Sign up for Weekday J and get the latest on what's happening in the Jewish Bay Area.

A friend of mine was on high alert after a close relative in his 50s was diagnosed with prostate cancer. That friend — I’ll call him Gabriel instead of using his real name — had the PSA level in his blood tested regularly to check for prostate cancer. The level began increasing when he was 71. 

The PSA — short for prostate-specific antigen — was still in the normal range for his age, but he still decided to undergo prostate biopsies. To his dismay, he found out he had prostate cancer.  

Prostate cancer is common in men. According to the American Cancer Society, about one in eight men will be diagnosed with prostate cancer in their lifetimes. The good news is that the 10-year survival rate is 98%.  

What are some of the factors that affect prostate cancer risk? Family history and genetics play a large role in raising risk. A study published in 2018 reported that men with a brother or father who had prostate cancer have a two to four times greater risk. Given Gabriel’s family history, he was right to be concerned. He is also of Ashkenazi ancestry, which is one of the criteria for genetic testing in those diagnosed with prostate cancer. In particular, the breast cancer susceptibility genes — the BRCA1 and BRCA2 mutations, which are much more common in both Ashkenazi women and men — may also raise the risk of prostate cancer in men compared with non-carriers.

Obesity increases the incidence of aggressive prostate cancer, while vigorous exercise three hours a week can have a protective effect. 

A diet high in animal fat and low in fruits and vegetables can pose a risk for developing prostate cancer. In a study comparing those who consume 14 servings of vegetables per week versus 28 or more servings of vegetables per week, researchers found a reduced chance of prostate cancer in the latter group. Consuming cruciferous vegetables was particularly beneficial.  Tomatoes, which are high in lycopene, as well as soy products and regular or decaffeinated coffee, may also lower risk.

Whether a prior vasectomy poses a risk for prostate cancer has been controversial, but the bulk of evidence suggests that if there is a risk, it is very low.

How does prostate cancer present? At the time of diagnosis, most men are asymptomatic and have localized cancer.

A PSA test is the most helpful way to detect prostate cancer early. It is not perfect, though. The reference range depends on age, and a normal PSA does not exclude prostate cancer. Obesity and medicines like finasteride and dutasteride that shrink an enlarged prostate can artificially lower PSA levels, which can make one feel falsely confident. 

Regardless, if the PSA increases by more than 0.75 ng/ml in one year, then further evaluation is warranted. An elevated PSA can be due to many benign conditions, including an enlarged prostate, perineal trauma (such as from bike riding) or prostatitis.

For those with increased risk of developing prostate cancer, such as family history, the American Urological Association advises PSA testing to start at age 40 to 45. Otherwise a baseline test should be offered to men between 45 and 50, and then subsequent testing is personalized. 

A particularly useful imaging test is called the prostate-specific membrane antigen (PSMA) positron emission tomography (PET) scan. In someone who has already been diagnosed with prostate cancer, it’s an accurate test to detect metastasis.

Getting back to Gabriel: The result of his first prostate biopsy revealed prostate cancer with a favorable pathological Gleason score of 6. (The Gleason grading system of cancer severity ranges from 6 to 10.) Because of the favorable score, he was advised by his urologist to do “watchful waiting.” After one and a half years and rising PSAs, Gabriel had a second prostate biopsy. To his surprise, this time his Gleason score was 9. 

His urologist gave him a choice of brachytherapy (placing radioactive seeds inside his prostate) or prostatectomy (surgical prostate removal). Gabriel specifically requested a PSMA PET scan. The scan was inconclusive whether the cancer resided solely within the prostate, so Gabriel opted for surgery. The pathology report revealed he had malignancy in the prostate margins, so he subsequently received pelvic radiation followed by medical treatment. Genetic testing showed he did not carry BRCA mutations, which was a positive note for his children. 

Gabriel encourages men to be proactive, as do I. Just because prostate cancer is not usually lethal does not mean it can be taken lightly.