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Men's Health:
Prostate Cancer Concerns

Volume 3, Number 8 - September, 1999

Editors: Carol A. Rice, Ph.D., RN, Professor and Extension Health Specialist, and Janet M. Pollard, MPH, Extension Associate-Health

Inside HealthHints....

• Men's Health: Prostate Cancer Concerns
• Increasing Early Detection
• Now You Know
• The Prostate
• Prostate Growth Through the Lifecycle
• What is Cancer?
• What is Prostate Cancer?
• Who is at Risk for Prostate Cancer?
• How Would I Know if I Had Prostate Cancer?
• Early Detection
• Diagnosis: Biopsy
• Diagnosis: Grade and Stage
• Treatment Options for Prostate Cancer
• Side Effects of Treatment
• Extension Resources
• New Cancer Prevention Resources
• Websites with Reliable Information
• References

Men's Health: Prostate Cancer Concerns

How many men do you know who have prostate cancer? Chances are, you know several. Prostate cancer is the second most common cancer among American men (skin cancer is the first). It is the second leading cause of cancer death in men, exceeded only by lung cancer (American Cancer Society, 1999a). Prostate cancer affects about one in five men during the course of a lifetime (Drkoop, 1998b). It is most common in men aged 50 or older, but can also be diagnosed in younger men.

It is estimated that in 1999 in the United States nearly 179,300 men will be diagnosed with prostate cancer (National Cancer Institute 1999).

Increasing Early Detection

What can you do to improve the number of men in your county seeking early detection?

• Start with a newspaper article about the increased risk of prostate cancer for men over 50, etc.
• Go to the Texas Cancer Data Center (TCDC) website (http://www.texascancer.org/) and find statistics for your county and include these in the article.
• Have the article written by a survivor who wants to help convince men of the advantages of early detection, including more treatment options and treatments with less severe consequences.
• Mention the higher risk among farmers study in an article if in a rural area (See Farmers at increased risk box).
• Ask a local health care provider to be a guest writer in your local column and to emphasize importance of seeking early detection.
• During your regular radio time or in your newspaper article, ask for people interested in helping to organize a prostate cancer screening initiative in the community to contact you.
• Find a group of community residents interested in participating on a task force to organize and implement a prostate cancer screening initiative.
• Partner with local health care providers including clinics and hospitals to offer lower cost screening options at convenient times for a set period of time. Advertise this and provide coupons in newspaper for these screenings.
• Present importance of early detection through screening to FCE clubs. Emphasize that women tend to make family health care decisions and appointments. Give them the new brochure created for this purpose called "It's Up to You! Getting the Man You Love to Have an Annual Exam." Take the exhibit "Real Men Get Screened" to fairs, etc. and hand out the "Real Men Get Screened! Getting an Annual Prostate Exam" brochures.

Now You Know

(Article by Dr. Linda A. Jouridine, Extension Health Specialist)

Successful Prostate Cancer Awareness Campaigns for African-American and Hispanic Men

A local ad features George Foreman, a former heavyweight boxing champion of the world, in his fighting stance. The slogan beneath the photo reads "Real Men Get Checked." Beside this photograph is the announcement of FREE prostate cancer screenings during the month of September (a $70 value) in recognition of Prostate Cancer Awareness Month. Which one of those messages do you think is more likely to get the attention of minority men? The one that says it's free, or the one that has the picture of Mr. Foreman? If you guessed the one with the picture, you are correct.

Free services are not necessarily going to get African-American or Hispanic men to rush out and get screened. For some minority groups there are still a tremendous amount of myths and folktales about what cancer is and what it isn't. Attitudes about cancer itself are an important first step in making a decision about getting tested. George Foreman is a tough competitor, a fierce opponent, and has had the respect of people from all over the world for his successes in a traditionally male sport. Having his endorsement of something like prostate screening may begin to break down barriers in men's minds about what it means to have an examination. Although we don't know the exact response of the George Foreman prostate screening campaign, there is information that tells us that who is delivering the message may be just as important as what they are saying. When Washington, DC Mayor Marion Barry was diagnosed with prostate cancer in the early 1990's, he announced his condition and treatment options on the 6 o'clock news. The minority community had a tremendously positive response to this. A prominent African-American figure was actually on national television talking about, of all things, cancer. Hospitals and clinics reported an increase in the number of men who participated in cancer screening after Mayor Barry's announcement.

