Could your patients answer these five questions? Dr. Alan Partin offers answers and explanations.
Question 1: After discussion with their physician, all men should consider getting a PSA checked and a digital rectal exam at age 50 years unless they have a family history of prostate cancer or are African-American, in which case they should be checked at an earlier age, between 40 and 45 years. A first PSA value of < 4.0 ng/ml at this young age is considered completely normal.
An initial PSA value for a man aged < 50 years should be < 0.6 ng/ml to be considered completely normal. Values higher than this should prompt closer observation or referral to an urologist.
Question 2: It is not possible to do surgery for prostate cancer after radiation treatment.
Granted, prostate surgery is rarely indicated as adjuvant/salvage treatment after failed initial radiation treatment. This is because the best treatment at that stage would require systemic (whole body) treatment(s), such as androgen deprivation and/or chemo- or immunotherapy; it—surgery—is indeed possible.
Salvage prostatectomy after radiation is only indicated if the initial tumor presentation was low-intermediate risk disease, PSA levels following radiation failed to maintain a sustained decrease to below the nadir (lowest value after treatment), and the post-radiation biopsy demonstrates microscopic evidence of active cancer cells.
Question 3: Transrectal ultrasound (TRUS)–guided prostate biopsy has a great chance of spreading prostate cancer cells into the bloodstream and rectum.
An excellent question. While it is not completely 100% free of possibility, the actual evidence that this might occur suggests that it is a very low probability. The reasoning is best described in Dr. Walsh’s book, where he addresses the question of needle tracking of tumor cells at biopsy and notes that if this was a serious risk, the concept of early diagnosis and treatment would be moot and that many thousands of patients have benefited from this intervention.
Dr. Walsh also notes that if the cancer is confined to the prostate, the few cells that might be dislodged into the blood stream during biopsy are unlikely to survive if they do not have the metastatic capability. For these reasons, we feel that it is very unlikely that prostate biopsy spreads cancer or causes disease to grow in the rectum.
Question 4: My friend was diagnosed with prostate cancer and began radiation treatment within 3 weeks. I was just diagnosed and was told by my physician that I didn’t need treatment at all—I just needed to be “watched.” My doctor gave me bad information.
When prostate cancer is detected on a biopsy and is felt by the pathologist and urologist to represent very-low risk disease (outlined below), it is often recommended that these men participate in a treatment option called “active surveillance”—an option in which no actual treatment is given; just a well-designed surveillance protocol.
Prostate cancer is the most prevalent male cancer, but the majority of men with the disease do not die of prostate cancer. Studies suggest that 30% to 50% of men > 60 years diagnosed with prostate cancer today by PSA screening undergo a treatment (either surgery or radiation) that will not extend their life or improve its quality. This does not mean that prostate cancer does not kill men, but, rather, some men who are older and/or in poor health with a slowly progressive form of the disease may not need immediate treatment. The key is to accurately identify those men who, for now, can safely forego treatment. Eligible men should meet the following criteria for very–low or low-risk disease:
- Life expectancy < 20 years
- Cancer not felt on digital rectal examination (stage T1c)
- PSA density (PSA divided by prostate volume) < than 0.15
- Gleason score ≤ 6 with no Gleason pattern 4 or 5
- No more than 2 cores with cancer, or cancer involving ≤ 50% of any core on at least a 12-core biopsy
Question 5: Robotic-assisted prostatectomy provides superior long-term cancer cure and better quality of life (urinary continence and sexual function) when compared with the traditional open surgical approach.
Many studies have reported the outcomes of robotic surgery. None to date has been randomized (a statistical method to limit selection and other bias), thus limiting our ability to draw a strong conclusion related to this question. The largest study which looked at men in the national SEER database suggested that, while blood loss and length of stay within the hospital were improved by the robotic method, there was an actual increase in treatment for some of the quality-of-life issues related to prostate surgery (eg, incontinence and erectile dysfunction) in the short term. No long-term matched or randomized comparative data exist to determine if either approach (traditional open or robotic) is better with respect to cure of cancer. At this time, it is safe to say that both approaches to removal of the prostate have similar risks and benefits. A careful discussion with your prostate surgeon will best determine the method that is best for you.