Three physicians weigh in on prostate cancer, testicular cancer and the benefits of testosterone replacement therapy. With age comes wisdom, or so we hope, but it can also herald an increase in the creaks and moans and simple the general breakdown of the human body. The years simply take their toll, and this can manifest in distinct ways along the biological gender divide, affecting men and women differently. SRQ spoke with three area physicians on the effects of aging with regards to the particularly male parts of the human body and aging process.

An interview with Dr. Richard Brown, M.D. with the Florida Cancer Specialists

Is there a connection between the rate of incidence of testicular cancer and advanced age? Does your risk go up?No. Testicular cancer is something that involves more the younger population than the older population. There is a sort of bimodal distribution, but the greater incidence is in younger men than older men. If you develop a testicular mass, in older men it could be a lymphoma of the testicle rather than a seminal or non-seminal mass. What is the difference between these masses? You can have lymphoid tissue anywhere in the body with those cells that fight infection and you can develop a lymphoma in your testicles, which we see in older men. But we divide testicular cancer, that is cancer of the testes themselves, into germ cell tumors and non-germ cell tumors – seminal and non-seminal – and we treat them a little bit differently. Both, in early stages, could be watched after having surgery, or could be treated with a dose of chemotherapy. Both are very curable diseases, even in advanced stages. Lance Armstrong is famous for having advanced stages of testicular cancer; he got it treated and then he won the Tour de France. What kind of side effects should people be aware of when undergoing chemotherapy? Does it affect fertility or function? Just having testicular cancer in general affects fertility, so when you look at men who have testicular cancer, their sperm counts are lower than the general population. So there are fertility issues from the get-go. Fortunately for men, chemotherapy can affect fertility but there are easy ways of storing sperm and banking it for future use. It’s a much more difficult process for women. What warning signs should men be on the look out for and how often should they be self-examining?  Well, most guys are going to be washing their scrotum and testicles in the shower, and usually you get swelling on one side. A lot of times it’s not painful. So if a young man feels swelling he didn’t have before and the testicle is enlarging, they should seek medical attention. Will there be any other signs, any functional issues? Rarely. It’s really a matter of swelling. A bunch of other things can happen, but in all of the ones that I’ve seen, it’s been swelling. Sometimes pain. How much of this is genetic? Are there good habits or bad habits that could affect your likelihood of developing testicular cancer? I don’t know of anything that could prevent it. You’re at risk if you had an undescended testicle at birth. There’s no family history I know of that puts you at higher risk. There’s nothing you can do to prevent it, it just occurs. Undescended testicle is the highest risk factor. Any gamechangers coming down the pipeline? The funny thing about testicular cancer is, if I had to have a cancer, it’s the one I would have. Because it’s so treatable? Because most of the treatments and studies right now are geared at trying to minimize what we have to do to cure people, not trying to give more in terms of curing. It has a very high cure rate. And if you relapse, there’s a very high salvage rate. We have additional treatments that have such great responses that we can still cure you. It’s a different paradigm for other cancers - we’re doing so well that we’re trying to do less. 

