Prostate Cancer

Opening Story

David, a 58-year-old firefighter, went to his doctor for a routine physical. His PSA came back at 5.2 ng/mL. "When my doctor said the word 'cancer,' my mind went blank," he recalls. "I didn't hear anything else for the next ten minutes. All I could think about was: Am I going to die?" David's biopsy showed Gleason 3+4 prostate cancer. Today, three years after treatment, he is cancer-free and back at work. "The fear was worse than the disease," he says. "Once I understood what prostate cancer actually is — how common it is, how treatable it is — I could breathe again."

This chapter will explain what prostate cancer is, how common it is, what causes it, how it spreads, and what can be done to reduce the risk of getting it.

What Is Prostate Cancer?

In Chapter 1, we learned that the prostate is a gland — meaning it is made mostly of glandular cells that produce fluid. Prostate cancer occurs when these glandular cells begin to grow in an abnormal, uncontrolled way. Because the cancer arises from glandular cells, the medical term for it is adenocarcinoma. More than 95% of all prostate cancers are adenocarcinomas.¹

However, the prostate also contains other types of cells, and rarely, cancer can arise from these non-glandular cells. These rare types include:

• Small cell carcinoma (SCC): A very aggressive, fast-growing cancer that often does not produce PSA. It is treated very differently from typical prostate cancer.
• Squamous cell carcinoma: Extremely rare, arising from the flat cells lining the prostate ducts.
• Sarcoma: Cancer arising from the muscle or connective tissue of the prostate. Very rare.
• Transitional cell (urothelial) carcinoma: Cancer that starts in the cells lining the urethra and can extend into the prostate.

These rare types together account for fewer than 5% of prostate cancers and are discussed in a later chapter on special cases.

How is prostate cancer different from BPH?

Both BPH and prostate cancer involve abnormal cell growth, but they are fundamentally different:

• BPH is benign (non-cancerous) overgrowth. The cells grow more than they should, but they stay organized, stay within the prostate, and never spread to other parts of the body.
• Prostate cancer is malignant. The cells lose their normal structure, invade surrounding tissues, and can spread (metastasize) to distant organs.

An important point: BPH does not turn into cancer. They are separate conditions that happen to occur in the same organ.

Prostate cancer is multifocal

Unlike many other cancers that form a single tumor, prostate cancer is often multifocal — meaning there are multiple separate areas of cancer within the prostate at the same time. This is why a biopsy may miss some areas of cancer, and why the full extent of the disease is sometimes only discovered when the entire prostate is removed during surgery and examined by a pathologist.

Prostate cancer is not contagious. It cannot be passed from one person to another through any form of contact.

Symptoms of Prostate Cancer

One of the most important things to understand about prostate cancer is that early prostate cancer usually has no symptoms at all. Most men are diagnosed because of an abnormal PSA blood test or an abnormal finding on a digital rectal exam (DRE), not because they felt something was wrong.¹ ²

When symptoms do occur, they can be similar to those caused by BPH:

Urinary symptoms:

• Difficulty starting urination
• Weak or interrupted urine flow
• Frequent urination, especially at night
• Difficulty emptying the bladder completely
• Blood in the urine (hematuria)

Sexual symptoms:

• Erectile dysfunction (difficulty getting or maintaining an erection)
• Blood in the semen
• Painful ejaculation

Symptoms of advanced (metastatic) prostate cancer:

• Bone pain (especially in the spine, hips, ribs, or pelvis)
• Spinal cord compression (weakness or numbness in the legs, difficulty walking, loss of bladder or bowel control — this is a medical emergency)
• Unexplained weight loss
• Fatigue and feeling generally unwell
• Swelling in the legs (from lymph node blockage or blood clots)
• Kidney problems (from tumor blocking the ureters)

Important: Having these symptoms does not mean you have cancer. Many of these symptoms are far more commonly caused by BPH, prostatitis, or other non-cancerous conditions. But they should always be evaluated by a doctor.

