if we consider gastrointestinal cancers and lung cancer, prostate cancer is still among the leading causes of death and is very common. If we want to provide you with some statistics, In a population of one hundred million, like our country, between 80,000 to 100,000 cases are diagnosed annually. The most important risk factor is age. The older a man gets, the more likely these events are to occur.
Okay. Firstly, what is the prostate? The prostate is an exocrine gland that produces secretions. It’s located below the bladder, in the area just in front of the rectum. It’s the part where men urinate from. Before the urethra and after the bladder, it’s shaped like a bulb, resembling an onion, with a passage inside. In fact, it encompasses the urethra and the prostatic urethra. Now, what’s the function of this gland? It produces secretions that play a role in fertility. For the survival of sperm, proper sperm function during fertilization is crucial.
Many times, people ask, “Doctor, what’s the purpose of the prostate? If it causes so much trouble, why does it even exist?” So, the prostate plays an important role in fertility. It’s worth mentioning the prostate-specific antigen (PSA). It’s also used for diagnosis. Even in sperm mobility, it plays a role. the same protein used for cancer detection also plays a role in sperm motility, helping them reach the egg.
So, that’s a summary of the prostate’s function. It’s a gland about the size of a small onion, located below the bladder and in front of the urethra, secreting its fluids into the passage during sexual intercourse. It directs the sperm collected in the seminal vesicles and creates an ideal environment for these sperm. But, well, it has its problems too. Its issues are relatively common. Besides benign enlargement, which most men over 50 suffer from. Symptoms such as dribbling urine, urinary difficulties, and burning during urination can occur.
Today’s topic is prostate cancer. Prostate cancer, as I mentioned, is a common disease and it also carries a mortality rate. But one positive aspect is that it’s a slow-growing disease.
It’s an interesting point written in books and it’s indeed true. Some men over 80 have their prostates removed, or even men who have passed away for any reason, had their prostates biopsied and found that 75% of them had cancerous nodules. The patient showed no symptoms. For example, they may have passed away due to heart disease, or in an accident, or for any other reason. They did an autopsy on this person, examined the prostate and found that 75% of men over 80 years of age have cancer centers. I’ve previously mentioned breast cancer. Out of every 10 women, three or four may develop cancerous lesions as they age. Here it’s even worse. Meaning, over 75% of men over 80 years old exhibit lesions. So, in fact, cancer has started, but they passed away due to other reasons. Anyway, there are other causes that lead to mortality at that age. Therefore, it’s a common disease. We often find it in tissues, even in prostate tissues that appear to be normal and undergo examination.
So, the most significant factor in causing this disease is age. Gender is also a determining factor; this disease is exclusive to males. In fact, 70% of prostate cases are in men over 65 years old. Therefore, the age of prostate patients is mostly high, over 65 years old. This is the age range for prostate cancer cases that we treat and that come to the attention of physicians. After age, the next significant factor is family history. The dietary behavior factor is indeed very important. It has been proven that individuals who consume a lot of red meat, especially processed meats, such as eating it daily, are at a higher risk. Processed meats include items such as sausages and deli meats (cold cuts). Processed meats also encompass salt-cured meats, aged meats, and animal proteins. White meat is less harmful, significantly so. Fish is good because it contains a substance called selenium.
These individuals become susceptible: Overweight individuals. The obese are at risk of developing prostate cancer. Those who are overweight. And if they develop it, they usually experience higher stages of the disease. So, what factors have we mentioned? Age, obesity, nutrition. There’s still room to discuss them further. Those who don’t eat vegetables or fruits. They don’t consume green vegetables. Antioxidants are more abundant in fruits and red vegetables.
For example, red cabbage, strawberries. Anything red tends to have more antioxidants. And there is a highly protective substance. Where is it located?
Lycopene, which is found in tomatoes. Tomatoes contain a substance called lycopene. Everyone has heard that tomatoes are good for the prostate. I believe every man should consume 2 to 3 tomatoes a day, which is excellent, or use tomato products. Like tomato paste or in any way incorporated into their diet. Fresh tomatoes are the best option. Using it in salads, for example, provides excellent protection. Even its pill form is available. I mean, its pill form is also formulated as a strong antioxidant.