An interview with Dr. Daniel Kaplon, M.D. with Urology Treatment Center

Prostate problems are known to emerge as you age. How strong is that connection and is the prostate singular in that regard? It generally is. In men under 50, it’s pretty rare to have any prostate-related conditions. We start to see enlargement of the prostate over time, that usually starts around age 50 and continues through the rest of life, and simultaneously the risk of prostate cancer goes up. It’s pretty rare – not never – that we see cases of prostate cancer in men under age 50. What is happening that causes the prostate to enlarge? That’s hyperplasia, and what’s happening there is the prostate is just one of these glands that, in every man, continues to grow throughout their lifetime. And the prostate happens to sit in a very precarious position, right at the floor of the bladder around the urethra. So as it grows, it starts to cause constriction of the urethra and the associated symptoms of what we call BPH – Benign Prostatic Hypertrophy. Does benign mean that it’s not always going to be a problem? Benign indicates that there’s no cancer. But hypertrophy, in most men, does cause some symptoms, ranging anywhere from mild – having to urinate more often and a weaker stream than when you were young and having to get up at night – all the way to severe symptoms like not being able to urinate at all and needing to have procedures and take medication. So many of the warning signs will be found in urinary activity? Yes. And what I remind my patients, is that the symptoms of this condition are not symptoms of prostate cancer. We don’t usually see symptoms of prostate cancer in its early stages. Prostate cancer doesn’t cause any urinary disruption until it’s advanced. What’s the difference between the growth that happens with enlargement and the growth that comes with cancer? The growth in enlargement is really just normal prostate tissue proliferating and making the gland itself bigger, but with normal tissue. By definition, cancerous tissue in the prostate is a totally different animal and it’s a different cell line that grows and overtakes normal prostate tissue. If there are few signs, how do people know when they should see a doctor? Because there are no early signs, the way that we screen for early prostate cancer have to do with doing a yearly exam of the prostate over age 50 and getting a yearly blood test. Those are really the only ways we have of picking up early prostate cancer. For people uncomfortable at the thought of yearly prostate exams, what’s the reality of the exam?  It’s a very quick, slightly uncomfortable test that’s not anything major. Are there any beneficial behaviors people can engage in to improve or maintain their prostate health? We’ve made some observations, looking at other cultures especially, and we know that, for instance, in Southeast Asia there’s almost no incidence of prostate cancer at all. And we think that has to do with the American diet – high-fat, high-carbohydrate – which is so different than over there. They’ve done follow-up studies on people who moved from Southeast Asia to the United States and then their risk of prostate cancer actually is like any other American. Even though it hasn’t been established what that exactly is in terms of diet, we do believe that our American lifestyle or diet in some way increases the risk of prostate cancer. What is the standard treatment for prostate cancer? The important thing to keep in mind is that for early prostate cancer there really is no right or wrong answer, because both radiation and surgery have come such a long way in their effectiveness and the minimization of side effects. A lot of the time, you give the patient the information and let them make the decision. Generally, people who are very young we steer toward surgery, because we do have good long-term data on the success rate of surgery, and people who are older we talk more about radiation. When you break down radiation treatment, you get into radiation seeds or beam radiation. There’s a lot of nuance in terms of who’s the best candidate for what, depending on how aggressive their cancer is, what their age is and whether they’re a good candidate for surgery.  It’s a good problem to have, in that you’re choosing between two very well-established treatment modalities that are very effective. What are the effects of simply removing the prostate? You can absolutely live without a prostate. The prostate contributes some of the fluid to male ejaculation, but the reality is that most men in the age group that we diagnose prostate cancer are over 50 and aren’t really concerned about fertility anymore, because that’s really the only tangible thing that you can’t do without a prostate. Sexual-wise, everything is normal. Can enlargement affect fertility? Not that we know of. Is there anything exciting coming in the future of treatment that makes you hopeful for the future of your practice? What’s really coming down the pike now is more focused diagnosis and treatment of prostate cancer. It used to be that we were really only able to diagnose prostate cancer and identify and treat the whole prostate with radiation or surgery. What’s coming is a much more specific diagnosis where we can pinpoint exactly where the cancer is in the prostate and how to treat just one area and leave the rest of the healthy prostate alone. 

