The Prostate Cancer Paradox
Daniel Hugus discusses the ongoing testing he’s undergoing to monitor his low-risk prostate cancer, during an interview at his Midway, Washington County, home last week. The former Uniontown resident was diagnosed with the disease more than a year ago but has not had to undergo curative treatment for it.
The prostate is situated just below the bladder and envelopes the urethra, the thin tube that delivers urine from the bladder out through the penis. Due to the prostate’s precarious positioning next to these vital structures and the nerves that control erections, treatment of prostate cancer often causes urinary and sexual side effects.
In a digital rectal exam, a doctor inserts a gloved finger into the rectum to feel for abnormalities in the prostate through the rectal wall. This exam is combined with blood tests to screen for prostate cancer.
Dr. Joel B. Nelson, chairman of urology at the University of Pittsburgh School of Medicine.
Dr. Jason Smith, a urologist affiliated with Uniontown Hospital, Southwest Regional Medical Center and Washington Hospital
Daniel Hugus has prostate cancer.
He and his urologist have known about it for more than a year, but they’ve yet to take steps to treat it.
Hugus isn’t worried, though. The 72-year-old former Uniontown resident and his doctor are closely monitoring the malignancy, allowing Hugus to delay, and potentially avoid, curative treatments and the urinary and sexual side effects that accompany them.
“It’s very minute. I don’t have an aggressive cancer,” Hugus says. “It’s something that the doctor feels does not need treatment at this point if it stays the way it is. There’s always a worry in the back of your mind, but you can’t let it take your over.”
A decision to screen for and treat a cancer that kills more than 29,000 American men annually would seem to be a no-brainer. But very little is clear-cut with prostate cancer, a disease embroiled in controversy. Medical experts continue to debate which men, if any, should be screened and, if they’re diagnosed with the disease, whether they need immediate treatment.
September is National Prostate Cancer Awareness Month. If you’re a middle-aged or older man, experts say you should be aware of your risk of prostate cancer and educate yourself about the pros and cons of screening, as well as the risks and benefits of all of your treatment options should you be diagnosed with the disease.
The screening debate
The prostate normally secretes a small amount of a protein, prostate-specific antigen (PSA) into the bloodstream. Prostate cancer and other conditions–including prostate infections and benign prostatic enlargement–can allow more PSA than normal to enter the bloodstream.
Measuring the amount of PSA serves as the basis of prostate cancer screening, with an elevated PSA level signaling a potential concern. Doctors combine the results of the PSA blood test with a digital rectal exam, in which the physician inserts a gloved finger into the rectum to feel for abnormalities in the prostate through the rectal wall.
In many cases, prostate cancer grows slowly, and most men with the disease die of something else before their cancer becomes life threatening. In fact, although prostate cancer is the second-most-common cancer among American men (behind skin cancer) and one man in seven will be diagnosed with the disease during his lifetime, only about one in 36 will die from it, according to the American Cancer Society.
Opponents of prostate cancer screening emphasize that the testing cannot determine conclusively whether a man’s PSA elevation is due to cancer or benign causes–a biopsy is necessary to diagnose prostate cancer. Plus, researchers have yet to identify a PSA threshold below which a man’s risk of having prostate cancer is zero.
Critics also contend that a finding of an elevated PSA can cause undue fear and worry in men–some have even suggested that PSA should stand for “prostate-specific anxiety”–and that screening identifies too many indolent cancers and may lead to unnecessary biopsies and overtreatment of a cancer that may never jeopardize a man’s life.
“There’s a lot of anxiety in men who have elevated PSAs because although there are other reasons why the PSA can go up, many men don’t know what’s going on with them,” says Dr. Joel B. Nelson, chairman of urology at the University of Pittsburgh School of Medicine. “All they have is this number that they focus on.”
Nevertheless, prostate cancer remains the second-leading cause of cancer death (behind lung cancer) among American men, according to the ACS.
Proponents of screening, including Nelson, point to the fact that deaths from prostate cancer have declined since PSA screening became widespread in the early 1990s. And, before the PSA era, about a quarter of men with prostate cancer would present with disease that had already spread, or metastasized, to bones or other distant sites in the body. Today, Nelson says, only about 2 percent of men newly diagnosed with prostate cancer have metastatic disease.
