Prostate cancer: A tailored approach
The prostate gland is not known for its size. It’s not much bigger than a walnut. That does not diminish its role, however. Nor its complications.
It sits right below the bladder and surrounds the urethra, a tube that carries urine out of the body. That’s partly why men have problems with urination when the gland acts up.
The prostate does double duty. It also plays a role in fatherhood. It produces the fluid that nourishes and transports sperm.
For the most part, it is able to perform both jobs well, but as with anything else, time takes a toll. The prostate often begins to grow larger, particularly after the age of 50. This is called benign prostatic hyperplasia, or BPH. It’s more annoying than dangerous. Frequency, particularly at night, is a common symptom.
Prostate cancer disparity
But some men have more than just an enlarged prostate. Cancer of the prostate is the most common cancer in men, and the second most deadly. According to the National Cancer Institute, almost 193,000 cases were diagnosed in 2020 and more than 33,000 died of the disease. The median age at diagnosis is 66, and the average age of death is 80.
The good news is that, when caught early, the estimated five-year survival rate is almost 98%, according to the NCI.
For reasons not understood, African American men are hit harder. Although generally one in nine men will be afflicted in a lifetime, for Black men the stats are one in six. Black men are diagnosed at a younger age and suffer a more aggressive form of the disease. They die at more than twice the rate of white men.
An ongoing study called RESPOND is evaluating possible causes of this disparity, including genetics, exposure to stress and tumor characteristics.
A recent study in Cancer offers a possible explanation. When Black men in the U. S. Department of Veterans Affairs health system were offered equal access to care as white men, they were no more likely to be diagnosed with more advanced prostate cancers. Nor were they more likely to die of their disease, and in some cases, the death rates in Blacks were lower than those of whites. The researchers suggest that disparity in access to care partly explains the high death rates.
There are no symptoms in the early stages of prostate cancer. Only testing will detect the problem. That’s why screening is critical. The National Comprehensive Cancer Network recommends that men start screening for prostate cancer at the age of 45. Black men and those with a family history, however, are advised to start five years earlier. Having a father or brother with prostate cancer more than doubles the risk of developing the disease, according to the American Cancer Society.
PSA and DRE
Several tests are used to screen for prostate cancer. The prostate-specific antigen, or PSA, is most frequently used. It’s not perfect but it has held its own through the years. “The PSA was introduced 30 years ago,” explained Dr. Michael Blute, chief of urology at Massachusetts General Hospital. “Since then 80% of the cancers are confined to the prostate,” he said. “Less than 10% have metastasized.”
The PSA is really not a test for cancer, as commonly thought. It actually measures the amount of a particular protein in the blood. The protein is produced by both cancerous and noncancerous tissue in the prostate. If above a certain level for a man’s age, there is a suspicion of cancer.
Another test is the digital rectal exam. The prostate sits directly in front of the rectum. The posterior section of the prostate can be easily felt and is the most common site of cancer. The doctor feels for lumps, enlargements and areas of hardness and asymmetry that are possible signs of an abnormality.
These tests alone give a fairly good indication of prostate cancer, but they’re not always 100% accurate. A man can have an elevated PSA but no cancer for a number of reasons. The PSA can increase with age, a urinary tract infection, BPH and inflammation. Even vigorous bike riding can hike it a bit. That is why it is best to repeat the PSA in three to six months, explained Blute.
Screening for prostate cancer includes a blood test called prostate-specific antigen, or PSA, and a digital rectal exam, or DRE. Below are general guidelines, which may be adjusted to accommodate individual medical conditions.
Age 45 to 75 for average-risk men, or Age 40 to 75 for African American men and men with genetic mutations
• PSA < 1 and a normal DRE if done: Repeat testing every two to four years
• PSA 1-3 and a normal DRE if done: Repeat testing every one to two years
• PSA > 3 and/or a very suspicious DRE: Evaluate for biopsy
Age > 75 – recommended for very healthy men only
• PSA < 4 and a normal DRE if done: Repeat testing every one to four years
• PSA ≥ 4 or very suspicious DRE: Evaluate for biopsy
Source: National Comprehensive Cancer Network
A new look
In recent years newer tests have been developed to improve the accuracy of the PSA. Some tests measure how quickly it changes over time. The percentage of free PSA measures the amount of PSA that circulates either free in the blood or attached to certain blood proteins. A high PSA coupled with a low percentage of free PSA is a likely indication of prostate cancer.
Two other blood tests — prostate health index and 4Kscore — combine the results of different types of PSA to determine the probability of cancer, especially cases that might require treatment. Even scanning has improved. A new state of the art form of MRI called multiparametric MRI can see into the prostate and identify suspicious areas. Biopsies can then target those areas directly.
The gold standard of diagnosis is the biopsy. Specimens removed are graded from one to five depending on similarity to normal tissue. A grade of one indicates that the tissue looks like normal cells. If the cancer cells look very abnormal, a grade of five is assigned. Most biopsy samples, however, are graded three or higher.
The two grades most frequently found are added to develop the Gleason score, which ranges from six to 10. The higher the Gleason score, the more aggressive the cancer.
Treatment is essentially divided into two groups, explained Blute. Those with advanced or metastatic cancer are treated by a medical oncologist using chemotherapy, hormone therapy or immunotherapy.
Some of these modalities are also used if there is a recurrence of the disease following surgery, according to the ACS. The Food and Drug Administration recently approved a tracer used in PET imaging for prostate cancer that is suspected of having returned or spread to other parts of the body.
In the other group, cancer is confined to the prostate. “Sixty percent of men fall into the low grade, low risk group,” Blute said, and are candidates for active surveillance. Their cancers are indolent, which means they will probably grow so slowly that treatment is not warranted. Instead, they are followed regularly with a repeat PSA, MRI and biopsy. Treatment is initiated if the cancer progresses.
African American men with low-risk prostate cancer are candidates for active surveillance as well, according to a recent study by the University of California San Diego. Because of their higher risk of progression, however, they undergo more intensive maintenance.
Men with a higher Gleason score who have 10 years or more to live are good candidates for prostatectomy, or removal of the prostate. Surgery has a high cure rate if the cancer does not progress and pathology is favorable. Older men may instead opt for radiation or radiation combined with hormone therapy. Cure rates for this level of cancer are about the same as radical prostatectomy.
Surgery, however, can impact a man’s quality of life, and result in urinary and erectile dysfunction. That is why shared decision making should precede all treatment.
The first step
The bottom line is that prostate cancer is detectable long before symptoms emerge. It takes a blood test and a five minute DRE. All told that’s about 15 minutes of your time. Those 15 minutes can extend your lifetime.