A Doctor with the Disease Shares What He Learned
There are good reasons why men worry about prostate cancer. According to the American Cancer Society, it is the second-most-frequently diagnosed cancer (after skin cancer) in American men and the second-leading cause of cancer deaths (after lung cancer). One in every six men will ultimately be diagnosed with prostate cancer—about 240,000 each year, resulting in close to 30,000 deaths.
Sometimes the treatment is worse than the cure. In their zeal to prevent prostate cancer deaths, doctors send thousands of men for prostate-removal surgery or radiation, and more than half sustain sometimes lifelong impairments of their sexual functioning and/or bladder control. And surgery or radiation isn’t always curative—about 25% percent of men relapse.
What’s particularly alarming is that of the nearly 100,000 men who receive these treatments each year, 85% don’t need them. This massive overtreatment has led expert government panels and medical associations to recommend discontinuing prostate specific antigen (PSA) testing, our most reliable early-warning test for prostate cancer—as if not diagnosing prostate cancer early will make the problem go away.
I was diagnosed with prostate cancer two years ago. Here’s what I learned—and what every man should know…
Dangers of Halting PSA Testing
Use of PSA screening began around 1990. It worked, and annual deaths from prostate cancer dropped by 40%, from 50,000 to 30,000 a year. But it is a nonspecific test that can signal many prostate problems. An elevated PSA test does not always mean prostate cancer, but that is how some doctors interpret it. The solution to overtreatment is not to tell men to forgo the PSA test. The solution is to modernize our approach to better differentiate the men who need treatment from those who don’t.
How to react to abnormal PSA results? An elevated PSA result can be caused by many factors such as prostate infection, an enlarged prostate gland, laboratory error, even recent sex. An elevated PSA test always should be repeated.
My advice: Begin annual PSA testing at age 50. If a blood relative has had prostate cancer or you are African-American, the risk for prostate cancer is higher, so begin PSA testing at age 40.
The New, Targeted Biopsy
If your PSA test has risen above 4 ng/mL on repeated tests, your doctor may recommend a prostate biopsy, an invasive, outpatient test in which fine needles are inserted through the rectal wall into the prostate. A biopsy is the only way to confirm that prostate cancer is present and to determine its level of aggressiveness (Gleason score). A biopsy is an important test, yet of the 1.2 million performed each year, about half are unnecessary.
The vast majority of prostate biopsies are blind. The doctor takes 10 to 12 samples (cores) from diverse areas of the prostate gland, but there’s no guarantee that he/she will hit the right spot. Blind biopsies miss at least 20% of prostate cancers.
A growing number of top-notch cancer centers now are using the new dynamic, contrast-enhanced MRI (DCE-MRI) that, for the first time, can identify prostate cancer within the gland (see below for more on this important test). If the DCE-MRI does not show areas suspicious for cancer, a biopsy may not be necessary. Moreover, approximately 40 doctors in the US perform an in-office test called color Doppler ultrasound that also can identify cancer within the prostate.
With DCE-MRI guidance or color Doppler ultrasound, the doctor can aim the biopsy needles at the targeted areas. Guided biopsies typically require fewer tissue samples, so there is less damage to the prostate gland and a lower risk of bleeding or infection. This is important because 4% of men undergoing blind biopsies require hospitalization for serious infection. Moreover, when blind biopsies do not obtain evidence of cancer, the biopsies may have to be repeated.
Advanced Prostate MRI
Although doctors have been using MRIs for virtually every other part of the human body for 25 years, the technology had not existed to differentiate normal prostate tissue from prostate cancer. Now that the DCE-MRI can accurately identify prostate cancers, diagnostic methods and treatment options are taking a giant leap forward. But this is being done today at only 13 major cancer centers in the US (see below).
With the DCE-MRI, the patient is injected with a gandolinium-based contrast agent that is absorbed more readily by cancerous tissue than by healthy prostate cells. This makes the cancerous tissue clearly visible if you have a high-powered MRI machine and the necessary software.
I was told by four prostate surgeons that I must have prostate surgery or radiation, but my DCE-MRI clearly showed that my cancer was limited and well-contained. This test was a game-changer for me—and for many others.
With the new technology, we now can see that many cancers are present in only a part of the prostate gland. With this information, some doctors are recommending focal therapy—that is, treatment that removes only half of the prostate gland or just the area around the tumor. This approach is similar to the lumpectomies that some women elect to have for localized breast cancer.
These focal therapies do not cause nearly as much damage as prostatectomy or radiation, so adverse effects are far fewer and less severe. Cryotherapy, a freezing technique, is available in the US. Focal laser ablation, which employs a thin probe to burn the cancer, is in the latter stages of study here, and you can sign up for treatment at certain cancer centers. High-intensity focused ultrasound (HIFU), which heats the cancer to nearly 212°F, is available in Canada and overseas and is in FDA-approved clinical trials in the US. These therapies are performed in outpatient centers.
The majority of prostate cancers are low risk—the risk for death from this type of prostate cancer is only 2% over 10 years. So active surveillance sometimes is a good option. In active surveillance, your PSA levels are drawn regularly (every three months at the start) and a DCE-MRI is performed annually. Biopsy may be needed but not in every case. The key is that with the new tests, your prostate cancer can be tracked. Treatment can be delayed (or avoided) if the cancer doesn’t change. With these methods, a man will know quickly if his cancer is getting more dangerous, and treatment can be started promptly.
It can be difficult for men to choose active surveillance. They often are so acutely stressed that they lapse into what I call the “get-it-out-now!” syndrome. This is another reason that there is so much overtreatment. Yet most prostate cancers grow slowly, so there usually is time to obtain a full diagnostic evaluation and to consider all of the options appropriate for your risk level. For example, you can consider active surveillance if you fit all of the following low-risk criteria—you have a normal digital rectal exam…your PSA is less than 10…your Gleason score is 6 or less…you have two or fewer positive biopsy cores out of the 12 samples taken…and none of the cores is more than 50% cancer.
After considering many options, I chose active surveillance and have done well for a year and a half.
The New Test for Prostate Cancer
The following medical centers offer the DCE-MRI, which can identify cancer within the prostate gland.
Sharp Hospital and Medical Center, San Diego
University of California-Los Angeles (UCLA)
University of California-San Francisco (UCSF)
University of Chicago Medical Center
The Johns Hopkins Hospital, Baltimore
Massachusetts General Hospital, Boston
Mayo Clinic, Rochester
- New York
Memorial Sloan-Kettering Cancer Center, New York City
NYU Langone Medical Center, New York City
Jefferson Prostate Diagnostic Center, Philadelphia
University of Pittsburgh Medical Center
MD Anderson Cancer Center, Houston
Sunnybrook Research Institute, University of Toronto