Diagnosing and Treating Prostate Cancer
Diagnosing and Treating Prostate Cancer
If a man lives long enough, he will eventually develop prostate cancer. Which sounds depressing, except: Prostate cancer is largely treatable. And it has a much lower mortality rate than other cancers, as long as it’s detected early.
It’s crucial to be aware early on about your prostate—what it is, what it does, enlargement, early screening—and to demystify the many misconceptions about it. It’s also important to understand the latest prostate cancer treatment options, which have significantly improved over the last decade, according to urologic surgeon Vincent P. Laudone, MD.
A Q&A with Vincent P. Laudone, MD
The prostate is a walnut-size organ that’s located in the pelvis. It is connected to the bladder and sits between the bladder and the urethra, which is the tube that runs from the bladder through the prostate and out the penis that men urinate and ejaculate through. The prostate itself is a sex organ. It is responsible for producing some ejaculation fluid, and that fluid contains chemicals that help the sperm function.
The prostate also has a role in urination because men urinate through the middle of their prostate—you can think of the prostate like a doughnut. Which is why when men get older and their prostates get bigger, they sometimes have trouble with urination.
Prostate enlargement is common with age. Not all men get it, but a significant fraction do. Although we don’t completely understand the reasons for this, it is partially related to genetics and the hormonal changes that men go through as they get older.
Early on, there are no specific symptoms for localized prostate cancer. It is not a symptom-driven diagnosis. If prostate cancer becomes advanced and spreads to other parts of the body, then there may be symptoms.
“Prostate cancer is more common in men over forty, so men should start thinking about their prostate health and having conversations with their primary-care physicians about prostate cancer once they turn forty.”
Prostate cancer is more common in men over forty, so men should start thinking about their prostate health and having conversations with their primary-care physicians about prostate cancer once they turn forty. Men who have a family history of prostate cancer have an increased risk of having prostate cancer themselves. The incidence of prostate cancer is also more common among African Americans.
There are two main tests for prostate cancer. The first is a blood test called the prostate-specific antigen (PSA) test, and the other is a physical exam called the digital rectal exam, in which the physician does a gloved-finger examination of the prostate through the rectum.
These days, the majority of men who are diagnosed with prostate cancer are diagnosed with the PSA blood test. PSA refers to a chemical enzyme that the prostate gland normally produces. PSA is a necessary component of ejaculate and helps the sperm function. It’s called prostate-specific antigen because only the prostate produces it. But what’s important to recognize is that PSA is not specific to prostate cancer. A man may have a blood test done that suggests that the PSA level in his blood is abnormal, but that doesn’t necessarily mean that he has prostate cancer. There are other conditions that can cause elevated PSA levels, such as an enlarged prostate, inflammation, or infection. Ejaculating right before a blood test can also cause a transient elevation in the PSA level, and the PSA level will sometimes just vary from day to day. PSA levels tend to rise as men get older. A PSA level that’s normal for a seventy-five-year-old is not the same as the one that’s normal for a forty-five-year-old. This has been the source of much controversy over the last thirty years, since the PSA test was developed. Because the PSA test is not specific for prostate cancer, it can create a lot of false positives, which leads to additional testing and worry for patients when they may not have prostate cancer at all.
However, the PSA test is the only way that we are able currently to detect early prostate cancer. If you wait until there are symptoms, it means the disease has already progressed into a more advanced stage. Physicians recommend screening based on the age of the patient, their risk factors, and what their initial PSA levels are. A forty-five-year-old man who has very low PSA is less likely to develop prostate cancer during the rest of his life and may not need to be screened as frequently as someone with a higher PSA level who is older and has a greater risk.
The digital rectal exam is used in combination with the PSA test to look for any changes or irregularity in the prostate tissue, such as firmness or lumps. It is much less sensitive for picking up early cancer, and it is a less reliable test.
The PSA test and the digital rectal exam do not make the diagnosis. They simply suggest that the individual potentially has prostate cancer. There are more extensive blood tests, such as the 4K test and the prostate health index (PHI), which take the PSA and other clinical information into account in an algorithm to predict the likelihood of someone having prostate cancer. Magnetic resonance imaging (MRI) of the prostate may also be used. Ultimately, the actual diagnosis is made with a biopsy of the prostate.
Not all prostate cancer is the same. When the pathologist makes a diagnosis of prostate cancer from the biopsy, they also give a measure of cancer aggressiveness called the Gleason grade. The Gleason grade goes from six to ten—six is the least aggressive prostate cancer and ten is the most aggressive. In the last few years, we have used an additional piece of information about cancer aggressiveness called the genomic profile. Using a limited analysis of the genes in that particular cancer, certain gene signatures can predict the cancer’s aggressiveness. Genetic profiling of cancer has become exceedingly important as we develop new targeted therapies for certain abnormalities specific to cancer subtypes that we determine from this genetic profiling. Cancer aggressiveness is a critical piece of information that goes into subsequent treatment decisions.
The second piece of information is the cancer’s stage. Meaning: How much cancer is there, and where is it? The cancer may be completely contained in one isolated part of the prostate, or it may be spread throughout the whole prostate. The cancer may be outside of the prostate, spreading to nearby tissues, lymph nodes, or bones. The extent of the cancer can be determined from MRIs or other radiologic imaging tests.
