The aging prostate is associated with changes in its vascular structure, which could lead to changes in oxygen levels. Hypoxia is an important environmental change that leads to the progression of many cancers mediated through a number of cellular changes, which included resistance to apoptosis. The role of hypoxia in initiating tumour development has not been previously investigated. We demonstrate that normal prostate epithelial cells develop a resistance to receptor-mediated apoptosis following 24 hr of 1% hypoxia. This effect is associated with the altered expression of a number of pro-and anti-apoptotic proteins, which leads to inhibition of Cytochrome c release and downstream caspase activation. This is mediated via decreased Bax translocation and upstream Caspase 8 activity. Despite increased expression of cIAP-2, small interfering RNA (siRNA) knockdown does not restore susceptibility to TRAIL-induced apoptosis. Gene expression analysis indicated potential changes in AKT activation, which was confirmed by increased phosphorylation of AKT. Inhibition of this phosphorylation reversed the resistance to TRAIL-induced apoptosis. AKT activation is emerging as a key survival signal in prostate cancer. This study demonstrates that short exposure to low oxygen can increase resistance to immune surveillance mechanisms and might confer a survival advantage onto normal prostate epithelial cells so that they can survive subsequent genomic instability and other carcinogenetic insults leading to the early development of prostate cancer. ' 2008 Wiley-Liss, Inc.Key words: hypoxia; prostate; apoptosis; inhibitor of apoptosis; AKT One of the most significant risk factors for the development of prostate cancer is age. Ageing has been associated with progressive changes of physiological functions with time. One example is the increase in tissue hypoxia of organs such as the kidneys 1 and brain. 2 Additionally, with advancing age, the incidence of ischaemic disease increases, for example, those of acute myocardial infarction and stroke. 3 The prostate is also associated with the development of age-related disease. For instance, benign prostatic hyperplasia (BPH) occurs in 20% of men aged 40 years and in 70% of men aged 60 years. Autopsy studies have shown that men aged between 20 and 29 years show evidence of high-grade prostatic intraepithelial neoplasia (PIN) (7.14%) and foci of prostate cancer (3.14%), which increases in men aged 50-59 years, who have increased incidences of PIN (23.8%) and prostate cancer (38.06%). 4 Although hypoxia is most frequently associated with malignancy, with >70% of prostate cancer displaying upregulated HIF1a, 5 the normal aging prostate is also thought to be associated with an hypoxic environment, with the ageing cardiovascular system leading to an age-associated decline in prostatic blood flow. 6 Additionally, men with clinical cardiovascular disease/atherosclerosis or hypertension are at an increased risk for BPH development. 7 Damage to the vascular region of the prostatic transitional zone...