Prostate cancer in younger men

[Wendy_Winnall]

Younger men who are diagnosed with prostate cancer face many challenges. They may be fighting this disease at a busy time in their working lives, or whilst looking after a young family, or dating or trying to conceive children. Younger men with advanced prostate cancer face having their lives cut dramatically short by this disease. New research is helping to understand the nature of early-onset prostate cancer and the best strategies for management and treatment.

Prostate cancer in younger men

Younger men, such as those less than 55 years old, often face additional challenges when diagnosed with prostate cancer. Their diagnosis is usually a big shock to them, as they considered this an older men’s disease. Younger men are diagnosed at what seems like the prime of their lives. They may have young families, mortgages to pay, busy jobs and social lives.

After initial treatment for localised prostate cancer, younger men usually need to return to work and to “normal life”. Few of their colleagues and friends understand the challenges they face soon after treatment. Whilst their friends are leading active lives, such as playing sport and taking holidays, recovery from prostate surgery makes these activities difficult. These men are often struggling to cope with temporary or long-term incontinence. This is difficult to manage in the workplace, makes sport and other daily activities much more challenging. These men face everyday challenges such as finding toilets where they can dispose of incontinence pads.

Treatments for both localised and advanced prostate cancer can have a terrible effect on a man’s sex life. This is perhaps more distressing for younger men. These men are more likely to be in new relationships or dating. Couples in their 40s and 50s expect to enjoy a full sex life and are often devastated when this is taken from them by the cancer treatment. Men in their 40s and 50s may be still trying to conceive children. But most prostate cancer treatments will leave them sterile. Whilst these are all issues that affect older men too, they can be more problematic for younger men.

Advanced prostate cancer in younger men, as for older men, is always bad news. Receiving such as diagnosis at a younger age can be devastating. This is particular so for men who have metastatic disease at diagnosis. These men face a life-threatening cancer at an age where their lives could be cut dramatically short. The distress could be all the worse for a man with a young family.

How young is young?

In Australia, the average age for prostate cancer diagnosis is 67 years. PCFA produces resources to provide information for younger men with prostate cancer. This information is aimed at men younger than 50 years of age. Approximated 3% of men diagnosed with prostate cancer are less than 50. But there is no particular age group that is universally agreed as “young” for prostate cancer. A good source of scientific information about prostate cancer in younger men comes from a review published in Nature Reviews Urology. It focuses on US men and defines young as 55 years old or less. In the US, approximated 10% of men diagnosed with prostate cancer fall into this age group.

There are some rare cases of prostate reported in much younger men. While most prostate cancers are a type called adenocarcinoma, there are rare prostate cancers that are different. Rhabdomyosarcoma is a type of rare prostate cancer that is more common in boys and younger men.

Is prostate cancer increasing in younger men?

We often hear, anecdotally, that prostate cancer is increasing in younger men. Indeed, there has been a detectable increase in the rate of prostate cancer diagnoses for younger men. This started in the early 1990s, at the time when PSA testing became popular. In fact, prostate cancer in older men increased at this time as well. One reason for the increase seen in younger men is that PSA tests were picking up prostate cancer earlier. It could be the only reason for this increase is that the same cancers are just being diagnosed earlier, rather than later. However, there is evidence that this is not the case. The increase in the rate of prostate cancers in younger men over the past 20 years is greater than that seen for older men. This indicates that, for some men, prostate tumours are starting earlier than they used to be. What might be causing this is unknown. Regardless, prostate cancer remains rare in men below 50 years of age.

In Australia, the numbers of men diagnosed with prostate cancer in some younger age groups has increased. For men between 40 and 55, there has been a steady rise in the number of diagnoses over the past 15 years, which is more apparent than for older age groups. For example, there were 2,166 men diagnosed with prostate cancer in 1999 who were 70 to 74 years old. This rose to 3033 diagnoses by 2014. But the diagnoses for men aged 40-44 rose from 9 to 106 in the same time period. These figures tell us that there has been a steep rise in cases among younger men. However, prostate cancer is still rare in the 40-44 age group.

For men aged below 40, the numbers diagnosed with prostate cancer remain very low. There was only 1 case of prostate cancer for men between 30 and 39 in 1999 in Australia. In 2014, there were 4 cases for men in this age group.

Is prostate cancer more dangerous in younger men?

There is some evidence that advanced prostate cancer is more dangerous for younger men. But the good news is that localised prostate cancer seems to bring no greater risk for younger men than for older.