Treatment will depend on the grade and stage of the cancer. Some cancers are suitable for certain treatments, while others are completely unsuitable for that treatment. Men may talk to other men who have been diagnosed with prostate cancer and share their experience of treatment, which is great. But I often emphasize that another man’s prostate cancer may not have been identical to yours, and what was appropriate for them may or may not be appropriate for you.
“In the past, many men may have been overtreated who would have gone on to never have an issue with their prostate cancer in their lifetime. In the last ten years, there’s been a major shift toward active surveillance.”
On the low-risk end of the spectrum for prostate cancer is a Gleason grade that is nonaggressive (a six), a favorable genomic profile, and a small amount of prostate cancer that hasn’t spread. For this type of cancer, the pendulum has swung in recent years toward recommending what we call active surveillance. This involves watching the prostate cancer on a consistent basis and treating it only if there is evidence of progression. Active surveillance has become a common strategy for managing low-risk prostate cancer. The advantage to active surveillance, from a patient’s perspective, is avoiding the side effects of cancer treatments that can ultimately interfere with the patient’s quality of life. It’s a very attractive option. Many men understand that they may eventually need treatment, but if they can put it off for several years, perhaps when that time comes, there will be better treatment options available than what we have today. Active surveillance also avoids the overtreatment of prostate cancer. For many years, if you had a diagnosis of prostate cancer, you got treated, no questions asked. In the past, many men may have been overtreated who would have gone on to never have an issue with their prostate cancer in their lifetime. In the last ten years, there’s been a major shift toward active surveillance.
Then there are patients with higher-risk prostate cancer for whom getting treatment is highly recommended. They may have a more aggressive Gleason grade or genomic profile, a higher-grade lesion, or more extensive cancer. For localized prostate cancer that’s completely contained within the prostate, men have two options for whole-gland treatment: Either the whole prostate is removed via surgery, or the whole prostate is treated via radiation. Men who have fairly isolated prostate cancer that’s just in one area and don’t need to have their whole prostate treated can be considered for focal therapy. Focal therapy treats just the affected area of the prostate and leaves the rest alone. There are various methods of focal therapy, such as cryosurgery (freezing), high-intensity focused ultrasound (HIFU), radiofrequency ablation, laser photodynamic therapy, and electroporation. Focal therapy is an evolving field. The advantage is that it has fewer potential side effects. The disadvantage is that you’re treating only part of the prostate, so the man will need to be monitored very closely after treatment in case he develops new cancer in his prostate. Focal therapy is less definitive in terms of putting prostate cancer treatment behind you.
The primary long-term side effects we consider are urinary issues and sexual issues. I recommend that patients consult with a surgeon and a radiation doctor to talk about the various treatments and side effects, if that’s appropriate for their type of cancer.
If you have an enlarged prostate that is causing urinary issues, along with prostate cancer, removing your prostate may be the best way to treat both of those things at once. However, surgical prostate removal can cause incontinence. When you remove the prostate, men may have leakage as they learn to recruit other muscles in their pelvis to control their urinary flow. An initial period of urinary leakage is common in most men until they gain back urinary control with certain pelvic-strengthening exercises.
Incontinence is less of a problem for men undergoing radiation because the prostate isn’t removed. But men with enlarged prostates who undergo radiation can still have issues and sometimes are given medications to shrink their prostate before radiation to minimize this issue. Men who undergo radiation often have some degree of increased urinary frequency.
The primary sexual side effect we are concerned about is erectile dysfunction (ED). The brain sends nerve signals to the penis to get an erection and these nerves surround both sides of the prostate. If the prostate is treated with surgery or radiation, it may negatively impact those nerves that are necessary for an erection. All treatments try to minimize impact on these nerves. Surgeons will do what’s called nerve sparing, which means that they separate nerves from the prostate before prostate removal to try to save these nerve signals and prevent ED. This can cause nerve trauma, so men may initially have some difficulty with erections after surgery as these nerves try to heal. It can be a slow, gradual recovery process that takes months because nerve tissue is one of the slowest-healing tissues in the body. Unfortunately, not all men recover function. It depends on a number of factors such as age—because nerves don’t heal as well as we age—and whether the man had some preexisting ED before treatment, and it also depends on the extent of the cancer. If a larger area that extends outside of the prostate has to be treated, it won’t necessarily be possible to spare those nerves from radiation or surgery.
We try to be as proactive as we can. There are programs to help with ED and sexual functioning as well as medications that men can start before their treatment in hopes of helping them recover faster.
With radiation, there is some difference in the timing of impact on erectile function compared to surgery. At first during radiation, most men won’t notice much of a difference and will still have normal function. They may start to notice a decline about six to twelve months later, as the full effects of the radiation begin to manifest.
There is no one best treatment. It depends on the individual, their age, their health, what’s most important to them in terms of their quality of life, and the extent and aggressiveness of their cancer. All of those things have to be taken into account.
Vincent P. Laudone, MD, is a board-certified urologic surgeon who specializes in robotic surgery for prostate cancer. He is the chief of surgery of at the Josie Robertson Surgery Center at Memorial Sloan Kettering Cancer Center.
This article is for informational purposes only, even if and regardless of whether it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of goop.