What does this all mean in terms of your communities? Well, it doesn't mean you have to find an African-American Texas celebrity or a Hispanic politician to talk about his own cancer screening. If any of those people do come out and promote prostate screening it will help in whatever you are doing locally. But at the level that you are getting the word out about early screening that may save lives, ask for assistance from African-American and Hispanic men who are recognized and respected for their leadership and their roles in the communities. Collaboration is a big part of this effort. With the facts in this newsletter and other materials that are available to agents, seek out the following list of sources that may provide support for a Prostate Screening Campaign in African-American and Hispanic Communities:

• Barber shops
• Service clubs and organizations
• The Faith community
• Radio stations that target Black and Hispanic audiences
• Popular school administrators, counselors, and teachers
• High school coaches who exemplify a healthy lifestyle
• Automobile Clubs (Lowrider, Detail Shops, etc.)
• Billboards
• Local newscasters
• Minority retired local sports figures
• Members of local Cancer Society organizations
• Car dealerships
• Motorcycle dealerships

Also enlist the help of Women's groups and organizations that cater to young children and teens. Several research studies suggest that minority men and women respond well to campaigns that include the support of family members. Women might be asked to give their spouses, brothers, cousins, and/or nephews a coupon for a prostate screening, or agree to accompany them to their checkup. Campaigns that feature children asking their parents and grandparents to engage in behaviors that will increase their chances for long life so that they, the children, can enjoy them longer, have been very effective with the minority community also.

Seek support from national organizations that have local chapters for your Prostate Screening and Cancer Education Campaigns. For example, 100 Black Men, Inc., is a national organization that seeks to "improve the economic vitality of Black communities and promote healthier lives for African-Americans." In addition to anti-violence campaigns, educational symposiums and academic achievement, this organization has a health forum as a part of its mission. Chapters in Texas include Austin, Houston, and Lubbock. For more information contact their website at http://www.100blackmen.org/. Also check out the National Hispanic Leadership Initiative on Cancer (NHLIC). This national organization has funded many grassroots and community groups to provide education, training, and support for the Hispanic and Latino individuals that might not otherwise be reached. Contact your local chapter of the American Cancer Society for web information for this organization.

Remember that after you get help with education and awareness, the population you serve may also need to overcome barriers and obstacles that come with a positive diagnosis. Be aware that issues such as transportation for treatment, educational level of patients, videos vs. written materials, informal and formal support networks, language and finances are all apart of being diagnosed with prostate cancer. Prepare in advance for these challenges by making sure that the channels that you use that are successful in your educational campaign will also be a resource for issues that are related to treatment.

Beginning November 1, 1999, Now You Know by Dr. Linda A. Jouridine, will be a monthly column dedicated to promoting healthier lifestyles for minority community members and the limited resource populations that we serve through the Texas AgriLife Extension Service. If you would like to share any success stories that your region has experienced working with minority populations, we'd like to share your stories with other agents.

The Prostate

The prostate is a male sex gland. This gland is a small organ, located just below the bladder and in front of the rectum. It surrounds the urethra, the tube responsible for emptying urine from the bladder.

The prostate needs male hormones, primarily testosterone produced by the testicles, to function. It is part of the male reproductive system, and produces a thick fluid that forms part of the semen, which helps transport sperm (Mayo Clinic, 1997c; National Cancer Institute, 1998b).

Prostate Growth Through the Lifecycle

The prostate goes through different stages of growth throughout a man's lifecycle:

• At birth, the prostate gland is about the size of an almond.
• During puberty, the prostate enlarges and grows until it is about the size of a walnut.
• After age 40, the prostate starts growing again, which is thought to be influenced by hormonal changes (Mayo Clinic, 1997c).

Occasionally, the prostate can grow abnormally large, due to cancerous or non-cancerous cell growth, both of which can cause problems for the male gastrointestinal tract, urinary tract, or reproductive system.

What is Cancer?

To understand cancer of the prostate, we must first understand how cancer develops. Cancer is a group of many different diseases, which all have one thing in common, they affect the body's basic unit of life -- cells. The body is made up of many types of cells, which grow and divide to produce more cells when the body needs them. This orderly process is what helps keep the body healthy. If the cells keep dividing when new cells are not needed, however, they form too much tissue. This excess tissue can form a mass called a tumor. Excess tissue can be benign or malignant.