What is healthy nutrition? Healthy nutrition is nutrition rich in vegetables or good spices. One spice that is very good is curcumin or turmeric. Everyone knows turmeric is a very good anti-inflammatory. No, it’s not about excessive consumption. Sometimes I see people dissolve these in water and, for example, consume a teaspoon or half a teaspoon of it. It can upset their stomach. It can cause gastritis or acid reflux. We’re talking about a spice that’s more beneficial than other things. When we say this, we don’t mean excessive consumption. Some people come and say, “Doctor, I take turmeric myself, I make capsules out of it and consume it!” This can cause gastrointestinal distress! When we say it’s good, we mean sprinkle it in your food. Spices are named as such because they are poured into food, not because they should be abundant. Their purpose is to enhance flavor. These give us mental warnings not to eat stale food, not to overindulge in red meat, and not to consume red meat for lunch and dinner every day. If we have a meal with red meat, for the next meal, we should lean towards vegetables. For example, we can have lentils. Let’s have salad. Let’s prepare some beans for ourselves. We can make a spinach stew. So, if we’ve had red meat for one meal, let’s not overindulge in subsequent meals, and let’s maintain balance and moderation ourselves.
For example, if I had rice with meat and beans, For example, if I had just a piece of meat, I should go light for the next two meals. The body has a capacity. These cancers occur if we don’t pay attention to this capacity. Overeating in food is never a good thing and can lead to trouble. Therefore, reducing red meat consumption is important. I recommend a balanced diet myself. If you like, you can follow it. But I tell this to my patients and I think it’s a good diet. For those who are vegetarians, that’s another thing. I don’t recommend anyone become vegetarian outright, I’m not myself. But my suggestion is this. I think a balanced diet is the best because the principle of our work in life is balance. If we eat red meat for one meal for two days, Three days of white meat, and for one meal, it must be fish. And then two days of vegetarian meals, For example, some countries say they eat vegetarian food on Tuesdays. We eat vegetarian food for two days, then red meat for two days. However, note that this is only for lunch. When you have dinner, try to avoid red meat. This should be taken into account. It’s part of the dietary plan. So now let’s go back to prostate cancer. So we’ve talked about nutrition.
So these are the risk factors. The most important one was age, then obesity. And now I want to mention something interesting about smoking. Smoking is an important factor in prostate cancer. It has been observed that individuals who quit smoking, their risk of prostate cancer increases for up to ten years. Interestingly, smokers who develop cancer tend to progress to more advanced stages of the disease more rapidly. Their disease is aggressive and invasive. It quickly metastasizes to the bones and spreads to other areas, and its stage progresses, becoming no longer treatable.
We’re talking about factors here. There are other issues that are not as crucial. And the use of certain medications is recommended, as well as specific dietary recommendations and certain micronutrients such as selenium. It’s not very strong for me to say, “Definitely use selenium.” A balanced diet should include vegetables and fruits. When we say fruits, we mean two or three pieces of fruit. Don’t overdo it because it’s high in calories. Some people come and say, “Doctor, I only eat fruit for dinner.” Certainly, such a patient is at risk of diabetes, high calorie intake, and fatty liver. So, we’ve talked about the diet.
We’ve also discussed other issues related to cancer, as well as its prevalence. Another risk factor is heredity. For example, if a father has prostate cancer, his son has twice the risk. If a father has prostate cancer and one of his sons also has it, the second son’s risk is four to five times higher. So, genetic factors are also important. If a man has prostate cancer, his sons and brothers are also at risk of developing it. So, to some extent, we’ve covered what this cancer does. And now let’s move on to the symptoms of the disease. Prostate cancer is usually a disease without symptoms. When the disease is detected, it’s usually due to high PSA levels. High PSA levels are detected during check-ups. It usually doesn’t have symptoms or has mild symptoms. For example, patients may say they’ve been having difficulty urinating for some time. They say if previously they used to wake up once or twice at night to urinate, now they wake up four times. Or they have to strain or push harder to urinate. All of these correspond with symptoms of an enlarged prostate.
Both benign and malignant forms can cause these symptoms: Burning sensation, frequency, urgency, feeling the need to urinate more urgently and involuntarily, dribbling, narrowing of the urine stream, dribbling urine drop by drop. These are symptoms of an enlarged prostate, which could be present in prostate cancer as well. In some rare cases, a person’s urine may become bloody, which is called hematuria. Another issue is pain. Sometimes, pain is felt in the pelvic area.
