According to the American Cancer Society, 1 out of 7 men will be diagnosed
with prostate cancer during their lifetime. Prostate cancer remains the
most common cancer diagnosed in men, and the second most common cause
of cancer death in men. There has been a good deal of controversy lately
about screening for prostate cancer, specifically related to prostate
specific antigen, or PSA. Most of the controversy arises from two trends
which have recently been recognized: (1) a rise in the incidence of complications
related to prostate biopsy and (2) the overtreatment of indolent, non-aggressive
prostate cancers. Because of these trends, some providers believe there
is no benefit to screening for prostate cancer.
However, research shows that since the advent of PSA screening in the late
1980’s, the mortality rate from prostate cancer has decreased by
nearly 50%. In addition, the proportion of prostate cancer cases which
were metastatic (spread outside the prostate) at the time of diagnosis
has decreased dramatically since PSA screening has been available. For
this reason, the American Urologic Association recommends PSA testing
every 1-2 years in all men between the ages of 55 and 69. Most providers
will also check PSA earlier in men with a family history and in African
Americans, both populations who are at increased risk of prostate cancer.
If a true PSA elevation is found, the next step is usually a prostate biopsy.
This test is typically performed in the office under local anesthesia
(numbing medication), using an ultrasound (sonogram) probe through the
rectum. The tissue samples taken are then examined by a pathologist under
a microscope. In 5-7 days the diagnosis can be made and the urologist
will be able to discuss the results.
If prostate cancer is diagnosed, the treatment options will depend upon
the risk category (low, intermediate, high) and whether the cancer is
contained within the prostate (localized) or not. Most patients have the
option to undergo surgery or radiation, both of which have experienced
recent technologic advancements. The robot-assisted radical nerve-sparing
prostatectomy is the most cutting edge approach to surgical removal of
the prostate. This procedure uses the da Vinci surgical system, which
utilizes the latest in robotic technology to provide better visualization,
smaller incisions, less blood loss, and a shorter recovery period. This
approach has virtually eliminated certain complications, and facilitates
better nerve-sparing, improving sexual function after surgery. This surgery
option is considered for most young and healthy prostate cancer patients.
For patients considering radiation, the newest technique is Cyberknife.
This form of radiation also uses robotic technology, this time to better
delineate the structures around the prostate (bladder, rectum), which
helps to cut back on radiation side effects. The main advantage of radiation
treatment is that it avoids anesthesia and thus is accessible to older
patients who may not be able to tolerate anesthesia. The biggest advantages
of surgery are the ability to physically remove and analyze the cancer,
the ability to remove lymph nodes, and the option to safely give radiation
after surgery when necessary.
An important response to the concerns of overtreatment has been increased
utilization of active surveillance for prostate cancer. Active surveillance,
which has been rapidly growing in popularity over the last decade, consists
of observing non-aggressive cancers rather than removing or radiating
them. It is important to distinguish this approach from pure observation,
in that active surveillance leaves open the door for definitive treatment
with surgery or radiation, if that becomes necessary. There are multiple
ways to implement active surveillance, but most will consist of PSA, rectal
exam, and repeat biopsy at varying intervals.
There have been many new advances in prostate cancer diagnosis and management
over the last several years. Prostate MRI has been perfected to the point
that it is now considered an important tool in diagnosis and workup of
prostate cancer. With the advent of a 3 Tesla (or 3T) machine, an improvement
over the previous 1.5T, prostate cancer can now be visualized before the
biopsy, for better accuracy and more meaningful diagnosis during biopsy.
In addition, many surgeons will use MRI images to assist their surgical
technique, allowing them to spare nerves when possible and take more tissue
In addition to MRI, there are multiple new laboratory tests which can help
predict prognosis and help select which treatments are likely to be most
successful for patients. Some tests can extract DNA from blood or urine
to determine a patient’s likelihood that a prostate biopsy will
be positive. This can be helpful if the PSA is found to be elevated, but
the patient does not want to rush into biopsy. Some tests will further
analyze the tissue removed at biopsy, to help determine whether a patient
will be best served by surgery, radiation, or just active surveillance.
While the diagnosis of prostate cancer can be a scary and solemn time in
a man’s life, recent clinical and technologic advances have made
this a promising era in treatment and diagnosis. With proper screening,
selection, and treatment, we will hopefully welcome a time when prostate
cancer is truly a thing of the past.
Learn more about urology services at Frederick Memorial Hospital by
Frederick Urology Specialists provide the highest quality urological care,
and apply cutting edge technologies, including da Vinci Robotic surgery,
to their evidence based practice. Their doctors are highly experienced,
knowledgeable, and include physicians certified by the MD Anderson Physician
fmh.org/certified to learn more.
To learn more or to make an appointment with Monocacy Health Partners Frederick