Citing the limitations of PSA testing and the potential consequences of screening, an influential government panel, the U.S. Preventive Services Task Force, in 2012 recommended against routine prostate cancer screening for all men.
The task force’s decision was based, in part, on results of a large study, the Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening trial, which found that screening did not reduce deaths from prostate cancer. However, Nelson and other experts have pointed to methodological flaws in this study, noting that another large clinical trial, conducted in Europe, did not have these flaws and found that screening reduced the death rate from prostate cancer by 20 percent.
“I’m of the opinion that a patient should be informed of the risks and benefits and should be in a position, with his physician’s guidance, to make a decision about whether he wants to be screened,” Nelson says. “To come out and say that no man should undergo prostate cancer screening is a step too far.”
Medical organizations differ in their recommendations for prostate cancer screening (see chart), but they generally agree that men should begin talking to their physicians about screening sometime in their 50s. They also acknowledge that African-Americans and men with a strong family history of prostate cancer are at greater risk of prostate cancer and should consider beginning screening earlier, perhaps at age 40 or 45.
Experts also agree that screening should not be offered to men who aren’t expected to live another 10 years and thus would be unlikely to benefit from screening or treatment if prostate cancer were to be found.
Dr. Jason Smith, a urologist affiliated with Uniontown Hospital, Southwest Regional Medical Center and Washington Hospital, recommends annual screening for men ages 50 to 75 who have at least a 10-year life expectancy. He and Nelson both note that while an elevated PSA level may cause anxiety among some men, others find the test reassuring.
“I have 80-year-olds who want their PSA checked,” Smith says. “A lot of guys really like that peace of mind knowing what their number is. …It’s important to talk to your physician. A PSA and a digital rectal exam are important, and it’s important to discuss them with your primary care physician or urologist to make sure they’re right for you.”
Guidelines typically have recommended that prostate cancer screening be done annually, but research suggests that, depending on previous PSA test results, the screening interval can be safely extended to every other year. However, if your PSA results are concerning, your physician may recommend repeat testing at a shorter interval, such as every three to six months.
Doctors also measure PSA velocity, changes in PSA over time, to gauge a man’s risk of prostate cancer. For instance, Nelson says, a PSA level that remains at 7 ng/mL for several years may be less concerning than one that rises from 2 ng/mL to 5 ng/mL to 7 ng/mL within that time.
“It doesn’t mean that everyone with an elevated PSA needs to be rushed to a biopsy,” Smith adds. “You have to take into consideration the PSA trend, the patient’s age and overall health.”
Newer tests, such as the 4K Score and the Prostate Health Index, incorporate PSA and other prostate biomarkers and have been shown in studies to outperform PSA alone in predicting the likelihood of prostate cancer, potentially reducing the number of unnecessary biopsies.
In a prostate biopsy, the doctor inserts an ultrasound probe containing a spring-loaded needle into the rectum. The needle is inserted into the prostate through the rectal wall to remove a dozen or more tiny samples of tissue (cores) from throughout the prostate. The 10- to 15-minute procedure, done under local anesthesia, can cause bleeding, and you may notice blood in your semen, stool or urine in the days and weeks after the biopsy.
Biopsy also may cause infection, as the biopsy needle may carry bacteria from the rectum into the bloodstream. Some of these infections can be serious, resulting in hospitalization. However, the risk of infection is relatively low, about 2 to 3 percent. As a precaution, your doctor will prescribe antibiotics before your biopsy.
Overall, Nelson says he strongly recommends screening for higher-risk groups, such as African-Americans and men with a family history of prostate cancer. And, he carefully counsels all patients about the ramifications of screening.
“I tell patients that if they screen positive, we can’t make a diagnosis of prostate cancer without a biopsy, and they have to understand that there are risks associated with biopsy,” he says. “I also point out that if we were to diagnose a cancer in them and the feeling was that the cancer was not risk, I may recommend that they not be treated for it. Before we even start prostate cancer screening, I try to lay those things in front of them so they understand the path that they’re going down.”
Deferring treatment
Daniel Hugus’s cancer was discovered incidentally when he sought treatment for urinary symptoms of an enlarged prostate. However, based on biopsy results, Smith determined that Hugus’s cancer was low risk and did not require immediate treatment.