• Benign tissue is not cancer. The cells do not invade nearby tissue or spread to other parts of the body.
• Malignant tissue is cancer. The cancer cells divide out of control, and can invade and destroy nearby tissue. The cancer cells can also break away from the tumor and enter the bloodstream or lymphatic system. This is how cancer spreads from the original tumor to create tumors in other parts of the body. The spread of cancer is called metastasis (National Cancer Institute, 1998b).

What is Prostate Cancer?

Most cancers are named for the type of cell or organ in which they begin. Cancer beginning in the prostate is called primary prostate cancer or prostatic cancer. Prostate cancer may remain localized in the prostate gland or spread to other parts of the body such as bones, bladder, rectum, or other organs.

When cancer spreads to other parts of the body, the new tumor(s) have the same malignant cells, and, therefore, the same name as the primary original tumor. Thus, if prostate cancer spreads to the bones, the cancer cells in the new tumor are prostate cancer cells, and the disease is called metastatic prostate cancer -- not bone cancer (National Cancer Institute, 1998b).

Who is at Risk for Prostate Cancer?

Although the cause of prostate cancer is still largely unknown, we do know that there are certain factors that put one man at higher risk than another. These risk factors include age, race, family history, nationality, diet, physical activity, and vasectomy.

• Age -- The chance of developing prostate cancer increases as a man gets older. Prostate cancer is rarely seen in men younger than age 50, but chances of developing the disease increase rapidly after age 50. Over 80% of cases are diagnosed in men over age 65.
• Race -- African-American men are more likely to develop prostate cancer than white American men. An African-American male is about twice as likely to develop the disease as a white male. African-American men are also more likely to die of prostate cancer than white men.
• Family history -- Men who have a close relative, particularly father, brother, or son, who has had prostate cancer, are at increased risk for developing the disease.
• Nationality -- Prostate cancer is most common in North America and northwestern Europe. It is less common in Asia, Africa, Central America, and South America. It is interesting to note, however, that when Asians immigrate to the U.S., their incidence of prostate cancer rises, suggesting some possible relationships with diet and/or environment (Drkoop, 1998b).
• Diet -- Results of most studies suggest that men who eat a high fat diet are at greater risk for developing prostate cancer. Still, other research shows that men who eat a high fat diet also tend to eat fewer fruits and vegetables and more dairy, suggesting that these factors could play a role. Recent research also suggests a diet high in calcium and low in fructose (fruit sugar) increases prostate cancer risk. Additionally, lycopenes, found in high levels in some fruits and vegetables (e.g., tomatoes, grapefruit, watermelon) seem to lower prostate cancer risk, as does the mineral selenium and moderate daily doses (about 50 mg) of vitamin E (American Cancer Society, 1999c; National Cancer Institute, 1998a; National Cancer Institute, 1997). Always consult a doctor before starting any type of vitamin or mineral supplements.
• Physical activity -- Maintaining a healthy weight and regular physical activity may help to reduce the risk for developing prostate cancer.
• Vasectomy -- Some studies have found than men who have had a vasectomy (surgery to make a man infertile) have a slightly higher risk (1 to 2 times more likely of developing prostate cancer) than men who have not had a vasectomy. Still, other studies found no difference in prostate cancer risk between the two groups. Additionally, some studies only showed a heightened risk for those men who had a vasectomy prior to age 35 (American Cancer Society, 1999c).

How Would I Know If I Had Prostate Cancer?

Prostate cancer often does not cause symptoms for many years. When symptoms do result, the cancer has often spread to other parts of the body. Some symptoms may include the following:

• frequent urination, especially at night
• inability to urinate
• trouble starting or holding back urination
• weak or interrupted flow of urine
• painful or burning urination
• blood in the urine or semen
• painful ejaculation
• frequent pain or stiffness in the lower back, hips, or upper thigh
• general pain in the pelvic area lasting several weeks or more
• loss of appetite and weight (Mayo Clinic, 1997a; National Cancer Institute, 1999).

Although all of these can be signs and symptoms of cancer, they are more often symptoms of a non-cancerous enlargement, such as benign prostatic hyperplasia (BPH). It is important to have an annual checkup and to check with your doctor if you have any of the symptoms listed.