An interview with Dr. James DeRespino, M.D. with Center for Men’s Health

What is testosterone doing in the body when it’s at normal levels? Testosterone is the male hormone that makes men men. It’s responsible for muscle growth when you’re developing and going through puberty. It’s responsible for hair growth and lowering your voice and development of sexual organs. What we’re talking about is testosterone replacement as you get older. In most men, your testosterone levels start to drop. The testicles, which make the testosterone, can’t do what they used to do. The drop typically occurs in late 40s or 50s and it’s a gradual thing. Is this a natural thing that will happen to most men in their lives? That’s exactly right. In the past you were told that you were getting old and you had to deal with the decreased energy and decreased sex drive and reduced muscle mass. And because testosterone is responsible for building muscle, if you don’t have it and you’re still taking in calories, it stores them, in men, in the gut. So that’s why men, as they get older, get this belly fat. Testosterone is one of many hormones in the body, and when you take one out of the mix the whole framework of the hormone levels breaks down and nothing works efficiently. We liken it to a sports car trying to run on regular gasoline. It’ll run, but it won’t run right. Same thing with the human body, designed to run with these hormones at peak levels. How can people know that what they’re feeling or experiencing – whether it be energy loss or weight gain – is the result of low testosterone and not something else? The only way to really know is to take a blood test and see your testosterone levels. And that’s one of the main reasons we created the practice, to give men the chance to find out, in a very cost-effective manner, if their testosterone levels are low and if they’re a candidate for testosterone replacement therapy. Is there anything else that could cause low testosterone other than aging? Should younger men be aware? Absolutely. Obviously, a severe injury or losing a testicle can affect this. Infection can affect the testicles later on in life and their ability to create testosterone. And there’s a very rare cause of low testosterone, which is a tumor in the pituitary gland of the brain. The testicles are normal, but the brain is sending them weird signals so they’re not making testosterone. But far and away, you’re talking about the normal aging process of men. What are the essential benefits of this therapy? You don’t have to feel like you’re 70 when you’re 50. By replacing testosterone, we can safely give you back some of the energy, the sex drive, the muscle strength, the muscle mass that you had in your 20s. This seems huge. Why isn’t it a bigger part of the general conversation? In the past, it was feared that testosterone replacement therapy would cause prostate cancer and heart disease and strokes and blood clots and a million other things, but it was all anecdotal. None of it had ever been proven by research. When they started to do the real research in the late ‘90s and ongoing, they found that none of those things were true. In fact, it helps almost everything. There’s no cancer risk, there’s no heart attack risk. Does it alleviate risk of a heart attack? Testosterone doesn’t affect the heart like a heart medicine. What it does is get the men who are on testosterone therapy off the couch. It gets you active. You want to go back to the gym again. You want to work out. You’re starting to lose weight. And all those things, in turn, promote good heart health. So, in a roundabout way, testosterone therapy has been shown to improve the cardiovascular risk of middle-aged men. How does the actual therapy progress? Injections? There are many ways to do it, we do it only by injection. It’s the most effective and is the most precise way. You have gels and creams that you can rub on to deliver testosterone through the skin, but it’s less effective – for about 15 percent it doesn’t work at all. And there are risks – you don’t know how much exactly is coming out of the pump, and depending on how much you sweat and what you’re wearing, you can get a varying amount of testosterone released into your skin. And it’s a daily ritual, as opposed to an injection every two weeks. With men, convenience is key. Just walk in any time we’re open, sign in, get your shot and leave. We do not give testosterone for people to take home, but you’re in and out in five minutes. But there are evaluations and check-ins with the doctor as therapy progresses? Absolutely. Initially, we look at your lab tests and start. Then we know that for 92 percent we can get the testosterone levels to the optimal range in six shots, which is three months. So after three months we check your tests again and see where you are. Then it’s up to you. If you feel you’ve had the benefits, you keep doing it. And from that point on we check routinely, every six months. We may space that to yearly. But it’s a lifetime thing. Your testicles do not ‘wake up’ or jumpstart or all the sudden start to make testosterone again.

Contacts

Dr. Richard Brown M.D. of Florida Cancer Specialists earned his undergraduate degree from Boston University before moving on to receive his medical degree from the University of Vermont. Serving an internship and residency at the University of Minnesota, Dr. Brown continued to a fellowship in oncology and hematology at New York University. Board-certified in internal medicine, medical oncology and hematology, Dr. Brown also serves as Chief of Staff at Sarasota Memorial Hospital.

Dr. Daniel Kaplon M.D. graduated with honors from the University of Pennsylvania before going on to medical school at Penn State College of Medicine for his M.D. After a surgical internship and residency in urology at Brown University, Dr. Kaplon received additional training in robotics and laproscopy at the University of Wisconsin Hospital and Clinics. A member physician of Urology Treatment Center in Sarasota, Dr. Kaplon also serves as reviewer for the Journal of Endourology and Urology and on the editorial staff of Urology Times. Prostate problems are known to emerge as you age. 

Dr. James A. DeRespino M.D.,moving on to the Georgetown University School of Medicine for his doctorate. After a residency at Cleveland Clinic Hospital System and Akron City Hospital and a fellowship at the University of Maryland Hospital, Dr. DeRespino went on to become a staff physician at Manatee Memorial Hospital and then senior emergency care physician. In addition, Dr. DeRespino is a founding member of and active physician at Center For Men’s Health.