How Prostate Cancer Spreads

Prostate cancer growth is usually driven by testosterone (produced mostly in the testes, and to a lesser extent in the adrenal glands) and its more potent form, dihydrotestosterone (DHT). This is why prostate cancer is classified as a hormone-driven cancer, and why treatments that lower testosterone levels are effective.¹ ³

Prostate cancer can spread in several ways:

1. Local spread (within and around the prostate):

• The cancer starts inside the prostate gland
• It may grow through the prostate capsule (the outer shell of the prostate) — this is called extracapsular extension (ECE)
• It may invade the seminal vesicles (SVI — seminal vesicle invasion)
• In advanced cases, it can grow into the bladder, sometimes blocking the ureters
• Rarely, it can grow into the rectum or the urinary sphincter

2. Regional spread (to nearby lymph nodes):

• Cancer cells can travel through the lymphatic system to lymph nodes in the pelvis (obturator, internal iliac, external iliac nodes)
• This is called "node-positive" disease

3. Distant spread (metastasis):

• Cancer cells can travel through the bloodstream to distant organs
• Bone is the most common site of metastasis (spine, ribs, pelvis, femur). The connection between the prostatic venous plexus and the vertebral veins (Batson's plexus) explains why the spine is so commonly affected
• Less commonly: liver, lungs, distant lymph nodes
• Rarely: brain, other organs

A critical point: Even when prostate cancer spreads to the bones, liver, or lungs, it is still prostate cancer — not bone cancer, liver cancer, or lung cancer. The cells still look and behave like prostate cancer cells under the microscope, and they are treated with prostate cancer therapies. The cancer may accumulate new genetic mutations as it spreads, but its identity remains prostate cancer.

How Common Is Prostate Cancer?

Prostate cancer is extremely common. Here are the key numbers:

In the United States:

• Prostate cancer is the most common cancer in men (excluding skin cancer) and the second most common cause of cancer death in men after lung cancer.¹ ⁴
• An estimated 313,000 new cases are diagnosed each year, with approximately 35,250 deaths.¹ ⁴
• About 3.4 million men in the US are currently living with prostate cancer.¹
• Approximately 1 in 8 men will be diagnosed with prostate cancer in their lifetime.⁵
• However, more than 95% of men diagnosed with prostate cancer do not die from it — most die with it, not from it.

Worldwide:

• Prostate cancer is the second most common cancer in men globally, with approximately 1.5 million new cases and nearly 400,000 deaths in 2022.¹
• Incidence is highest in Northern Europe, Australia, the Caribbean, and North America — likely due to a combination of PSA screening, longer life expectancy, genetics, and lifestyle factors.¹
• Incidence is lowest in South-Central Asia.²

By age:

• The median age at diagnosis is 67 years.¹
• Prostate cancer is rare before age 40.
• Autopsy studies show that 59% of men older than 79 have histological evidence of prostate cancer — meaning they had cancer cells in their prostate but never knew it and never had symptoms.¹

By race and ethnicity (in the US):

• Black/African American men have the highest incidence rate — approximately 67% higher than in White men (173.0 vs. 97.1 per 100,000).¹ ⁶
• Black men also have double the mortality rate compared to White men (38.7 vs. 18.0 per 100,000).¹
• Hispanic men have lower incidence than White men.⁷
• Asian American/Pacific Islander men have the lowest incidence rates.⁷
• American Indian/Alaska Native men have 13% lower incidence but 12% higher mortality than White men.⁴

These racial disparities are complex and not fully understood. They likely reflect a combination of biological differences (genetics, tumor biology), social determinants of health (access to care, insurance, education), and screening patterns. Importantly, studies show that when Black patients receive equitable treatment, their outcomes improve significantly.⁶

Trends over time:

Prostate cancer incidence has had a roller-coaster pattern:⁴

• Rates rose sharply in the early 1990s when PSA screening became widespread.
• Rates declined from about 2007 to 2014, partly due to the USPSTF recommendation against routine PSA screening.
• Since 2014, rates have been increasing again by about 3% per year.
• Concerning: the incidence of distant-stage (metastatic) disease has been increasing by about 5–6% per year, likely reflecting reduced screening.⁴

What Causes Prostate Cancer?

The exact cause of prostate cancer is not known in most cases. However, research has identified several factors that increase or decrease the risk. These are divided into factors you cannot change (non-modifiable) and factors you may be able to change (modifiable).

Non-Modifiable Risk Factors (You Cannot Change These)

1. Sex:

Only people with a prostate can get prostate cancer. This includes cisgender men and transgender women.