More and more experts are recommending observation as an initial approach for men whose prostate cancer is determined to be low risk, based on biopsy results, PSA levels and other factors. In active surveillance (the protocol Hugus is following), patients are followed closely with periodic PSA testing, digital rectal exams and biopsies and can forgo curative treatment unless testing indicates that the cancer is growing or becoming more aggressive. Another observation strategy, usually reserved for older or less healthy patients, is watchful waiting, which generally entails fewer tests and relies on changes in a man’s symptoms to determine if treatment is needed.
“The challenge for our field is not necessarily should you screen but, if you detect a cancer, should you treat it?” Nelson says. “Increasingly, we are trying to, at least initially, observe patients and make sure that when we treat them that the treatment is necessary.”
By choosing active surveillance, you must be willing to commit to repeat PSA testing, digital rectal exams and biopsies. (Both Nelson and Smith recommend a repeat biopsy a year after an initial diagnostic biopsy, and this repeat biopsy determines the need for, and frequency of, subsequent biopsies.) You also must be willing to accept the fact that you have an untreated cancer. Also by deferring treatment, you run the relatively low risk that your cancer will progress, thus reducing the odds that later curative treatment will be successful.
“A lot of guys are hesitant to try active surveillance because they’re worried about having a cancer in there,” Smith says. “But it’s a great option for the right patient because it’s a chance to have no treatment and no side effects from the treatment.”
Hugus’s wife, Jean, says she was somewhat surprised when Smith recommended active surveillance for her husband’s prostate cancer, especially since she underwent successful treatment for breast cancer a few years ago.
“That has been rather strange, that they’re not doing anything,” she says. “I did feel it was odd that he had a cancer and didn’t get treated, because I had one that did.”
Just last week, Daniel Hugus underwent a repeat biopsy and should learn the results within the next week or two. He says he’s satisfied with his choice of active surveillance and has learned to live with the fact that he has prostate cancer.
“Mentally and emotionally, it hasn’t bothered me,” he says. “You always think the worst when you hear the word ‘cancer,’ until you find out differently. My cancer is very miniscule. Hopefully it’s going to stay that way. If everything stays status quo, it’s not anything that needs treatment.”
When treatment is necessary
The primary curative treatment options for prostate cancer include surgical removal of the prostate (radical prostatectomy), external-beam radiotherapy and radioactive seed implants (brachytherapy). Studies have yet to demonstrate whether one treatment is superior to the others in terms of cure rates, so a decision about curative therapy should be made primarily on the basis of side effects, Nelson says.
All of the treatments can damage nerves adjacent to the prostate and cause erectile dysfunction (impotence) and urinary incontinence. With prostatectomy, these side effects tend to be greater initially, while the effect may be delayed for several months or years with the radiation therapies. Radiation also may cause urinary irritation or obstruction, as well as some rectal side effects.
Nelson also notes that research has yet to show any difference in terms of cancer control and functional outcomes between standard open surgery and robot-assisted prostatectomy, in which the surgeon uses robotic arms that provide precise movement of the surgical instruments in the body.
Patients need to explore all their treatment options and should consider the experience of the surgeon or radiation oncologist and the quality of the center performing the treatment, rather than the treatment technique, when deciding on a curative therapy, says Nelson, who recently performed his 3,000th radical prostatectomy.
“You really want to have an idea of what the potential side effects and the risks and benefits of all approaches are,” he says. “You don’t want to see someone who does these procedures just every so often or casually.”
Action Points
If you’re a man over age 50, talk to your doctor about the pros and cons of prostate cancer screening. If you’re an African-American man or you have a family history of prostate cancer, begin these discussions at age 40 or 45.
Ask your physician about newer assessments, such as the Prostate Health Index and the 4K Score, which might better assess your risk of prostate cancer.
Discuss the risks associated with prostate biopsies and what preventive steps your physician can take to reduce these risks.
If you’re diagnosed with low-risk prostate cancer, carefully weigh all of your treatment options, including active surveillance. Ask yourself whether curing your cancer or avoiding the side effects of curative treatment is more important to you.
While on active surveillance, follow your doctor’s recommendations for periodic PSA testing, digital rectal exams and prostate biopsies.
Before undergoing curative treatment for prostate cancer, talk to multiple specialists, including urologists, radiation oncologists and medical oncologists. Studies suggest that doctors tend to recommend their treatment specialty, so review all your options and decide which is best for you.
Ask about the background of your treating urologist or radiation oncologist, and choose a specialist well-experienced in your choice of treatment.