Early Detection

Because there are typically no symptoms in the early stages of prostate cancer development, regular checkups, beginning at age 40, are important for early detection. If you have a family history of prostate cancer or are an African-American man, consult your doctor about being screened earlier.

There are three types of tests that are commonly done to detect prostate cancer. The digital rectal exams, blood tests, and urine tests.

• Digital rectal exam -- A digital rectal exam is done when the doctor inserts a gloved, lubricated finger into the rectum and feels the prostate through the rectal wall for hard or lumpy areas.
• Blood tests -- In a blood test, the man's blood is drawn and the lab will measure the levels of prostate-specific antigen (PSA) and prostate acid phospatase (PAP) in the blood. The level of PSA in the blood may rise in a man who has prostate cancer, BPH, or an infection in the prostate. The level of PAP typically rises above normal in men with prostate cancer, when the cancer has spread beyond the prostate. Unfortunately, prostate cancer cannot be diagnosed using these tests alone, since they may indicate other, non-cancerous problems. The doctor will take these tests results into account, however, in deciding whether to check the patient for further signs of cancer.
• Urine test -- In a urine test, the lab will check for blood or infection in the patient's urine sample. Additional tests may be ordered to help the doctor learn more about the cause of a patient's symptoms.

Diagnosis: Biopsy

If any of these tests results suggest that cancer may be present, a biopsy will be needed. A biopsy is the only sure way to confirm that there is cancerous prostate tissue. This procedure requires that a doctor remove a small portion of prostate tissue, usually with the use of a needle. After the procedure, a pathologist looks at the tissue under a microscope to check for cancer cells.

Diagnosis: Grade and Stage

If cancer cells are present, the pathologist will usually report the grade and stage of the tumor.

Grade

The grade is a term used to describe how closely a tumor resembles normal tissue, and may suggest how fast the tumor is likely to grow. The pathologist may describe the tumor as low-, medium, or high-grade cancer. One way of grading prostate cancer, known as the Gleason system, uses scores 2 to 10; another system uses G1 to G4. Either way, the higher the score, the higher the grade of tumor. High grade tumors grow more quickly and are more likely to spread than low-grade tumors.

Stage

Staging of prostate cancer is determining the site and location of the disease.

• Stages 1 and 2 represent early prostate cancer, which is localized in the prostate gland only.
• Stage 3 prostate cancer is locally advanced outside the gland.
• Stage 4 prostate cancer has spread to other organs or tissues (American Cancer Society, 1999a; National Cancer Institute, 1999).

If results of all tests do not suggest cancer is present, your doctor may recommend medications or surgery to reduce symptoms of an enlarged prostate. The surgery performed in this case is transurethral resection of the prostate (TURP), where an instrument is inserted through the penis to remove prostate tissue that is pressing against the upper part of the urethra (American Cancer Society, 1999a).

Treatment Options for Prostate Cancer

There are five primary types of treatment for prostate cancer.

1. Surgery -- Some common types of surgery include radical prostatectomy, in which the entire prostate gland is removed, or cryosurgery in which the cells of the prostate are frozen using a metal probe.
2. Radiation therapy -- Radiation therapy uses high energy rays and particles to kill cancer cells.
3. Hormone therapy -- Hormone therapy has the goal of lowering levels of male hormones, androgens, particularly testosterone. This may be done through the use of drugs, an orchiectomy (an operation which removes the testicles), or a combination of these and other treatments. Hormone therapy is thought to work most effectively in early stages of prostate cancer.
4. Chemotherapy -- Chemotherapy is used for patients whose cancer has spread beyond the prostate. This treatment uses anticancer drugs injected into the vein, muscle, or taken by mouth. These drugs kill cancer cells, but may also damage some normal cells.
5. Watchful waiting -- Watching and waiting may be recommended if the cancer is not causing any symptoms, is expected to grow very slowly, and is small and contained within one area of the prostate. This approach is particularly used among men who are elderly or have other serious health problems (American Cancer Society, 1999d).

Treatment is handled on a case by case basis. Your choice in treatment may be different depending on your particular circumstances. Your doctor can help you consider what treatment options are best for you. The most important thing is to have regular checkups -- early detection can mean more, better treatment options with fewer possible side effects.

Side Effects of Treatment

One reason men often do not want to go in for their annual checkup is concern about discovering the disease and the idea that they may have to undergo some type of surgery. It is not the surgery itself that concerns most men, but rather it's possible side effects -- primarily the fear of impotence, followed by concern about incontinence.

