Crossing Prostate Lines
Posted On Dec 26, 2016
Prostate cancer affects one in six men, making it the most common male malignancy?in the U.S. Meanwhile the latest screening and preventative measures offer plenty of hope.
BY KAREN ASP | RESEARCH BY LISA KOMINSKY
Picture this: you’re a guy who’s just turned 50 and you’re on top of the world. Your career is skyrocketing. At this rate, you might be president of the company soon. You may not be Michael Phelps, but you get to the gym a few times a week and are sturdy and strong. You’ve swapped out complex carbs for more greens and beans. To say you look and feel great is an under- statement. Then, a visit to your doctor yields a bombshell diagnosis. You have prostate cancer.
This scenario happens more fre- quently than you think. Prostate cancer affects one in six men, making it the most common non-skin cancer in the United States, according to the Prostate Cancer Foundation (PCF). The upside: The cure rate is high. “Most men die with it, not from it,” says Herbert Lepor, MD, Martin Spatz chairman of the department of urol- ogy at NYU Langone Medical Center in Manhattan, professor of urology at NYU School of Medicine, and co-author of Redefining Prostate Cancer (Spry Publishing, 2013). The downside: The American Cancer Society estimates that in 2014 about 233,000 new cases will be diagnosed, and 29,480 men will indeed die from it. These num- bers suggest that men ought to be screened regularly. Yet, just as recommendations for mammograms have come under f ire, so, too, have prostate cancer screenings.
In this two-part series, we first look at the debate about screenings—particularly for prostate-specific antigen (PSA)—and offer vital information about the pros- tate. In the second part, we will take an in- depth look at the latest treatments. Bottom line? Screening saves lives, and with today’s advances, no man with prostate cancer should have to experience disabling side effects.
Although every man has a prostate, few know what this organ really is or why they should be concerned about it. A dra- matic case in point: 61 percent of men aged 45 and over don’t know what the pros- tate does, according to a survey of over 2,000 men by Prostate Cancer U.K. the prostate is a walnut-sized gland located beneath the bladder and is part of the male reproductive system. It plays a criti- cal role in a man’s sex life, secreting the fluid in which semen swims. That fluid protects semen and makes up the major- ity of ejaculate, says Gilad E. Amiel, MD, professor of urology at Baylor College of Medicine in Houston and president- elect of the American Association for Cancer Education.
PSA is a protein made by the prostate, and although small amounts may be in the blood, most of it is found in the semen. High levels of PSA can indicate problems with the prostate, including an inflamma- tion called prostatitis, benign prostatic hypertrophy (BPH), or prostate cancer (which usually doesn’t exhibit symptoms in early stages).
Until recently, regular PSA testing, done through a simple blood test, has been con- sidered the gold standard for prostate can- cer screening. (The average PSA is around 1.0 ng?mL while normal is generally any- thing below 4.0 ng?mL—or nanograms per milliliter—a chemical measurement that accounts for about one billionth of a gram.) Yet a high PSA shouldn’t scare you. “Roughly 70 to 75 percent of men with ele- vated PSA don’t have prostate cancer,” says Abraham Morgentaler, MD, FACS, assis- tant clinical professor of urology at Harvard Medical School and founder of Men’s Health Boston. So why the controversy?
THE PSA SCREENING DEBATE
When the PSA test was introduced in the 1980s, it was a significant advance- ment. “Prior to PSA screening, men were diagnosed with prostate cancer when it was causing symptoms, and by then it was no longer curable,” Lepor says. Rates of death from prostate cancer have dropped by about 40 percent since the early 1990s.
While the PSA test is good, it’s not per- fect. “PSA isn’t prostate-cancer specific,” says Robert L. Bard, MD, director of the Bard Cancer Center in New York City. As mentioned, high PSA levels could be caused by conditions other than prostate cancer.
Elevated PSA levels often prompt many doctors to order biopsies, which are used to detect abnormal cells. The trouble with biopsies? “It’s like playing pin the tail on the donkey in knowing where to put the needles,” Dr. Lepor says. Men often undergo unnecessary testing and treat- ments, many of which are invasive and come with side effects. Plus, biopsies can cause unnecessary anxiety, especially given that about 70 percent of men with elevated PSA who get a biopsy don’t have cancer. Meanwhile, there’s the risk of infection, which is why men are usually given antibi- otics before a biopsy.
