Prostate cancer (PCa) is not a basic yes/no diagnosis. It would be so easy to say, “You either have it or you don’t.” If that were the case, treatment decisions would be simplified.

Instead, PCa can be seen as a spectrum of diseases from precancerous conditions that can become full blown cancer, all the way to highly aggressive metastatic colonies. In between those two extremes lie everything from meek cell lines that may never pose a threat to life to quiet killers that don’t signal their presence in a PSA test but are progressing rapidly.

Let’s look at two prostate conditions that are considered precancerous: PIN and ASAP.

Prostatic intraepithelial neoplasia (PIN)

As we age, so do our cells. Over time, the genetic program for cells to reproduce themselves can begin to break down, and newly reproduced cells have flaws that make them appear and behave less normally. You can think of this as making a xerox copy of a document, then making a copy from the copy, and so on. Each subsequent copy will be that much less faithful to the original, though you can still read the document well.

Neoplasia is detected during a prostate biopsy, and one estimate suggests that about 14% of biopsies pick up PIN. It is identified under the pathologist’s microscope, since the differences between normal cells and PIN are visible. Like PCa itself, PIN ranges from very small differences to pronounced aberrations. The most aberrant PIN is called high grade PIN, or HGPIN. These are the cells considered most likely to evolve into cancer as the copies further degrade. According to an earlier study, if HGPIN is found in a biopsy but there is no evidence yet of cancer, it’s probable that PCa will develop within 10 years.^[i]

Atypical small acinar proliferation (ASAP)

When unusual looking cells are found in a biopsy, and there is no clear diagnosis, they are called atypical. They don’t have enough features, or there aren’t enough of them, to be called cancer. However, the presence of ASAP raises suspicion that PCa has already begun in the gland (but was missed by the biopsy). According to experts, up to 60% of patients with an initial finding of ASAP are eventually diagnosed with prostate cancer.^[ii]

Monitoring PIN and ASAP

To date, there is no treatment for either PIN or ASAP. In 2010, results of a clinical trial of a drug called toremifene to treat PIN were announced. Although the men who took it appeared to have a reduction of PIN, they did not have significantly less conversion to PCa than men who did not take it, and FDA approval for the drug was not sought.^[iii] However, lifestyle changes are encouraged in order to diminish the odds of developing inflammatory conditions that foster cancer development: switch to an anti inflammatory diet like the Mediterranean diet, exercise vigorously, and reduce stress.

In addition, develop a schedule of noninvasive prostate monitoring using PSA blood tests and multiparametric MRI. As a matter of fact, men with HGPIN or ASAP might do well to see themselves as embarking on Active Surveillance. As the Prostate Cancer Foundation puts it, this is “a strategy to treat you only if and when your cancer warrants treatment.” Let’s modify that to include HGPIN and ASAP.

There is compelling evidence that lifestyle changes can actually affect the genes that switch tumor cells on and off.^[iv] If you’re eager to learn more, read the entire study by Dr. Dean Ornish and colleagues.

Keep in mind that not all abnormal prostate cells are bad actors, but high grade PIN and ASAP are certainly unstable characters worth keeping an eye on.

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] Bostwick DG, Liu L, Brawer MK, Qian J. High-Grade Prostatic Intraepithelial Neoplasia. Rev Urol. 2004;6(4):171-179.
[ii] Bostwick D and Meiers I. Atypical small acinar proliferation in the prostate. Arch Pathol Lab Med.
2006(Jul);130:952-57.
[iii] “The Toremifene/PIN trial.” March 26, 2011. https://prostatecancerinfolink.net/risk-prevention/prevention-prostate-cancer/other-trials/
[iv] Ornish D, Magbanua MJ, Weidner G, Weinberg V et al. Changes in prostate gene expression in men undergoing an intensive nutrition and lifestyle intervention. Proc Natl Acad Sci U S A. 2008 Jun 17;105(24):8369-74.