Impotence

Impotence, also called erectile dysfunction, is the inability to have an erection of the penis adequate for sexual intercourse. In some procedures for prostate cancer treatment, the nerves that allow a man to get an erection may be damaged or removed. This is why early detection of prostate cancer is so crucial. The earlier the cancer is detected, the more options a man may have for treatment, especially treatments with limited risk of this type of side effect.

Incontinence

Incontinence may also be a serious concern regarding prostate cancer treatment. Incontinence is the inability to control the flow of urine from the bladder, resulting in leakage or dribbling of urine. These problems may result due to damage to a muscle or nerves that keep the bladder muscles working effectively. Again, however, the importance of early detection is clear. The earlier prostate cancer is detected the more options available for treatments that have lower risk of side effects.

Questions about screening or treatment? Call 1-800-4-CANCER.

Extension Resources

Prostate Cancer

Exhibits

• Real Men Get Screened. Their Lives Depend On It! (1999) (available in all County Extension offices)

Teaching Resources

• Listen Up: It's a Man's Responsibility Prostate Cancer (available from Educational Resource Library)
  For ages 40 plus. Video, workbook, handouts, presenters guide and poster.

Videos

• Listen Up: It's a Man's Responsibility (VHS 1152, available from Educational Resource Library.) This educational video motivates the participants with a fast-paced mixture of men from different backgrounds discussing their knowledge of prostate cancer. These men, 40 years and above, are responding to the question, "What do you know about prostate cancer?" This video addresses the objectives of the module while discussing the risk factors, signs and symptoms, and treatments for prostate cancer.
• Every Man Should Know About His Prostate (VHS, 10:07 minutes, available from Educational Resource Library.) A disease awareness video that discusses the primary function of the prostate gland, symptoms to look for in screening for prostate cancer, and the examination procedures. It also addresses the differences in prostate cancer and the BPH (benign prostatic hyperplasia) condition. Encourages men to take responsibility for these conditions.
• Prostate Cancer: A Journey of Hope (VHS, 56:46 minutes, available from each District Extension office and Educational Resource Library.) General Norman Schwarzkopf narrates the very informative prostate cancer video. Physicians, prostate cancer survivors and their families provide insight into the cancer that effects 1 in 10 men during a lifetime. Three out of ten men in their 30's and 40's have pre-cancerous signs of prostate cancer. The video discusses surgery, radiation, and hormone therapy. Excellent video to check out for FCE groups and individuals who would like to check it out to watch at home.

Now Available: New Cancer Prevention Resources

Video

• Prostate Cancer: A Journey of Hope (VHS, 56:46 minutes, available from each District Extension office and Educational Resource Library.) General Norman Schwarzkopf narrates the very informative prostate cancer video. Physicians, prostate cancer survivors and their families provide insight into the cancer that effects 1 in 10 men during a lifetime. Three out of ten men in their 30's and 40's have pre-cancerous signs of prostate cancer. The video discusses surgery, radiation, and hormone therapy. Excellent video to check out for FCE groups and individuals who would like to check it out to watch at home.

Displays

• Caution Signs of Cancer (available from each District Extension office and Educational Resource Library.) This fold out display with color drawings, explanations and warning signs includes: What is Cancer?, Seven Warning Signs of Cancer, Skin Cancer, Cancer of the Mouth, Breast Cancer, Lung Cancer, Cancer of the Larynx, Cancer of the Liver, Endometrial Cancer, Leukemia, Stomach Cancer, Ovarian Cancer, Cancer of the Urinary Bladder, and Cancer of the Colon and Rectum.
• Skin Cancer: The Bare Facts (available from each District Extension office and Educational Resource Library.) This fold out display with photographs and color drawings includes information on skin cancer risk factors, treatment and prevention of skin cancer, self-examination, and types of skin cancers.
• Don't Get BURNED by Indoor Tanning (available at each County Extension office.) This laminated exhibit is ready to be spray mounted to a foam core exhibit board. It includes pictures of indoor tanning equipment, a list of warning signs and risks related to tanning indoors, and other information people should know before they decide to tan without the sun. Also included with the exhibit is a camera-ready copy of a brochure with the same name.
• Can You Afford the REAL COST of Using Snuff or Chew? (available at each County Extension office.) This laminated exhibit is ready to be spray mounted to a foam core exhibit board. It includes a list of problems that smokeless tobacco can cause, a list of things you could buy if you don't have to buy snuff or chew and some tips for quitting. Also included with the exhibit is a camera-ready copy of a brochure with the same name.