2. Age:

Age is the strongest risk factor. Prostate cancer is rare before 40, uncommon before 50, and becomes increasingly common with each decade of life. By age 80, autopsy studies show that the majority of men have some cancer cells in their prostate.¹

3. Family history:

Having a first-degree relative (father or brother) with prostate cancer approximately doubles your risk. The risk increases further if:⁸ ⁹

• Multiple family members are affected
• The affected relative was diagnosed at a young age (before 55)
• A brother is affected (slightly higher risk than if a father is affected)

Men with a strong family history should discuss earlier screening with their doctor. The NCCN recommends that men with a concerning family history consider beginning shared decision-making about PSA screening at age 40.⁹

4. Genetics:

Prostate cancer is one of the most heritable cancers. Twin studies suggest that more than 50% of prostate cancer risk is attributable to genetic factors.¹ Specific genes associated with increased risk include:

• BRCA2: The strongest known genetic risk factor. Men with BRCA2 mutations have a 4.5- to 8.6-fold increased risk of prostate cancer, with an absolute lifetime risk of 27–60%, and their cancers tend to be more aggressive and diagnosed at younger ages.¹⁰ ¹¹
• BRCA1: Also increases risk (up to 3.8-fold), but less than BRCA2. Absolute lifetime risk estimated at 15–45%.¹⁰
• HOXB13 (G84E mutation): Associated with early-onset prostate cancer.⁹
• ATM gene mutations: Associated with increased risk.⁹
• [Lynch syndrome](/rare-disease/lynch-syndrome) genes (MLH1, MSH2, MSH6, PMS2): Increase risk of multiple cancers including prostate.⁹ ¹²
• Polygenic risk: Hundreds of common genetic variants (SNPs), each contributing a small amount of risk, can be combined into a polygenic risk score.²

Men with known or suspected hereditary cancer syndromes should be referred to a genetic counselor.⁹

5. Race/Ethnicity:

As discussed above, Black men have the highest risk, followed by White men, Hispanic men, and Asian men. The reasons are complex and include both biological and social factors.¹ ⁶

Modifiable Risk Factors (You May Be Able to Change These)

1. Diet:

• High red and processed meat intake may increase risk, particularly of aggressive disease.¹³
• High-fat diets (especially saturated fat) have been associated with increased risk in some studies.¹³
• High calcium intake (primarily from supplements, >1500 mg/day) may increase risk of aggressive prostate cancer.¹³
• Dairy products: Higher consumption has been associated with increased risk in several studies.¹⁴

2. Obesity:

Being overweight or obese is associated with an increased risk of advanced and aggressive prostate cancer, though not necessarily overall prostate cancer risk.¹⁵ Central obesity (belly fat) appears to be particularly important. Obesity may also worsen outcomes after diagnosis.

3. Smoking:

The relationship between smoking and prostate cancer is complex. Current smoking may be associated with a lower overall incidence of prostate cancer (possibly due to lower PSA levels and less screening), but smoking is consistently associated with higher risk of aggressive, fatal prostate cancer and worse outcomes after treatment.¹⁵ ¹⁶

4. Physical activity:

Regular physical activity, particularly vigorous exercise, appears to reduce the risk of advanced prostate cancer. A large umbrella review found that occupational physical activity was associated with a 13% reduction in prostate cancer risk.¹⁶

5. Vasectomy:

Some studies have suggested a small increase in prostate cancer risk with vasectomy, but this remains controversial and may be due to detection bias (men who have vasectomies may be more health-conscious and get screened more).¹⁵

6. Environmental exposures:

• Agent Orange: Vietnam War veterans exposed to Agent Orange may have an increased risk of high-grade prostate cancer. The NCCN recommends that patients with Agent Orange exposure be informed of this association.⁹
• Ionizing radiation: Occupational exposure to radiation may increase risk.

Prevention: Can You Reduce Your Risk?

