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Prostate Cancer – Diagnosis, Discussion and Decision

Prostate cancer is the most common of the visceral cancers, those having to do with the soft internal organs of the body. It is estimated that there will be approximately 170,000 new cases of prostate cancer in the United States and around 26,000 deaths in this year alone. It is second only to lung and non-melanoma skin cancer as the leading cause of cancer deaths and cancer respectively among US men. Although this is a serious and common disease, data reveals that most men do not die of prostate cancer.

Most prostate cancers are adenocarcinomas, that is, they start within mucous-forming glands and spread out from there. Some of these cancers are aggressive and grow quickly but most grow quite slowly.

Screening for prostate cancer involves digital rectal exam and prostate specific antigen (PSA) levels. Professional organizations tend to vary in their recommendations as to whether or not PSA screenings should be routinely done. Some have guidelines while others suggest it should be left to the physician and patient to discuss. Risk factors for prostate cancer include family history, African ancestry or advancing age. About 5 to 10 percent of all prostate cancers diagnosed are hereditary, meaning that an increased risk for the disease runs in the family. Family history is the strongest risk factor for prostate cancer.

Current treatment options for prostate cancer include surgery, radiation therapy, chemotherapy or watchful waiting until the disease progresses. Some men choose to delay treatment until symptoms progress; others might choose a treatment regimen based on the side effects that accompany the recommended treatment or their comorbidities, or additional conditions. It is important for patients to discuss these options with their health care provider at the time of diagnosis.

It is generally recommended to follow patients with active surveillance who have a low risk of disease as indicated by a PSA of less than 10 and a Gleason score of less than 7. A Gleason score is based on a biopsy-based test that helps to determine how aggressively the prostate cancer is likely to behave both in how quickly it grows and how likely it is to spread outside of the gland.

A recently published study in the New England Journal of Medicine ¹ has concluded that there was no survival difference in clinically localized prostate cancer (meaning the cancer is completely contained within the prostate gland and hasn’t spread anywhere else in the body) in terms of what treatment modality is chosen up front. Over eighty-two thousand men ages 50 to 69 participated in the study. Almost 2,600 were noted to be clinically localized and almost 1,600 agreed to participate and were divided equally in the radiation, surgery and active surveillance alone arm. Patients were followed for ten years and the results were:

  • Prostate cancer specific mortality remained low in all three groups;
  • There was no difference in death rates from prostate cancer nor was there a difference in the death rates from any of the three modalities;
  • There was increased incidence of symptoms and disease progression in the observation alone arm compared to the other two modalities.

There continues to be debate about whether men should have their PSA checked routinely. Early detection causes over treatment leading to increased treatment side effects, anxiety and over expenditure. A cutoff PSA value of 4ng/ml has been recommended for further testing as the risk of false positive testing is high in values below this value.

There is consensus, however, that patients with aggressive, advanced or symptomatic prostate cancer should be treated. Currently, the treatment options for advanced prostate cancer include surgery, radiation therapy, and medical treatment which range from hormonal agents to chemotherapy, immunotherapy and radioisotopes.

My recommendation would be that patients discuss the many treatment options with the specialists who can help them make an informed decision about their disease.

Dr. Rehman is a member of the hematology/oncology department at The Cancer Center at Harrington. He is board certified in internal medicine, hematology and oncology, and is a Member of the American Society of Clinical Oncology.

1 Hamdy F, Donovan J, Lane A, et al.10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. New England Journal of Medicine. 2016. DOI 10.1056/NEJMoa1606220

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