That’s why the U.S. Preventive Services Task Force issued new recommendations in 2012, saying that men without symptoms, regardless of age, should not routinely get PSA testing. “Potential benefits do not out- weigh the harms,” state the guidelines. The task force cited a statistic that PSA screen- ing prevents zero to one prostate cancer deaths per 1,000 men.
To confuse matters more, organiza- tions such as the American Urological Association (AUA) and American Cancer Society didn’t back the above guidelines. Rather, they endorsed their own. The AUA doesn’t recommend PSA screening for men under 40, or routine screening for men aged 40 to 54 years old (who are at average risk). Those in this age group who are at higher risk are advised to work with their doctor to determine if screening is appropriate. And unless you’re a man 70 or older with a 10- to 15-year life expectancy, PSA screening is not recommended.
SCREENING SUGGESTIONS FROM TOP DOCTORS
Despite the guidelines mentioned above, many physicians believe that aban- doning PSA screening is unwise. “PSA test- ing is still important to find more aggressive cancers,” says Dr. Lepor.
Many experts hold the opinion that all men—even those at low risk of prostate cancer—should get a baseline PSA test at the age of 40. This should be accompa- nied by a digital rectal exam (DRE), during which a doctor inserts a gloved finger into the rectum, checking not only for pros- tate cancer but also colon cancer via rec- tal masses. (Though not typically a beloved procedure, a DRE is very important at this stage of life.)
After that, men with a PSA level of 2.0 to 4.0 or high-risk factors should be screened annually, Lepor says. The risk factors that raise the most significant flags include a family history of prostate cancer and if a patient is of African-American descent. If you have a first-degree relative such as a father or brother who has been diagnosed with prostate cancer, you’re twice as likely to develop the disease, per the PCF.
If you’re of African-American descent, the risk of developing prostate cancer is approximately three times higher than the risk for Caucasian men. African-American men tend to contract more aggressive pros- tate cancer, and develop it at a younger age, says Thomas Polascik, MD, professor of sur- gery and director of the genitourinary pro- gram in focal therapy at Duke University in Durham, North Carolina.
There are varying opinions of how often men at average risk should repeat the PSA after the initial screening. Some profession- ls say every two to three years, others sug- gest approximately five years, before annual screenings at age 50. Most then recom- mend stopping screening at 70 or 75 years old. Morgentaler recommends that all men should have annual DRE tests.
Another, more specific screening option is available: 3D Doppler Ultrasound, which Bard prefers to the PSA. “While the PSA is 2 percent accurate and DRE 6 percent accu- rate, ultrasound is 95 percent accurate,” he says. He suggests that men at average risk get their first ultrasounds at age 45, age 40 for men with high risk, and then repeat this— along with the DRE—every six months. If you’re interested in this, you’ll have to work directly with a radiologist.
WHAT TO DO ABOUT AN ELEVATED PSA
In years past, physicians sent men with elevated PSA levels straightaway for a biopsy. While many take this route, technol- ogy has made it so a biopsy isn’t necessar- ily warranted. That said, be sure to evaluate your choice of doctors carefully.
Unless your doctor suspects infection— for which you’d be given antibiotics before repeating the PSA a few months down the road—you might undergo additional screening tests. One such test is an MRI, which helps doctors examine the pros- tate more closely. Another is the prostate cancer antigen 3 (PCA3), a urine test that detects genetic material released by pros- tate cancer cells. If your PSA and PCA3 are high, that could indicate cancer and there- fore necessitate a biopsy, Dr. Lepor says. In centers with advanced MRI imaging, biop- sies can be done with precise visuals and much less trauma.
After the biopsy, you’ll be given what is known as a Gleason score—a grading sys- tem from two to 10 used by pathologists to signal the aggression of your cancer. A score of two to four generally means your can- cer is less aggressive. Eight to 10 indicates aggressive cancer.
ACTIVE SURVEILLANCE: A NEW TREATMENT OPTION
For men diagnosed with a low-risk cancer (men with a Gleason score of six or lower, roughly 70 percent of men), treat- ment plans have undergone a recent make- over. The reason for this is a cutting-edge protocol called active surveillance.
Although it sounds counterintuitive, active surveillance means that doctors monitor you closely, setting up a screening schedule based on your specific can- cer. The goal? “Avoid treating for as long as possible, since some treatments have devastating side effects like erectile dys- function and incontinence,” says Polascik, adding that even without treatment, 90 percent of men will be alive within 10 years. If your cancer changes or becomes more aggressive, a more aggressive treatment will be recommended.
To read Part II of this article please click here