While there is no guaranteed way to prevent prostate cancer, several strategies may help reduce risk:

Diet and Lifestyle

The best evidence supports a "heart-healthy equals prostate-healthy" approach:¹⁷

• Eat plenty of fruits and vegetables — especially tomatoes (rich in lycopene), cruciferous vegetables (broccoli, cauliflower, kale), and legumes.
• Lycopene (found in cooked tomatoes, watermelon, pink grapefruit): A prospective study from the PREDIMED trial found that men in the highest quartile of lycopene intake had a 54% lower risk of prostate cancer compared to the lowest quartile.¹⁸
• Green tea catechins (especially EGCG): Preclinical studies show promising anticancer activity, including suppression of prostate cancer cell proliferation. However, clinical evidence in humans remains limited.¹⁹
• Phytoestrogens (found in soy products): Some evidence suggests a protective effect, particularly in Asian populations where soy consumption is high.¹³
• Carotenoids (beta-carotene, lutein, etc.): Found in colorful fruits and vegetables; some studies suggest a protective effect.¹³
• Mediterranean diet: Plant-based and Mediterranean dietary patterns may be associated with lower risk of prostate cancer progression.²⁰
• Limit red and processed meat, high-fat dairy, and saturated fats.
• Maintain a healthy weight.
• Exercise regularly — aim for at least 150 minutes of moderate activity or 75 minutes of vigorous activity per week.

Finasteride: The Prostate Cancer Prevention Trial (PCPT)

The most important prostate cancer prevention study ever conducted was the Prostate Cancer Prevention Trial (PCPT), published in the New England Journal of Medicine in 2003.²¹

The study: 18,882 men aged 55 or older with normal PSA (≤3.0 ng/mL) and normal DRE were randomly assigned to take either finasteride (5 mg/day) or placebo for 7 years.²¹

The results:

• Finasteride reduced the risk of prostate cancer by 24.8% (18.4% in the finasteride group vs. 24.4% in the placebo group).²¹
• This means approximately 1 in 71 men treated for 7 years would avoid a prostate cancer diagnosis.²²
• The reduction was primarily in low-grade cancers (Gleason 6 and below).²³

The paradox: More high-grade cancers (Gleason 7–10) were found in the finasteride group (37% of cancers vs. 22% in placebo). This raised concerns that finasteride might cause aggressive cancer.²¹

The resolution: Subsequent analyses showed that this paradox was likely due to detection bias — finasteride shrinks the prostate, which makes biopsies more accurate at finding cancer, including high-grade cancer. Additionally:²⁴ ²⁵

• The 18-year follow-up of the PCPT showed no difference in overall survival between the finasteride and placebo groups (15-year survival: 78.0% vs. 78.2%).²⁴
• There was a non-significant 25% reduction in prostate cancer mortality with finasteride.²⁵
• A 16-year follow-up using Medicare data confirmed a sustained 21% reduction in prostate cancer risk with no increased risk after stopping the drug.²⁶

The REDUCE trial tested dutasteride (another 5-alpha reductase inhibitor) in higher-risk men (PSA 2.5–10 ng/mL with a negative biopsy) and found a similar 23% reduction in prostate cancer.²³

A large Swedish study of over 350,000 men found that 5-ARI use was associated with a 9% reduction in prostate cancer mortality (HR 0.91), with a stronger effect among men who used 5-ARIs for more than 4 years.²⁷ A Canadian study of over 3 million men similarly found that 5-ARI use was associated with a 31% reduction in prostate cancer mortality (HR 0.69).²⁸

Side effects of finasteride include:²¹

• Erectile dysfunction
• Decreased ejaculate volume
• Breast tenderness or enlargement (gynecomastia)
• Depression (see below)

Important note: Despite the evidence, the FDA has not approved finasteride for prostate cancer prevention, and in 2011 added a label warning about the potential increase in high-grade cancer. Most experts now believe this concern was overstated based on detection bias.²⁴

Finasteride and mental health:

There has been concern about psychiatric side effects of 5-alpha reductase inhibitors. A large Swedish study of over 2.2 million men found:²⁹

• No association between 5-ARIs and suicide.
• Both finasteride and dutasteride were associated with an increased risk of depression (the association was persistent but modest).
• An initial association with dementia appeared to diminish over 4 years of exposure, suggesting it was due to increased detection of pre-existing undiagnosed dementia rather than a true drug effect.

