Early screening and detection play key roles in combating prostate cancer
Published: Tuesday, September 3, 2013 at 6:01 a.m.
Last Modified: Friday, August 30, 2013 at 3:01 p.m.
In 2010, Tony Braun of Ocala faced a dilemma: After years of carefully monitoring his PSA, or prostate specific antigen test to detect prostate cancer, he'd been diagnosed with the disease from which his father suffered a brutal death.
“He was a robust man, and he looked like someone who hadn't survived a concentration camp when he died,” Braun recalled.
Braun's cancer was caught early enough so that he wouldn't likely suffer a similar fate.
But one treatment for prostate cancer — namely surgery to remove the prostate in arguably the most delicate part of a man's anatomy — can have devastating side effects.
“My concerns were the same as everyone else because if [surgery is] done wrong, you'll never have an erection again,” Braun said. “I have a girlfriend, I have an active sex life. I was only 58, and I didn't want that to end.”
And up until the moment Braun was rolled into the operating room, he was questioning his decision to have surgery. His surgeon, Dr. Li-Ming Su, a urologist at the University of Florida Health Shands Hospital told him, “ 'Look Tony, if you're not ready, we can call this off right now,' ” Braun said. “I looked at him and said, 'What's my alternative?' ”
“They call it a slow-growing cancer, but you never know when it speeds up. I said, 'Let's do it.' ”
Braun was lucky. The surgery didn't affect his sex life, and he didn't suffer incontinence, or loss of bladder control.
The biggest adjustment has been having orgasms without ejaculating, since the prostate gland is mostly what contributes to seminal fluid.
Prostate cancer: A statewide problem
Florida has the second highest incidence of prostate cancer in the country, with an average of one in four men affected, compared to one in six in the U.S. That's not necessarily alarming, however, considering the disproportionate number of retirees living in the state, and the fact that age is one of the risk factors of prostate cancer.
Still, the magnitude of the problem here led experts, among them Prof. Johannes Vieweg, chair of the urology department at UF, to create the Prostate Advisory Council two years ago.
The idea is to coordinate educational, clinical and state resources to educate people on prostate cancer.
“Not all prostate cancer diagnoses lead to death. There's a lot of confusion when treating it,” Vieweg said. “It has probably become one of the most misunderstood malignancies in the country.”
He added, “Many things will induce the transition from a normal cell to a prostate cancer cell. Prostate cancer is a result of many screw-ups: unstable genes, bad food, hormonal changes, aging.”
Much of the discussion on prostate cancer has centered on screening guidelines. While the PSA test is simple enough (it can be taken as part of routine blood work), it's not a perfect measure of the existence or potential of prostate cancer.
However, it can detect cancers that might otherwise go unnoticed until it's too late.
“Prostate cancer, unless it's in the very late stages, is not going to be symptomatic,” Su said. “My patients are mystified that there's not blood in the urine,” or other urinary symptoms.
But in the clinic, the tendency has been to err on the side of caution, so when presented with abnormally high PSA levels, a patient is advised to undergo a prostate biopsy. Since the early 1990s, the PSA test has allowed for identification of tumors in its very early microscopic stage where treatments are more effective.
In the pre-PSA era, only a digital prostate examination could detect larger established cancers, many of which were locally invasive and not curable by surgery or radiation. However, this has come at a cost in that, in some cases, the tumors identified by PSA screening are of very low malignant potential, posing very little harm to the patient even years after diagnosis.
This wouldn't be a problem, except the treatments for prostate cancer — from surgery to remove the prostate, to radiation to destroy the tumor with radioactive waves — have potential side effects ranging from erectile dysfunction, urinary incontinence and bowel dysfunction. This dilemma has raised concerns that widespread PSA screening efforts may lead to both overdiagnosis and overtreatment of some prostate cancers.
“A lot of [prostate] cancer is harmless and doesn't need treatment,” Vieweg said. “If we operate and radiate on everyone, that's what's causing problems.”
A more prudent approach is selecting those patients for treatment who are at greatest risk of succumbing to their cancer, and considering monitoring others with extremely low-risk cancers.
Prostate cancer screening debate
On the other hand, screening and early detection can save lives. When urologists set the screening age at 50 — and 40 for African-Americans, who are at higher risk of prostate cancer, and those with a family history of the disease — mortality from the disease dropped with the introduction of PSA, said Su.