Smoking Prevention Resources

• Simulated Smoker's Lung Comparison Kit (available from each District Extension office and Educational Resource Library.) This inflatable lung comparison kit is designed to demonstrate the effects of prolonged smoking. It utilizes the Simulated Smoker's Lungs and a set of healthy preserved pig lungs to demonstrate the difference in color and texture of a smoker's and a nonsmoker's lungs. Each kit includes a cross-section of healthy lung, inflation rack and tray, air pump, and teacher's guide.
• Poison Trap Smoker (available from Educational Resource Library.) This new smoking machine enables you to demonstrate without "stinking up" your classroom or exhibit hall. Smoke and tars are trapped inside a 1 cubic foot plastic box. The display also makes a graphic demonstration of how much smoke from just a single cigarette is released as secondhand smoke. A long list of poisons in cigarette smoke is included.
• Smokey Sue (available from Educational Resource Library.) When Smokey Sue's bulb is pumped, tars collect in the tube placed where her "lungs" would be. The tube can be passed around for an effective lesson. Comes with three collection tubes and a carrying case.

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References

• American Cancer Society (1998). Key Terms. In: Progress: Research news from the American Cancer Society. Atlanta, GA, p3.
• American Cancer Society (1999a). Prostate cancer [on-line]. Available:
  http://www3.cancer.org/cancerinfo/main_cont.asp?st=wi&ct=#36stats.
• American Cancer Society (1999b). Prostate cancer: Get the facts [brochure]. No. D-878.
• American Cancer Society (1999c). Prostate cancer: Prevention and risk factor [on-line]. Available:
  http://www3.cancer.org/cancerinfo/main_cont.asp?st=pr&ct=#36cause.
• American Cancer Society (1999d). Prostate cancer: Treatment [on-line]. Available:
  http://www.3.cancer.org/cancerinfo/main_cont.asp?st=tr&ct=36#treat.
• DrKoop.com, Inc. (1998a). Healthcare providers for prostate cancer [on-line]. Available:
  http://www.drkoop.com/conditions/cancer/page_75_391.asp.
• DrKoop.com, Inc. (1998b). Prostate cancer [on-line]. Available:
  http://www.drkoop.com/family/mens/cancer/prostate.asp.
• Mayo Clinic (1997a). Prostate cancer warning signs [on-line]. Available:
  http://www.mayohelath.org/mayo/9702/htm/pros_1sb.htm.
• Mayo Clinic (1997b). Prostate cancer: What you should know [on-line]. Available:
  http://www.mayohealth.org/mayo/9702/htm/prostate.htm.
• Mayo Clinic (1997c). The prostate gland: Just the facts [on-line]. Available:
  http://www.mayohealth.org/mayo/9702/htm/pros_2sb.htm.
• National Cancer Institute (1997). Selenium supplements lower incidence of lung, colorectal, and prostate cancer [on-line]. Available: http://cis.nci.nih.gov/fact/4_14.htm.
• National Cancer Institute (1998a). Study in Finland suggests vitamin E prevents prostate cancer [on-line]. Available: http://cis.nci.nih.gov/fact/4_16.htm.
• National Cancer Institute (1999). Questions and answers about early prostate cancer [on-line]. Available:
  http://cis.nci.nih.gov/fact/5_23.htm.
• National Cancer Institute (1998b). What you need to know about prostate cancer [on-line]. Available:
  http://www.cancer.gov/cancer_information/doc_wyntk.aspx?viewid=b94a9092-bbc1-4ba2-8c75-6793238d92a4.
• National Institutes of Health (1998). Screening tests for prostate cancer [on-line]. Available:
  http://www.drkoop.com/wellness/prevcenter/care/men.asp.
• Parker, AS, Cerhan, JR, Putnam, SD, Cantor, KP, Lynch, CF (1999). A cohort study of farming and risk of prostate cancer in Iowa. Epidemiology, 10: 452-455.
• Speicher, J. (1999). Farmers have greater risk of prostate cancer [on-line]. Available:
  http://www.drkoop.com/news/stories/june/farmers.html.

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