A Canadian study of 93,197 men found similar results: no increased suicide risk, but increased risk of self-harm (HR 1.88) and depression (HR 1.94) during the first 18 months, with the absolute increase being small (237 additional depression cases per 100,000 patient-years).³⁰

A 2025 pharmacovigilance analysis found stronger signals for depression and suicidality with finasteride in younger men (ages 18–44), particularly when used for hair loss rather than BPH.³¹

Bottom line: Men taking finasteride should be aware of the potential for mood changes and should report any symptoms of depression to their doctor promptly.

Selenium and Vitamin E: The SELECT Trial

The Selenium and Vitamin E Cancer Prevention Trial (SELECT) was a large randomized trial of 35,533 healthy men testing whether selenium (200 μg/day), vitamin E (400 IU/day), both, or placebo could prevent prostate cancer.³² ³³

The results were disappointing and concerning:

• Selenium did not reduce prostate cancer risk.³²
• Vitamin E alone actually increased prostate cancer risk by 17% (HR 1.17, p=0.008).³³
• The combination of selenium and vitamin E showed no benefit.³²
• Among men with already-high selenium levels, selenium supplementation increased the risk of high-grade prostate cancer by 91%.³⁴

The earlier NPC trial (1983) had suggested selenium might reduce prostate cancer risk (HR 0.48), but this was a secondary endpoint in a smaller study of men who may have been selenium-deficient. The SELECT trial, conducted in a nutritionally replete population, definitively showed no benefit.³²

Bottom line: Men should avoid selenium or vitamin E supplementation at doses exceeding recommended dietary intakes. Getting these nutrients from food is preferred.³⁴

Zinc

The prostate contains the highest concentration of zinc in the male body, and zinc plays important roles in prostate cell function.³⁵ ³⁶ However, the relationship between zinc supplementation and prostate cancer is complex:

• Low-dose zinc (1–24 mg/day) after a prostate cancer diagnosis was associated with lower risk of lethal prostate cancer and all-cause mortality in one study.³⁷
• High-dose zinc (>75 mg/day) or long-term use (>15 years) was associated with a 76–91% increased risk of lethal and aggressive prostate cancer in the Health Professionals Follow-up Study.³⁸ ³⁹
• A meta-analysis of 52 studies found that serum and tissue zinc levels are lower in prostate cancer patients, but zinc intake was not clearly associated with risk.⁴⁰

Bottom line: Moderate zinc intake from food is likely safe and may be beneficial. However, high-dose zinc supplements (>75 mg/day) should be avoided, as they may increase the risk of aggressive prostate cancer.³⁸

NSAIDs, Statins, and Metformin

These common medications have shown some promise in prostate cancer prevention, though none is approved for this purpose:

• Aspirin/NSAIDs: Some studies suggest aspirin may reduce the risk of lethal prostate cancer. The anti-inflammatory properties of NSAIDs may inhibit tumor progression. However, results are mixed, and aspirin carries its own risks (bleeding).¹⁷
• Statins: Evidence is mixed. Some studies show reduced risk of advanced prostate cancer, while others show no benefit. A recent target trial emulation in older adults found statin initiation was associated with lower prostate cancer incidence.¹⁷
• Metformin: This diabetes medication has shown promise in reducing prostate cancer incidence among diabetic men. The combination of metformin and statins may have synergistic effects. However, these benefits have been seen primarily in observational studies, and randomized trial data are still needed.¹⁷

Bottom line: These medications should not be taken solely for prostate cancer prevention. However, men who are already taking them for their primary indications (heart disease, diabetes, pain) may derive some additional prostate cancer benefit.¹⁷

Symptom Assessment Tools

Several validated questionnaires are used by doctors to measure and track symptoms related to prostate conditions. Understanding these tools can help you communicate more effectively with your medical team.

IPSS (International Prostate Symptom Score) / AUA Symptom Index

The IPSS is the most widely used questionnaire in urology worldwide.⁴¹ It contains:

• 7 questions about urinary symptoms: incomplete emptying, frequency, intermittency, urgency, weak stream, straining, and nocturia (nighttime urination)
• 1 quality-of-life question about how bothersome your symptoms are
• Each symptom question is scored 0–5, for a total score of 0–35

How to interpret your score:⁴¹

• 0–7: Mild symptoms
• 8–19: Moderate symptoms
• 20–35: Severe symptoms
• A decrease of at least 3 points is considered a meaningful improvement after treatment.