But because of concerns of overtreatment that also resulted from those screening guidelines, the U.S. Preventive Services Task Force (USPSTF), a national panel made up of health care experts, concluded in 2009 that the benefits of PSA testing did not outweigh the potential harms associated with treating cancer, and that there was insufficient evidence to prove that PSA, in fact, was saving lives.
“As a field we were obviously very disappointed by that statement,” said Su, pointing out that urologists were not among the experts on the USPSTF committee. “It totally turns back the clock to 30 years ago,” to detecting cancers through the digital rectal exam alone. “If we wait until we can feel [a cancer] by digital prostate examination, then it's often too late to treat and cure,” Su added.
In response to the USPSTF guidelines, the American Urological Association recently came up with its own revised guidelines, recommending men between age 55 and 69 get screened, with those at higher risk starting earlier. In addition, they recommended that PSA screening could be extended safely to every two years instead of annually.
“We are basically revising our guidelines to address the group of patients who we believe benefits the most from screening based upon the currently available medical literature,” Su said, adding that screening past age 70 is inadvisable for the general population because men at that age often invariably have an elevated PSA, but treating them might not be necessary and could, in fact, impinge on quality of life in their golden years without actually extending overall life expectancy.
However, Su said that in the end all men should discuss their screening options with their doctor. “Each individual patient is unique. Having that conversation with your doctors [on whether to screen or not with routine PSA testing] is really the bottom line.”
That individualized care carries over into treatment once a man has been diagnosed with prostate cancer, Su continued. “We have excellent treatments for prostate cancer. It's not a cookie-cutter decision what a man should undergo.”
Su said that the biology of the tumor — determined through a prostate biopsy — is the best indicator of how aggressively a tumor is likely to progress, which in turn dictates treatment decisions. Risk factors such as family history and race also influence treatment.
“Understanding the biology of the tumor with the patients' medical background and projected life expectancy in mind is a key component of decision-making,” Su said. “I spend an hour with my patients. This is not a conversation you can have in five minutes.”
Options discussed include robotic surgery (i.e. radical prostatectomy), radiation, active surveillance and combination therapy.
For Braun, after conversations with several surgeons and radiation oncologists, and having a family history of prostate cancer tipped him toward the surgery option.
“I determined that I should have the prostate removed rather than go through the different radiation modalities,” Braun said. “If you have surgery, and it is totally confined to the prostate, the likelihood of it returning is fairly slim.”
Still, Braun was nervous about the surgery, not least because he'd never spent a night in the hospital. He recalls Dr. Su telling him, “ 'Look, if you weren't scared, I would think there was something wrong with you,' ” Braun said.
Braun said the worst part of his surgery was having a catheter for a week afterwards.
Otherwise, he bounced back quickly, resuming a normal sex life with his girlfriend, working out twice a week with a former Mr. Florida, and eating healthily.
“I feel blessed,” Braun said. “I am a very lucky person.”
Braun said he also feels fortunate that his prostate cancer was caught early through a routine PSA screening. He feels passionately that regardless of what the guidelines say, men should get screened.
“If you dissuade one man from being tested who might have prostate cancer, you've helped kill someone,” Braun said, adding, “When you go for a yearly physical, it's just one more box to check off.”
For KTK radio host Storm Roberts, 62, checking off that box since age 50 helped detect a slowly creeping cancer that his doctors at North Florida Regional Medical Center caught in 2010.
Roberts opted for radioactive seed implants, in which the seeds deliver radiation to the cancer cells without damaging surrounding tissue.
“I've had more dental pain,” Roberts said of the treatments.
Before undergoing radiation, he took a drug called Lupron, which decreases testosterone in the body and often has side effects such as headaches and hot flashes.
Roberts said he didn't have the side effects, he speculates because he was working out a lot during the treatments.
Like Braun, Roberts supports timely PSA testing — and any type of test that can spot cancers early. Roberts' mother was a triple cancer survivor who died of a stroke at 90, and all her cancers were caught early, he said.
He also supports genetic testing for diseases. He did testing through a company called “23andMe,” and for $99, learned that he's at slightly higher risk for melanoma and heart disease and lower risk for rheumatoid arthritis and Alzheimer's disease.
“It's an amazing service. I just love knowing so you can be proactive,” Roberts said. “We're living in a molecular level now.”
Contact Kristine Crane at 338-3119, or firstname.lastname@example.org.
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