Regarding localized pain, sometimes it puts pressure on the rectum and causes constipation. And it also affects urination, and the individual may be unable to urinate. The prostate can enlarge to the point where it blocks the urinary tract. Sometimes, signs of metastasis are seen in individuals whose condition has progressed. Sometimes, patients come and say they have developed pain in their arms. They say, “I was fine, I had no problems, but now my arm has been hurting for two months.” Without any reason, without any injury. We scan and see that the bone is fractured. So, our issue is this asymptomatic nature.
Now, what should we do to diagnose the disease? So, this disease doesn’t have a specific indicator or gold standard. Changes in urination, changes in bowel habits, pain in the pelvic or perineal area, all of these exist.
Now, what should we do to screen for the disease? Previously, there was a lot of emphasis on PSA, and we used to screen annually. But as I mentioned, this disease tends to grow slowly. Now, we check this for everyone, and in the early stages of the disease, we detect it through these signs. One advantage is that the patient gets treatment earlier. But the downside is that we subject them to treatment-related harms.
What is the standard treatment? Prostate surgery. When someone has prostate cancer, the standard treatment is surgery to remove the prostate. Like with the ovaries, where we say the whole ovary needs to be removed. When the prostate is removed, what signs might it show? It might experience urinary incontinence, fertility issues, and erectile dysfunction. And the person who undergoes prostate surgery may face challenges in their sexual life. There are risks. We should perform prostate surgeries for patients when their disease is not in very early stages. Because it may not progress to symptomatic stages for another ten years. Later on, it was found that when PSA is screened at younger ages, cases can be detected. In a study, about 800 patients were screened over a period of 5 years with annual PSA tests. It’s a very interesting research. Out of these, approximately 38 cases of prostate cancer were detected. Then, they underwent early treatment and underwent surgery quickly. Besides the complications they experienced, Only one of them survived.
What I mean is that if the remaining patients had delayed treatment by a little, it would have happened around 5-6 years later. They could have the same lifespan. So, they no longer recommend widespread PSA screening for everyone. PSA screening is recommended by the cancer society only in cases where either the individual’s father has had prostate cancer or if the individual is African American. Obviously we don’t have that kind of racial diversity in Iran, but African Americans are at higher risk. In Western societies, Scandinavia, and such, their cancer risk is high. In Asian societies, Japanese people are at a high risk. Southeast Asians have a lower risk of prostate cancer, and I’ll explain the reason for it. The reason is their consumption of soy. They consume a lot of soy. Soy has some benefits and some drawbacks. Soy contains phytoestrogens, which are plant-based estrogens. In Southeast Asia, soy sauce and other soy products are widely used. So, this plant-based estrogen may affect men by weakening their sexual balance and causing some degree of sexual dysfunction.
This is a concern for us. But it still comes back to a balanced diet and balanced lifestyle. It means consuming soy is fine, even having soy three times a day, it’s not a problem. But having soy every day could pose issues. Just like we discussed regarding breast cancer, for those with cancerous hormones, consuming soy with phytoestrogens could stimulate the tumor. So, balance in nutrition. Soy is good, yes. You can use it in your diet once a week or once every two weeks, or for example, soy milk. That’s good. Let that tissue breathe. Don’t keep it under constant hormonal pressure. Don’t put it under pressure from excessive proteins and extra foods because in that case, the tissue can encounter problems. This was one of the points I mentioned about soy. And that’s why it’s less common in Southeast Asia.
Prostate cancer is more prevalent in Western diets. It’s much more common in Scandinavia and America. Iran also has a relative prevalence of prostate cancer because our diet is neither purely Western nor purely Eastern. It’s something in between the two. This balance is still very, very important. Now, back to PSA screening. If a father has prostate cancer, it’s advisable to start screening and monitoring the son from the age of 45. Every two years until the age of 50 is sufficient. It doesn’t need to be annually. The norm for PSA is up to 4. There is also a table. Not every PSA above 4 necessarily means cancer. They recently conducted a study which is very good. They performed a biopsy on three individuals whose PSA levels were high. Out of those three individuals, only one had cancer. So, a high PSA doesn’t necessarily mean cancer. Yes, it’s a good way for diagnosis. We take a biopsy for high PSA levels.
But let’s not overdo it. Let’s not overuse it. Why? Because we might end up detecting those early foci and remove a man’s entire prostate at the age of 48. Or we might suggest radiation therapy. Radiation therapy is also not a gold standard; it’s when the patient is not surgically eligible and has its own indications. Anyway, it does the same thing: it eliminates prostate tissue, and then the problems I mentioned earlier might occur for the patient.