SHIM (Sexual Health Inventory for Men) / IIEF-5

The SHIM is a 5-question version of the longer International Index of Erectile Function (IIEF) questionnaire.⁴² It is used to diagnose the presence and severity of erectile dysfunction (ED):

• Scores range from 1 to 25
• 22–25: No ED
• 17–21: Mild ED
• 12–16: Mild to moderate ED
• 8–11: Moderate ED
• 1–7: Severe ED

EPIC-26 (Expanded Prostate Cancer Index Composite)

The EPIC-26 is a 26-question tool specifically designed for prostate cancer patients. It measures quality of life across four domains:

• Urinary incontinence
• Urinary irritation/obstruction
• Bowel function
• Sexual function

This questionnaire is particularly important because it captures the side effects of prostate cancer treatment and helps doctors and patients track changes over time. The NCCN recommends measuring baseline function with a tool like EPIC-26 before starting any treatment.

Myth vs. Fact

• Myth: "Prostate cancer is an old man's disease — young men don't need to worry."

Fact: While prostate cancer is more common in older men, it can occur in men in their 40s and 50s, especially those with a family history or genetic predisposition. Younger men with prostate cancer sometimes have more aggressive disease.

• Myth: "If I have no symptoms, I can't have prostate cancer."

Fact: Early prostate cancer almost never causes symptoms. By the time symptoms appear, the cancer may be advanced. This is why screening with PSA is important.¹ ²

• Myth: "Prostate cancer is always a death sentence."

Fact: More than 95% of men diagnosed with prostate cancer do not die from it. The 5-year relative survival rate for localized and regional prostate cancer is nearly 100%.¹

• Myth: "Taking vitamin E and selenium supplements will protect me from prostate cancer."

Fact: The SELECT trial showed that vitamin E supplements actually increased prostate cancer risk by 17%, and selenium provided no benefit. Getting these nutrients from food is safer.³³ ³⁴

• Myth: "Prostate cancer is contagious."

Fact: Prostate cancer cannot be transmitted from one person to another. It is not caused by an infection (unlike some other cancers such as cervical cancer).

• Myth: "A high PSA always means cancer."

Fact: Many conditions can raise PSA, including BPH, prostatitis, urinary infections, and even recent sexual activity. PSA is a screening tool, not a diagnostic test.²

Questions to Ask Your Doctor

1. Based on my age, race, and family history, what is my risk of prostate cancer?
2. Should I be screened for prostate cancer? At what age should I start?
3. Are there genetic tests I should consider based on my family history?
4. What lifestyle changes can I make to reduce my risk?
5. I am taking finasteride/dutasteride — does this affect my PSA results?
6. Should I take any supplements for prostate health?
7. I have urinary symptoms — could these be from cancer or from BPH?

Key Takeaways

1. Prostate cancer is the most common cancer in men (excluding skin cancer). About 1 in 8 men will be diagnosed, but more than 95% will not die from it.
2. Early prostate cancer has no symptoms. Screening with PSA is the primary way it is detected early.
3. The strongest risk factors are age, family history, genetics, and Black race. Modifiable risk factors include diet, obesity, and physical activity.
4. Finasteride reduces prostate cancer risk by about 25% with no increase in mortality, but it is not FDA-approved for prevention and may cause sexual side effects and depression.
5. Vitamin E and selenium supplements do not prevent prostate cancer and may increase risk. A diet rich in tomatoes, cruciferous vegetables, and fish is a better approach.
6. "Heart-healthy equals prostate-healthy" — the same lifestyle that protects your heart also appears to protect your prostate.

Support Resources

• Prostate Cancer Foundation (PCF): www.pcf.org — Comprehensive information on prostate cancer risk, prevention, and research
• ZERO — The End of Prostate Cancer: www.zerocancer.org — Risk assessment tools and education
• American Cancer Society: www.cancer.org/cancer/prostate-cancer — Risk factors and prevention information
• National Cancer Institute: www.cancer.gov/types/prostate — Evidence-based information on prostate cancer
• CDC — Prostate Cancer: www.cdc.gov/cancer/prostate — Statistics and screening information
• NCCN Patient Guidelines: www.nccn.org/patients — Free patient-friendly versions of clinical guidelines

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