Whether prostate cancer is more dangerous in younger men has been difficult to determine through research. Numerous different studies have had quite different results. There are many studies that indicate no difference in survival rates across different age groups.  But these are old studies, from 20-30 years ago. Much has changed for prostate cancer detection and treatment over the past 20 years.

A more recent study looking at registry data for over 300,000 US men diagnosed from 1988-2003. Results showed that men diagnosed before 55 years were more likely to have low-grade cancers. But the younger men diagnosed with high-grade cancers had a greater risk of dying from prostate cancer. There are two possible reasons for this. Firstly, younger men are less likely to be dying of other causes. Whilst an older man with advanced prostate cancer has a life-threatening disease, he may die of other causes, such as heart disease, instead of the prostate cancer. Younger men are less likely to have heart disease, or other conditions that may take their lives before prostate cancer does. The second reason, is that a very aggressive prostate cancer grows more quickly. Therefore it’s likely to be detected more quickly, in a younger man. So it’s possible that the high-grade prostate cancers seen in younger men are more aggressive and spread quicker than those detected later, in older men.

Recent research findings for early-onset prostate cancer

There are many important questions about prostate cancer in younger men that need to be answered, to provide better care for these men. Is early-onset prostate cancer different to late-onset? Is active surveillance safe for these men? What treatments are best for localised prostate cancer, given the expectation of a longer life after treatment than for older men? Some recent studies are helping to answer these questions:

What genetic markers are associated with early-onset prostate cancer?

A team of researchers from the UK, led by Prof Rosalind Eeles, have recently published an analysis of the genetics of early-onset prostate cancer. For their study, they defined early-onset as diagnosed in men 60 years or less. The researchers sequenced 167 genes that are involved in DNA repair. The reason for this choice is that DNA repair genes mutations are associated with a predisposition to prostate cancer. Men with mutations in these genes may be more likely to get prostate cancer.

Their study was a case-control design. DNA was sequenced from 1281 men with early-onset prostate cancer. Each man was “matched” to a control, being a man with similar ethnic background, therefore similar genetics. Controls were men without prostate cancer. The researchers sequenced DNA from blood samples, not from tumours. The aim was to look at existing gene mutations that might lead to cancer, rather than what is going on in the tumour cells.

Results uncovered 233 unique “truncated” proteins made from these genes. A truncated protein is one that is not made properly. DNA mutations have resulted in smaller-than-normal versions of each protein. One or more of these smaller proteins might be contributing to the prostate cancer. The men in this study with prostate cancer had more truncated proteins than the men without the cancer. The researchers identified 20 of these truncated proteins associated with a greater risk of prostate cancer. They also found 4 that increased the risk of aggressive prostate cancer. This panel of gene mutations may improve risk prediction for younger men and help inform the best treatments for men with early-onset prostate cancer.

Is active surveillance safe for younger men with prostate cancer?

A study from the US has assessed active surveillance for younger men with prostate cancer. The senior author of the study was Prof Peter Carroll from the University of California.

The US study recruited 1,433 men starting active surveillance for prostate cancer. Their progress was tracked for an average of 49 months. The average age at diagnosis was 63. 42% of the men were 60 or less at the time they were diagnosed. Results from this study indicated that the younger men, with low-risk localised disease on active surveillance, were at no greater risk of their cancer progressing or needing treatment. However, the long-term consequences of active surveillance for these men were not measured in the study. We will need to wait much longer, possibly decades, before we know whether survival rates are different.

The recommendations for active surveillance for most of these men were 3-monthly PSA tests and a biopsy after 12 months to confirm the original grade group. It’s not uncommon that men on active surveillance will be “re-staged” after the second biopsy. Restaging means that the biopsy done after 12 months shows a higher Gleason grade than the first biopsy. These men would often have treatment recommended, rather than continuing active surveillance. Restaging is generally thought to occur because the first biopsy was inaccurate, rather than the cancer having changed rapidly. Interestingly, in the US study younger age was associated with a lower chance of restaging. So the younger men in the study were less likely to have their Gleason grade increased after the 12-month biopsy.

The results of this study indicate that, for younger men with low-risk, localised prostate cancer, active surveillance is a relatively safe strategy for management of their cancer. Longer term follow-up of these patients is needed to look for differences in survival rates.

PCFA produces resources to provide information for younger men with prostate cancer. This information is aimed at men younger than 50 years of age.

Younger men may also find PCFA's Speaking from Experience videos useful. In these videos, younger men who have been through treatment talk about how it has impacted on their mental health, relationships, and sex life; as well as how they sought support.