Prostate cancer is a unique but common medical problem, and a very difficult one for the lay person to fully comprehend. The greatest challenge to the patient first diving into the topic, especially on the internet, is what Dr. Jason Engel calls the great paradox. On the one hand, prostate cancer is now often presented as always slow growing, not particularly dangerous or harmful, and that eventually every man gets prostate cancer. On the other hand, the fact remains that prostate cancer can be as aggressive and deadly as any other cancer, as it is the number two cause of cancer mortality in men in the United States today. So which one is true?
The answer is that both are true in a sense. The treatment of prostate cancer and PSA screening in general has come under fire recently. Data from the US Preventative Task Force, released over five years ago but only more recently presented to the lay press, suggested that PSA screening in America was more harmful than good, even to the degree that guidelines for screening were changed and some primary care physicians stopped PSA screening altogether. This was a dangerous message, and only part of the story.
For the first 20 years of widespread PSA screening, PSA was used as a true screening test, one where if a man’s PSA was above a certain level (4 ng/dl) a man underwent a biopsy. This lent itself to extreme over-testing, and extreme over-treatment in America. It is estimated that almost half of all cancers treated in the 1990’s through 2005 or so were very minimal and low grade. These cancers would now be deemed insignificant and perhaps not treated at all. PSA testing was finding cancer, but not cancer that really always needed to be treated. Thus, PSA was in some ways actually hurtful to American society more than helpful.
Most Urologists now do not use PSA as a single point screening test. PSA is now properly used as a trend test, especially with the doctors at USW. If used this way, PSA moves from perhaps the worst performing screening test in contemporary medicine to possibly the best of all screening tests available today.
The part that was not told to the lay press however is that most Urologists now do not use PSA as a single point screening test. PSA is now properly used as a trend test, especially with the doctors at USW. If used this way, PSA moves from perhaps the worst performing screening test in contemporary medicine to possibly the best of all screening tests available today. The most commonly used philosophy employed now is one where the goal of screening for prostate cancer is to find only aggressive cases, the ones responsible for the deaths in America. We call these significant cancers. Thus the old adage that all men will eventually get prostate cancer may be true if one includes low grade cancers that are not harmful as well as cancer grades that are now not even called cancer. We don’t look for those anymore. So, the first step in understanding prostate cancer is to first understand these points about PSA screening, which leads to the concept of significant versus insignificant prostate cancer.
In fact, to try to avoid finding insignificant prostate cancer, Dr. Engel generally will not offer a biopsy until at least two, or perhaps even three successive rises of the PSA are seen in a patient. These days, there is much interest in non-invasive tests such as 3-D Ultrasound, MRI and others to see if these technologies can be sensitive and specific enough to supplant an actual biopsy to look for prostate cancer. Dr. Engel has not found these tests to be particularly helpful in his practice yet, and feels that the philosophy of demanding successive rises of the PSA before biopsy is far more specific for finding aggressive cancers and excluding insignificant ones. In the same light, Dr. Engel is generally not an advocate for MRI targeted biopsies, as he feels that if such precision is required to find a cancer, the likelihood is so high that this will lead to finding insignificant cancers that he does not do them.
What is (Prostate) Cancer?
After understanding first whether a biopsy is indicated by these standards, it is important for a patient to then understand what cancer is in general. Cancer is an uncontrolled growth of cells in an organ or in the blood. When enough of these cells are present, this is called a tumor. Unlike cells in a benign tumor which also grow in an uncontrolled manner, malignant (cancer) cells have the ability to spread throughout the body. This process is called metastasis, and it is metastasis that can lead to death and thus should be seen as the real enemy.
The challenge with all cancers is to catch them early before they have spread which is of course what PSA seeks to do. If treated at that early stage, cancers are really not much different than benign tumors. The term prostate cancer refers to this process starting in this organ. Patients will often see the term adenocarcinoma on their biopsy report. This just refers to the cell type that transformed into prostate cancer. In the case of prostate cancer, well over 95% of cases are this cell type.
Risk Stratification & Treatment
Patients must then understand the details of their own prostate cancer. These include parameters such as how much cancer was present on their biopsy (number of needles), the percentage of each needle or core that contains cancer, the PSA pattern and velocity of rise (much more important than just the latest PSA), and the highest grade of cancer seen on the biopsy report (Gleason grade). One thing to note regarding PSA is that patients found before their PSA gets to 10 ng/dl are considered to have been caught early, with a far lower risk of metastasis. In terms of Gleason score, Dr. Engel tries to explain this as really four grades, just like most other cancers have. The lowest grade is a 6(3+3). All Gleason grades lower than this are no longer called cancer. There are two grades of seven, 3+4 and 4+3, in order of aggressiveness, and finally Gleason scores 8-10, the most aggressive.
These factors must be combined and not used in isolation to be able to assign risk stratification. Dr. Engel often uses the terms:
- No risk
- Low risk
- Moderate risk and
- High risk
Treatments for prostate cancer may include:
If you have been diagnosed recently with prostate cancer, Dr. Engel (robotic prostatectomy, cryotherapy) or Dr. Losee (brachytherapy or RRP) would be happy to have a consultation with you in our office. We will make sure we review your case with you, make sure you understand the problem first thoroughly, and will then go over all treatment options before zeroing in on the right one for you.
When coming for your consultation, please bring all pathology, radiology, and lab reports with you. As well, we encourage you to bring your spouse, family or significant other as usually these people are also integral to your education and decision process.