Preventative Measures and Cancer Screening Recommendations Aid Male Population

Hagen F. Kennecke, MD, MHA, FRC

Men’s health issues are brought to light during Men’s Health Week annually to generate further awareness of these diseases, which include cancer, the number 1 cause of death in the United States. The likelihood of men developing cancer during their lifetime is 50%, whereas women have about a 33% chance of developing cancer. Overall, men are at a greater risk of developing cancer and should consider screening recommendations, as well as preventative measures that they can take.

The consumption of red and processed meat, which is considered a class 2a carcinogen by the World Health Organization (WHO), should be minimized. Low-fat diets and exercise are also important preventative measures that men could take to help avoid a diagnosis of cancer during their lifetime.

Prostate cancer, specifically, is a unique cancer type in the male patient population, but men also may run the risk of developing lung, colon, rectal, and pancreatic cancer as well. In terms of screening, men are recommended to begin screening for colorectal cancer (CRC) at the age of 50 years, but the American Cancer Society recommends that suggest screening begin earlier at the age of 45 years. For prostate cancer, screening discussions should begin around the age of 50, but it is also important to consider the patient’s family history of cancer that may put them at a greater risk of developing cancer.

In an interview with Targeted Oncology, Hagen F. Kennecke, MD, MHA, FRCP, medical oncologist, medical director of the Virginia Mason Cancer Institute and current chair of the NCI Rectal-Anal Cancer Task Force, discussed the prevalence of cancers, particularly CRC and prostate cancer, in the male population. He also spoke to screening recommendations and preventative measures that can help reduce the risk of developing cancer.

TARGETED ONCOLOGY: Could you discuss the prevalence of cancer in the male patient population compared with females, and what does the prognosis look like?

Kennecke: Cancer is now the number 1 cause of death in many parts of the United States and overall, men are at a 50% likelihood of having some sort of cancer diagnosed in their lifetime, where it is slightly lower in women at about a third. Overall, the burden of cancer is higher for men.

The male unique cancer is prostate cancer, which is number 2 in terms of mortality behind lung cancer. For both men and women, colorectal cancer is the third most common cause of cancer mortality, otherwise, cancers are quite non-gender discriminatory. In CRC, men and women are equally affected. Pancreas cancer is sometimes more common in males, but this is not a strong trend.

TARGETED ONCOLOGY: Could you discuss what men should be getting testing done for cancer? For men with a family history of cancer in particular, what steps should they be taking?

Kennecke: In CRC, the current national guidelines recommend, regardless of family history, to start screening at age 50. The American Cancer Society suggest starting at age 45, but that is due to a significant recent increases in cancers diagnosed less than age 50. At the very latest, men should start testing at 50 or even 45 years of age, particularly if there is a family history.

When it comes to prostate cancer, that is a much longer-winded answer. There is some evidence to support screening for prostate cancer in the form of a PSA blood test. There is a lot of discussions, however, on when the best time is to start testing and what the best thing to do is if a diagnosis of an early-stage prostate cancer occurs. Overall, although the recommendation is to start the conversation for prostate cancer screening at age 50 in average-risk men and age 40 to 45 in men with a family history and in African American men who are also at higher risk of the cancer. It is important to define that family history, and a family history is a first-degree relative, so a brother or parent at the age of less than 65 years. When we talk about family history, it is important to be specific about that.

TARGETED ONCOLOGY: Could you provide an overview of the current treatment options in CRC and prostate cancer?

Kennecke: The cornerstone of CRC generally involves a diagnosis that has been made, which is generally made with a colonoscopy, and then treatment involves a surgery. Once that is done, the surgery is generally not significantly morbid. Particularly for patients diagnosed with rectal cancer, it is important that this surgery is done by a colorectal surgeon due to the complexities of pelvic surgery and the rapidly changing treatment paradigms for this cancer. In terms of further therapy, that depends on how advanced the tumor is. If the cancer has gone to the lymph nodes, then we most often offer chemotherapy to reduce the risk of future recurrence. For rectal cancer, it is different because this is a cancer where it is better to give radiation before surgery which was been shown to be more effective and have less side effects. A colorectal surgeon will be familiar with these requirements and generally initiate the referral to medical and radiation oncology. For rectal cancer, there is also an increasing trend to offer chemotherapy before surgery which may decrease the need for a permanent colostomy. 

For prostate cancer, there are many treatment options, and I would also like to point to decision aids. Decision aids that involve the patient are offered online by the American Cancer Society, as well as the American Society of Clinical Oncology, Mayo Clinic, and other major cancer organizations. It helps initiate the discussion about not only screening but 1 of the things that happens is many prostate cancers that are diagnosed are very early stage and may not necessarily require any initial treatment. That is where there is a continuum between the screening and treatment discussions. It is not quite as black and white as with other cancers. Overall, though, if treatment is required, that is usually for those that have established high-risk criteria. The options are either a surgical approach to remove the prostate and surrounding tissue or a radiation approach, which involves seeds implanted into the prostate or external radiation. It may also require all of those things if the tumor is high risk and meets certain criteria.

TARGETED ONCOLOGY: What should physicians keep in mind when they are treating their male patients with either prostate cancer or CRC?

Kennecke: In terms of men in general, they are not as good as women when it comes to follow-up and seeing primary care doctors and pursuing screening as much as they should. You should continue to encourage that screening discussion. When it comes to actual toxicities that are unique to men, we do know that rectal and prostate cancers are an area where men are more likely to experience sexual, bowel and bladder dysfunction after treatment. From a treatment perspective, those are very important subjects that should be discussed prior to initiating therapy. There are also new ways of treating rectal cancer designed to reduce the long-term toxicities and reduce the use of permanent colostomies. For prostate cancer, we know that cancer of survival of men who are diagnosed with early stage prostate cancer is very high, which makes it important to balance the treatment versus the disease and its side effects. There is a lot of emphasis on quality of life and survivorship.

TARGETED ONCOLOGY: What would you like for community oncologists to know when they are treating men with cancer?

Kennecke: I have an incredible amount of respect for community oncologists. They are very knowledgeable and take care of many different cancer types whose treatment is rapidly changing. At times it is necessary refer for those cancer patients that need extra attention for special care while making arrangement for the remainder of treatment and follow-up to be offered closer to home. We know that can make a difference, and I think overall, talking about the risks and benefits of therapy, and involving the patients in that is really important.

TARGETED ONCOLOGY: What is your main message now in regard to diagnosing and treating men with cancer?

Kennecke: Cancer touches almost everyone, directly or indirectly and we need to have balanced discussions about treatment and outcomes. Today we talked a lot about screening and treatment, and we need to remember prevention, which all about healthy habits for the rest of our lives. Things like reducing red and processed meat, a low fat, high fiber diet, exercise and weight loss are key to prevention of colorectal and prostate cancer. We cannot say this often enough.