PROSTATE CANCER – NOT AS BAD AS YOU MIGHT THINK

     A gentleman recently came to the clinic for his annual review of health status.  He was very concerned that a PSA test be done.  PSA stands for prostatic specific antigen.  It has become the most common screening test for men, as mammography is the most common screening test for women.  Both are covered by Medicare.

     Mammography for women has resulted in a major improvement in survival.  If a lady’s breast cancer is found with mammography screening, there is an 80% chance of a 5-year survival.  This is opposed to only 40% survival if the tumor is found as a lump that can be felt by the lady or her healthcare provider.

     In fact, the PSA blood testing in men has had no such impact.  Of all the men who are found to have a prostate cancer, only 1 in 6 die from the condition itself.  Unfortunately, unlike mammography screening for women, PSA testing in men has had no impact on survival.  To this time, in spite of extensive studies, there is no data that shows a survival benefit from detecting prostatic cancer early.  This situation is a high disappointment.

     The gentleman above had his PSA test done as he requested.  In addition, he had a digital rectal exam which was normal.  His PSA test returned at 10 ng/ml., a value about 2-½ times normal.  Now there was a dilemma of what to do with this blood test.

     My first advice was to have an ultrasound test of the prostate.  This is done by using a small finger shaped probe that is inserted into the rectum.  Other than the discomfort of the probe, the test is painless.  It takes a picture of the prostate gland and can identify areas of abnormal tissue present.  This gentleman’s exam showed one small area the size of a pea in the middle of the prostate gland.   The next step in evaluation was to biopsy this area to determine if it was a malignant tumor and its degree of invasiveness.  The biopsy did indeed show a cancer of the prostate.  It was graded as a Gleason Grade 5.

     The Gleason grading system rates a tumor from 1 being the least aggressive to a 10 being the most aggressive.  When the grade is 6 or less, there is no detectable difference in the survival of men with prostate cancer as compared to the general public.  This observation is based on a study of more than 3,000 men monitored for fifteen years.  When the Gleason Grade is 7 or more, there is a significantly increased mortality from prostate cancer.

     This gentleman’s cancer had a Gleason Grade 5.  He was 76 years of age.  The likelihood that his cancer would ever cause symptoms or be the cause of death was remote.  I therefore advised him that there was no specific treatment necessary.

     Now came the hard part.  There is no word in our language scarier than the word cancer and to know that one has a cancer and is going to do nothing about it, is very frightening.  It creates a group of people we call the “walking worried”.  Patients and their families often become obsessed with monitoring the PSA test and seek second and even third opinions on what to do.  After I first advised the above gentleman that there was no specific treatment necessary at this point, he returned for a clinic visit accompanied by his wife and his son.  Neither could understand the wisdom of doing nothing for a person who had cancer of the prostate.

     I first explained the above statistics indicating that there was no likelihood that this gentleman’s cancer would be a cause of symptoms or mortality.  But then I explained the alternatives to doing nothing.  The first alternative was to surgically remove the prostate.  If the tumor were limited to the prostate gland as this gentleman’s probably was, it would completely cure the problem.  The wife and son couldn’t understand why that wasn’t an appropriate choice.  I explained that of the men who have surgical removal of their prostate, there is a very significant likelihood of urinary incontinence.  There is in addition a very high likelihood of sexual dysfunction.  This gentleman was still sexually active and was certainly not incontinent of urine.  He was not specifically interested in either of these complications, which carry a very high likelihood with surgical intervention.

     The second choice of treatment for this cancer would be radiation therapy through a variety of techniques.  There are substantial risks of the radiation damaging the rectum or the urethra and causing a chronic irritation of either structure.

     I explained to the patient, his wife, and his son that it did not make sense to me to take risks such as the above when there was no demonstrated benefit in longevity or in symptom prevention when the gentleman was treated or simply allowed to pursue his natural history.  I instructed them that the PSA test should be followed up in 3 months and then every 6 months depending upon changes that might occur.  If the PSA rose very little or not at all, there would be no treatment necessary.  If the PSA were to increase significantly, a reconsideration of options was appropriate.

     I am sure this gentleman and his family are still considering the advice they received and perhaps sought a second opinion, but to this time have not elected to proceed with treatment.

     For patients whose tumor grade is 7 or more, the considerations become more complex.  Surgery, radiation therapy, hormonal treatment, freezing treatment, and a variety of other types of chemotherapy are all possibilities.  For each patient, treatment must be individualized and recommendations based upon predicted benefits versus predicted side effects and complications.  There are many men who have elected to proceed surgically or with other treatments who are incontinent of their urine and non-function in regard to sex.  Risks and benefits of treatment of prostate cancer are a very complex problem.  The healthcare providers at your local clinics can help in advising men regarding carcinoma of the prostate and appropriate therapeutic options.