The prostate cancer dilemma: 4 critical considerations
The American Cancer Society estimates that in the year 2017, 161,360 men will develop prostate cancer and 26,730 men will die from the disease, suggesting that Prostate cancer is the most common cancer in men. It is the third leading cause of death from cancer in men.
Prostate cancer screening and more effective treatments have improved the 5 year survival rates, increasing from 66% in 1975 to 99% in 2005. Despite such dramatic improvements, PSA screening has remained controversial. There have been legitimate concerns about false positive PSA’s prompting unnecessary prostate biopsies, the overdiagnosis and overtreatment of men who were not going to die from their disease, and the main complications associated with prostate cancer treatment — Erectile Dysfunction and Urinary Incontinence (leakage). Despite these concerns, most urologists are in favor of screening, and they are using “Active Surveillance” (AS) for low-risk patients in order to offset the risk of overtreatment; however, they are generally failing to properly address the complications of Erectile Dysfunction (ED) and Urinary Incontinence (UI).
To screen or not to screen
The conversation about prostate cancer screening starts with the question, “Do you believe screening decreases the mortality of the population being screened? This concept has been a matter of debate for many years; however, in May of 2012, the United States Preventative Services Task Force (USPSTF) gave prostate cancer screening a “D” rating, recommending against routine PSA-based screening in all men. Simply, they believed the benefits of screening did not outweigh the risks, and they based this data largely on the outcome of a large randomized trial (The PLCO trial) which failed to identify a decrease in mortality due to prostate cancer screening.
More recently, in May of 2017, it became clear that the PLCO Study was flawed, and the European Randomized Study of Screening for Prostate Cancer continued to show an approximately 20 percent reduction in prostate cancer mortality after a median follow-up of 13 years. As a result of this data and the more frequent use of Active Surveillance for low risk prostate cancer (avoiding the complications of treatment), the USPSTF upgraded PSA screening to a “C”.
Most Urologists are generally in favor of screening and recognize the role PSA has played in the diagnosis of prostate cancer at very early stages. Before the PSA era, it was very common for men to be initially diagnosed with metastatic prostate cancer which is not curable. Today, 80-90 percent of prostate cancer is diagnosed by PSA alone without any presenting signs or symptoms, and this early detection appears to translate into improved survival rates from early prostate cancer treatment. At the current time, the American Urological Association (AUA) states that the greatest benefit of screening appears to be in men aged 55-69, and they recommend “a shared decision making process” with the physician, proceeding based on their values and preferences. It should also be noted that the AUA does not recommend routine PSA screening in men over 70 or any man with less than a 10-15 year life expectancy.
Overdiagnosing and Overtreating
Once you jump over the hurdle of “the prostate cancer screening controversy” and obtain a PSA, the risk exists that we may over diagnose and overtreat men who are not destined to die or be affected by their disease. Prostate cancer is a very slow growing disease, and we are aware of the large discrepancy between those men who have prostate cancer and those that die of it. It has been estimated that as many as 50 percent of men over the age of 50 have prostate cancer, but only 3 percent die of the disease. Autopsy studies have shown that approximately two-thirds of men who die over the age of 80 actually have prostate cancer and die of other causes.
As a result of this discrepancy, urologists have embraced “Active Surveillance” for their low risk prostate cancer patients based on tumor grade, tumor volume and PSA level. These men are monitored with more frequent PSA testing and repeat prostate biopsies rather than immediate treatment with surgery or radiation. In this way, patients avoid the complications of treatment, optimizing their quality of life. Importantly, if patients show signs of disease progression, they may leave the AS protocol and embrace definitive treatment without decreasing their prognosis.
More recently, genetic testing can be done on the prostate biopsy tissue samples in order to determine the “genetic grade” of the cancer. This can be helpful for patients to make an educated decision regarding treatment options.
Once a patient is faced with a new diagnosis of “localized” prostate cancer that is not amenable to Active Surveillance, he is presented with a daunting array of definitive treatment options: Surgery, Radiation, Cryoablation and High Intensity Focused Ultrasound.
How does a patient choose an option?
In many cases, there is actually no single right answer. The decision process is difficult as there are no research trials that effectively compare all of the treatments against each other for any given cancer stage. This is further complicated by the fact that physicians have their own medical and/or financial bias. Furthermore, all of the treatment options have relatively similar cure rates, however, they have markedly different post-op courses and complications. As a result, it is very important to choose an option that works with your value system, an option that you are comfortable accepting. When making your decision, make sure to choose a urologist willing to educate patients on all of the treatment options, disclose any personal bias and help patients make a decision that will work well with their value system.
Quality of life after treatment
Finally, if a patient has undergone treatment for his localized prostate cancer, he must contend with the possible complications of Erectile Dysfunction and Urinary Incontinence (urinary leakage). The rates of these complications vary substantially based on the patient’s pre operative erectile function, the severity of the prostate cancer, and the physician’s treatment skill and technique. Nevertheless, these complications have a profound effect on a male’s quality of life, and often, they can be a cause for low self-esteem and clinical depression.
If there is no improvement in ED or UI by the end of one year to 18 months, it is very probable that you will have these problems for the rest of your life. It is at this point that you should seek consultation with a physician that specializes in “Prosthetic Urology” (a urologist that specializes in penile implants, artificial sphincters, and male slings). Most importantly, you do not need to suffer because your problem can be fixed!
Dr. Shawn Blick, M.D. is the founder and president of the premier urology group, Valley Urologic Associates. He has practiced in Phoenix, Arizona for 18 years, and he was awarded TOP DOCTOR by Phoenix Magazine in 2009 and 2015. He completed his medical school training at Mount Sinai Medical School with honors, and he performed his residency at Beth Israel Medical Center in New York City. In addition, his residency required him to complete 6 months of oncology (cancer) training at Memorial Sloan Kettering Cancer Center in New York City. As a urologist in private practice, Dr. Blick has specialized in Men’s Health, Erectile Dysfunction, Male Incontinence, Peyronie’s Disease, and BPH (enlarged prostate). He is the founder of ED Specialists of Arizona , a center of excellence for men’s health and penile implant surgery.