Originally published 3/10/2016
Dr. J. Curtis Nickel is a Canadian urologist who is an authority on prostate inflammation and BPH. In January, 2018 he opened his presentation to an audience of urologists and oncologists with the wry observation, “My job is to keep patients away from you guys, that are interested in prostate cancer. He proceeded to deliver surprising information on prostate inflammation and prostate cancer (PCa) at the 2018 2nd Annual International Prostate Cancer Update.[i] He told them the REDUCE clinical study on chemoprevention of PCa generated longitudinal data based on serial biopsies that could be used to evaluate tissue for prostate inflammation and its implications for prostate disease (BPH, chronic prostatitis/CPPS, and PCa). For example, if the initial (first) biopsy was negative for PCa but positive for either inflammation or BPH, it predicted that either condition would progress. This is not surprising.
He also pointed out that patients with chronic prostatitis who are seeing a urologist have a higher risk for being diagnosed with PCa. Note the distinction: we don’t know if they have greater risk of developing PCa, but during ongoing treatment for chronic inflammation patients tend to receive more frequent PSA blood draws and biopsies, both of which are more likely to detect PCa if present. This is called urology overutilization, and it doesn’t actually tell us if inflammation of the prostate can lead to developing PCa.
Now, we know from some other organ cancers that inflammation is linked with the beginnings of cancer cell development. However, Nickel’s team showed that despite previous prostate studies linking the two, this does NOT appear to be the case in the prostate. Their analysis of the REDUCE study findings produced the surprising conclusion that baseline prostate inflammation is in fact associated with lower prostate cancer risk.
In 2021, they published a further conclusion: “Chronic inflammation in a negative biopsy was associated with lower prostate cancer grade among men with cancer on follow-up 2-year biopsy.”[ii] Thus, this update essentially overturns the original blog below and gives rise to yet another question: Can prostate inflammation somehow prevent PCa? The mystery goes on.
Imagine that you get a very small sliver in your thumb, and you can’t get it out because it broke off below the skin level. At first, it might be annoying, but if left in place, in a day or two you might experience swelling and redness at the site. If ignored, that swelling may grow bigger, harder and more painful. This is part of a normal immune system defense against injury or worse infection, and it’s called inflammation.
Everyone has experienced some form of inflammation at one time or another. When the problem lies on the surface, common signs are redness, swelling, heat and pain. When the condition is internal, as in a knee injury, the signs might be increasing discomfort, pain, and lack of mobility.
Did you know the prostate gland can become inflamed? This is called prostatitis. According to Sfanos and DeMarco, causes can include “infections, dietary factors, hormonal changes and/or other unknown environmental exposures.”[iii] There are two kinds of prostate inflammation: acute and chronic. Acute means it comes on suddenly, can be painful, and doesn’t last long. Chronic prostatitis, however, can linger for months, even years, at a relatively low-grade level. It’s estimated that about 16% of men experience some symptoms of prostatitis at some time or another. According to Mayo Clinic, symptoms can include
- Pain or burning sensation when urinating (dysuria)
- Difficulty urinating, such as dribbling or hesitant urination
- Frequent urination, particularly at night (nocturia)
- Urgent need to urinate
- Pain in the abdomen, groin or lower back
- Pain in the area between the scrotum and rectum (perineum)
- Pain or discomfort of the penis or testicles
- Painful orgasms (ejaculations)
- Flu-like symptoms (with bacterial prostatitis)
However, many more men don’t even know they have it. If left unrecognized and untreated, it doesn’t always get worse, but it can lead to misery and to complications.
Chronic inflammation is associated with the development of certain cancers. This is true with prostatitis and prostate cancer (PCa). At the December, 2015 meeting of the Society of Urologic Oncology, Dr. Daniel Moreira of the Mayo Clinic gave a poster presentation on the connection between chronic prostate inflammation and the presence of low grade prostate cancer.[iv] They drew data from the clinical records of 889 men (between 50-75 years of age) with negative first biopsies, but whose repeat biopsies 2 years later were positive for PCa. Approximately 10% of the biopsies showed inflammation in addition to PCa. Some of the inflammation cases had a mixture of chronic and acute inflammation; however, 60% of the cases had only chronic prostatitis while a very small minority (1%) had only acute prostatitis. The study noted that chronic inflammation was more associated with enlarged prostates. Perhaps the most important association was the finding that 70% of the cancers were low grade (Gleason < 6) while 30% were higher grade. What’s interesting about this is that the men with chronic inflammation who had prostate cancer had less risk of high grade disease when compared with men who had no inflammation.
The more we learn about prostate cancer, certain aspects of it become increasingly mysterious. Why would prostates with chronic prostatitis be connected with lower grade disease than healthy glands? Why do some men with cells that appear precancerous never develop PCa, while other men with apparently healthy cells suddenly develop a rogue cell line that is highly dangerous? While cancer in general is less fearsome than it used to be—people survive with cancer far longer than ever before, and a higher percentage of cancer patients no longer die of their cancer but from other causes—the true nature of the disease still eludes us.
One reassuring fact to keep in mind: In the hands of an expert radiology team, 3T multiparametric MRI can reveal normal and abnormal conditions in a prostate gland, including infection, inflammation (prostatitis), and prostate cancer. In the case of infection, imaging can be used to monitor how well medication, such as a course of antibiotics, is working. Also, this powerful form of prostate imaging is excellent for determining whether or not a biopsy is needed. Our center offers top-shelf detection and diagnostic services to help keep your prostate gland in the best condition possible.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.
[i] Nickel, JC. “Prostate Inflammation and Prostate Cancer: What Do I Need to Know?” Presentation at 2nd Annual International Prostate Cancer Update, January 27, 2018. Posted Mar. 2018 at https://grandroundsinurology.com/prostate-inflammation-and-prostate-cancer/
[ii] Naha U, Nickel JC, Andriole GL, Freedland SJ, Moreira DM. Chronic Baseline Prostate Inflammation is Associated with Lower Tumor Grade in Men with Prostate Cancer on Repeat Biopsy: Results from the REDUCE Study. J Urol. 2021 Mar;205(3):755-760.
[iii] Sfanos K, De Marco A. Prostate cancer and inflammation: the evidence. Histopathology. 2012 Jan; 60(1): 199–215.