It’s essential to have a thorough conversation with the patient and explain everything in detail. And the risks, dangers, and benefits should be completely clarified so that a rational and logical decision can be made. Because it’s not as easy for me to simply tell everyone to have their prostate removed because of a small focus. So, they say not to do anything about it for now. We’ve seen that unnecessary medical interventions in these cases are not beneficial. Now, the risk is determined as follows: If a father has prostate cancer, they start screening his son from the age of 45. They perform PSA tests every two to three years, and if the PSA level rises, they perform a biopsy. Given that their father had prostate cancer and their brother also has the same risk, the second brother should start screening around the age of 45. From the age of 40. If two individuals have had it, screening starts from the age of 40. One comes and says, “Doctor, I don’t have any history. Put me under control once a year.” For such cases, it is recommended to have an examination once every two years. Previously, they used to say, “Check every year, do a DRE.” DRE is also recommended now. It means the urologist performs the examination using their finger to check the prostate gland via the rectum. They say it’s enough to have DRE done every two to three years.
And there are two other interesting points as well. For example, if a 75-year-old man comes and says he doesn’t want a PSA check. Because he’s already over 75-80 years old. Considering that the average age is around 80-90 years old. They say to perform this surgery on someone who has a considerable amount of natural life expectancy left. Because with this procedure, you are also affecting their natural life expectancy. It doesn’t provide any benefit in terms of extending their lifespan. Or someone, for instance, has a heart condition. Their heart is functioning at around 25 to 30 percent. He is now 60 to 65 years old. For example, he is on dialysis. This is called “cumulative disease.” It is a co-existing condition that shortens life expectancy. He has another cancer. Now, there is no benefit in checking his PSA to find out if he has cancer and then impose treatment for that cancer as well. Because even now, in the current conditions, this person’s life expectancy is estimated to be five years. As I mentioned, this disease tends to progress, and with metastases, the patient may live for many years. We have seen several cases where we keep the patient for years with good medications and various treatment methods. So the disease is not explosive. It doesn’t progress rapidly. The patient should be given the opportunity to try various treatments. PSA screening also has a few points to consider that I mentioned to you. Above the age of fifty, it should be done every two to three years. I also talked about those with a family history of the disease. For individuals over 75 years old, the importance of PSA screening diminishes, unless they are in good health and fit. In such cases, if PSA levels are elevated, we would initiate a biopsy and proceed with treatment based on the patient’s condition. Screening with PSA and subsequent biopsy confirmation confirm the diagnosis. Biopsy is very important as it examines the tissue. This complicates the diagnosis. PSA is a very good marker for diagnosis and disease detection. In 5 to 10% of cases, there is this weakness where PSA levels do not rise, which is called a “PSA non-secretor.”
Now that we have diagnosed it, what is the treatment? First, we perform a whole-body scan (SAG). We scan the patient thoroughly, including bone and lung scans. If the patient is not metastatic, localized treatment is administered. The standard treatment for younger individuals and those without heart conditions is surgery. And depending on the conditions, we use hormone blockers. Just like the anti-estrogen used in breast cancer, here we use anti-androgens to prevent the growth of the disease. In fact, we need to reduce the production source of hormones because this disease is dependent on male hormones. We treat the testicles with drug therapy or rarely with surgical methods to eliminate the hormone source. So if the disease has progressed, the first step is to proceed with surgery. If surgery doesn’t provide a solution, we move on to hormonal therapy. If surgery is not feasible, then radiotherapy is the next option. Radiotherapy targets the prostate cancer cells and destroys them. Radiotherapy affects the prostate gland, which is a separate topic altogether. And then hormonal therapy, which is essentially a form of anti-hormonal treatment. We block male hormones with various medications. There are different types of these drugs available, such as GnRH agonists, and they are now accessible to us. And then if none of them are effective, we move on to chemotherapy. Chemotherapy targets cancer cells and destroys them.
Immunotherapy is also a new treatment approach for prostate cancer. Immunotherapy, colloquially referred to as a vaccine, is another emerging treatment for prostate cancer. There is a drug called Provenge, which is actually a method similar to cancer vaccine. And in this way, they take immune cells (T-cells) and co-culture them with cancer cells in the laboratory, which perpetuate and strengthen the cells and then reintroduce them into the body. They reintroduce the strengthened immune cells back into the individual’s body.
