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Welcome to Grand Central Station-the prostate, the bustling, walnut-sized hub at the crossroads of a man's urinary and reproductive tracts. What makes such a small, relatively obscure gland so important to men? The answer is not immediately obvious: The prostate is not, for example, a vital organ like the heart. Its biggest job, as far as we know, is to provide about one third of the fluid that makes up semen. But even this contribution does not appear to be crucial for reproduction - leading some scientists to theorize that the prostate's main purpose actually may be to safeguard the reproductive tract from infection in the urinary tract. (In fact, its name in Greek means “stands before,” or “protector.”) The prostate has few other redeeming features, isn't necessary for life or even for sexual function, and is known primarily for the clinical problems it causes to nearly all men who live long enough.

What the prostate does have, however, is a highly strategic location, right at the outlet to the bladder. Urine cannot leave the body without passing through the prostate, via a tube called the urethra. (Think of the urethra as an expressway, and the prostate as the Lincoln Tunnel.)

Nothing about the prostate is easy. From a urologist's standpoint, even a routine checkup - to feel for lumps or hardness in a digital rectal examination-is more complicated and takes more skill than many of our patients realize. (For a detailed discussion of diagnosing prostate problems. The prostate is as tucked away - and as surrounded by booby traps - as any of the prizes sought by Indiana Jones in Raiders of the Lost Ark. It lies in the midst of vulnerable structures - the bladder, the rectum, the sphincters responsible for urinary control, major arteries and veins, and a host of delicate nerves, some of them so tiny that we've only recently discovered them - that can foil any physician who ventures into the area without exquisitely precise knowledge of the terrain. This is why any procedure to treat prostate cancer - surgery, external-beam radiation therapy or implantation of radiation “seeds,” or attempts to kill cancer cells by cooling or heating the prostate - can produce side effects including incontinence, impotence, and rectal bleeding.

The prostate fits snugly within the pelvis; there isn't much “breathing room” here. Unfortunately, not only is the prostate packed tightly amid other structures, like pieces of a jigsaw puzzle, it is poorly insulated. The flimsy wall of tissue separating the prostate and the seminal vesicles is thinner than a piece of tissue paper - not much of a “buffer zone” for cancer. Consequently, once cancer reaches a critical size, it can easily penetrate the wall (also called the capsule) of the prostate, and escape into this overcrowded region of the body, spreading to the nearby seminal vesicles or lymph nodes, or even further, into the bloodstream.

This is why-even though treatment for prostate cancer is improving dramatically-a man's best protection against this disease is to have it detected as quickly as possible. For the American man at average risk of prostate cancer, this means, after age fifty, a yearly prostate checkup (a physical and digital rectal examination, and a blood test for PSA, prostate-specific antigen. Men at higher risk-African-Americans, and men with a family history of prostate cancer-need to start screening for prostate cancer much sooner, at age forty.

In short, the prostate is a gland that does much more harm than good, located in a terrible area that complicates any attempt to treat it. Despite this, there has never been more hope in our field. At last, we are finding answers to the toughest questions of prostate cancer: Where exactly does it begin, and why? How does it spread? If we can't cure it, can we contain it-can we make advanced prostate cancer a chronic illness, like diabetes, instead of a fatal one? Can we change our thinking, and try drugs that were once considered “last-ditch” measures sooner-can we create adjuvant therapy? Can we actually prevent cancer, or somehow slow its progress with diet? If PSA comes back after surgery or radiation, what does it mean-and how much time do we have to find a more effective treatment? As for radical prostatectomy itself, can we make the operation even better, with fewer side effects and quicker recovery of potency and continence? How can we help men and their families get their lives back? How can we improve quality of life? All of these areas will be covered in detail in later chapters.

Tags: Prostate Cancer, Cancer

About the Author

Janet Farrar Worthington is a science writer and commentator on American Public Radio.

About the Author

Patrick C. Walsh, M.D., urologist-in-chief at Johns Hopkins Hospital and director of the Department of Urology at Johns Hopkins University School of Medicine is the surgeon who created the Nerve-Sparing Technique (also known as the Walsh procedure), which has made it possible to preserve potency in men who lose their prostate.