Prostate cancer is one of the most common cancers that men can experience. If detected early, many patients respond well to treatment. In observation of September as Prostate Cancer Awareness Month, Steward Health Care urologist, Amr Fergany, MD, addresses the importance of prostate cancer screening, as well as what is new in the treatment of this disease.
Q: What are the current guidelines for prostate cancer screening? Any changes or updates that have recently been made to them?
The current accepted urologic practice is for yearly PSA checks and digital rectal examination (both) for males between the ages of 50 and 70. Screening can start earlier than 50 in high-risk groups like African Americans or patients with a strong family history of prostate cancer. There is a significant amount of scientific information that in patients who have a very low PSA level less than 1 at initial screening at age 50 can be followed less closely given that these patients have a very low risk of eventually being diagnosed with prostate cancer. On the other end of the age spectrum, most guidelines do not recommend prostate cancer screening for patients older than 70 years of age as the benefit of early diagnosis of prostate cancer is overcome by other competing causes of mortality as individuals become older. Clearly all these age numbers have to be used in conjunction with a patient’s general state of health and the presence of other medical problems.
Q: What’s new in the detection of and treatment of prostate cancer?
Digital rectal examination of the prostate and PSA blood tests remain the basis of detection of prostate cancer. No new modality supersedes these basic tests. In patients where an abnormality of the prostate is detected, the decision to proceed to a prostate biopsy becomes almost confirmed and any additional testing provides useful information for the biopsy but generally cannot be avoided.
Significant advancements are continuously being made in the realm of patients with a slightly elevated PSA test who have normal digital rectal examination with the purpose of differentiating patients who have prostate cancer and thus need a biopsy from patients who have other benign noncancerous conditions of the prostate and in that case do not need biopsy, avoiding discomfort and potential biopsy related problems.
Most significantly among these advances have been prostate MRI which has become an essential tool in identifying suspicious lesions within the prostate and is rapidly becoming a standard procedure before doing prostate biopsies. Other blood tests like different forms of PSA, genetic testing on urine samples also help guide biopsies in these patients with a slight elevation of the PSA.
In the realm of treatment of prostate cancer, robotic surgery to remove the prostate has become highly refined and is one of the standards of care. Significant advancement in radiotherapy techniques also continue and benefit patients who are treated with radiation. Another area of significant interest is the area of focal treatment of prostate cancer with the idea of treating the cancerous part of the prostate only and avoiding whole gland treatment which carry a risk of alteration of normal urinary continence and sexual function. Multiple different modalities of focal treatments are currently available including cryotherapy (freezing), high intensity focused ultrasound, and laser ablation. It is important to note that most of these modalities are currently considered non-standard of care and at the same time are only suitable for a very limited and highly selected group of patients.
Q: What makes prostate cancer very treatable if it is detected early?
Two factors are responsible: Prostate cancer is most commonly (but not exclusively) slow growing, and it commonly occurs in older age groups. The combination of a very slowly progressive tumor with possibly two or three decades before mortality and the occurrence in the 60s and 70s decades of life make it usually not a very lethal tumor although it is one of the most common malignancies in men.
Q: What’s the most important thing patients and their families need to know about prostate cancer?
Several important points. Prostate cancer is highly treatable when detected early. Early prostate cancer is generally asymptomatic. Goals of treatment from a treating physician perspective are cancer control, normal urine continence, and preservation of sexual function. These goals are achievable in most healthy patients with most forms of early prostate cancer. Even patients with advanced and metastatic forms of prostate cancer can expect long and active survival with current modalities of treatment.
Patients with a family history of prostate cancer i.e., a brother or a father with prostate cancer, or multiple family members with breast, colon, prostate cancer are at increased risk of developing prostate cancer themselves and should be monitored closely.
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