About 70 percent of men diagnosed with prostate cancer through PSA screening have low-risk, low-grade disease. Unfortunately, over 90 percent of these men are placed under aggressive treatment soon after diagnosis when in real sense up to 60 percent of them may not need treatment, even in the long-term. Why does this happen? The common screening tests are not able to distinguish between men with prostate cancer that requires treatment and those with clinically insignificant disease. In fact, the PSA test, which is the most frequently used screening test, gives up to 12.5 percent false positive results.

Tackling overdiagnosis and overtreatment

There have been growing concerns over the increased number of prostate cancer cases diagnosed and treated following PSA testing. For instance, overdiagnosis through PSA tests has resulted in more men undergoing biopsy, which comes with adverse effects such as pain, acute urinary retention and urosepsis. Likewise, for men placed immediately under aggressive treatment, there are concerns over psychological distress and adverse effects to treatment such as urinary incontinence, bowel dysfunction and erectile dysfunction, among others, which are typically longstanding and life-altering. So because of the quality-of-life issues and financial costs, attention is shifting to ways of minimizing the harm caused by PSA screening, particularly ways of mitigating the conversion of overdiagnosis to overtreatment.

Risk-based screening

At Advanced Urology Institute, we have designed our screening, diagnosis and treatment processes for prostate cancer to respond to these growing concerns and minimize both overdiagnosis and overtreatment. For instance, we have included a candid patient-urologist discussion of both the PSA and digital rectal exam to make sure our patients are properly informed of their pros and cons. We also perform these screening tests in an individualized manner, based on each patient’s risk factors. As a baseline, we allow men to take their first PSA screening only when in their 40s. This enables us to develop the right screening protocol for each patient.

If a man’s PSA is low during the first test, we generally consider him to have a low lifetime risk of the disease and may not recommend frequent PSA measurements for him. And if we find PSA < 2 for a man in his 60s, we consider him to have a negligible chance of dying from the cancer and recommend that he not undergo any further PSA screening. It’s only for men with higher risk, such as those who have had a first-degree relative with the cancer — which doubles their risk of developing prostate cancer — that we may recommend more frequent screening.

Taking advantage of newer diagnostic tools

Previously, any man with a PSA result that was worrisome, such as one showing a rise over time or has an absolute high value, would automatically be a candidate for biopsy. At Advanced Urology Institute, we have changed this and now may perform other tests before we can recommend a biopsy. For instance, we can use a second test called PCA3 to define a man’s risk level and assess whether or not a biopsy is necessary for him. The PCA3 is a more specific marker for prostate cancer than the PSA and it can be measured in urine, usually after a DRE. Similarly, we can assess the aggressiveness of a tumor through genomic testing and use the results to determine whether immediate treatment or active surveillance is appropriate. So we use such tests to reduce the harm that our patients may suffer from biopsies done due to PSA-based overdiagnosis.

Individualized approach to treatment

To further reduce the chances of treating indolent prostate cancer, we use a combination of PSA and biopsy to assess and classify patients according to degree of aggressiveness of their disease. At AUI, we are committed to minimizing unnecessary, worthless or even harmful treatment after cancer diagnosis. Our most preferred management strategy, particularly for men diagnosed with localized, low-risk prostate cancer, is active surveillance as opposed to immediate treatment. It involves following men with low-grade, low-risk cancer closely and only providing treatment for tumors that exhibit aggressive behavior or are spreading to other areas of the body. Through careful observation, we have realized that a majority of men do not need treatment and therefore are spared the unnecessary aggressive interventions.

During active surveillance, we usually recommend serial PSA testing and biopsy to help monitor the behavior of the tumor. Before we put patients on active surveillance, we inform them that there is a possibility that the cancer may spread to keep them psychologically prepared just in case we detect progress. We also make them aware of the cancer-specific mortality with and without treatment, which is usually less than 10 percent without treatment and reduced by about 50 percent with radiation or surgery. We also inform them of the pros and cons of active surveillance and provide them with all the information they need to make personal treatment decisions.

Our approach is quite different for patients with high-risk prostate cancer. For them, we usually begin curative treatment as soon as possible, using the tools available to deliver safe, timely and effective treatment. The most common treatments for high-grade, high-risk prostate cancer are radiotherapy, high-intensity frequency ultrasound and robotic prostatectomy. Want to know more about prostate cancer screening, diagnosis and treatment? Visit the “Advanced Urology Institute” site.

How is Prostate Cancer DiagnosedProstatic cancer occurs on the prostrate of the male reproductive system. However, instances of metastasis (spread) of cancer cells to the bones, lymph nodes and other areas in the body have been noted. The cancer will usually begin and grow slowly without notice of the patient. In fact, many men having prostrate cancer die of other diseases without ever realizing that they have the cancer; while only few cases of rapidly progressing prostrate cancer have been reported. When developed, the cancer manifests in symptoms like pain, problems during urinating, difficulties with sexual intercourse and even erectile dysfunction.

Prevalence Rates

Though the cancer has been detected often in men of 50 years or more, the prevalence rates vary from country to country. Presently, East and South Asian countries have fewer cases than the USA and European countries. Cancer of the Prostrate is ranked 2nd in the USA and 6th globally among leading causes of cancer deaths. The cancer is also hurting developed nations more than developing nations.

Diagnosis of Prostrate Cancer

Urologists and other physicians diagnose the cancer by conducting physical examination, studying symptoms, biopsy, and prostrate-specific antigen (PSA) tests. The gold standard diagnostic test is biopsy, a procedure involving sampling of a small tissue from the prostrate, processing it and examining the disease picture under the microscope.

Since biopsy is invasive, less-invasive tests may be used more often. For instance, many urologists would conduct urinary tests to detect protein Engrailed-2 (EN-2). The test is considered more reliable, accurate and precise than other non-invasive tests. Some non-invasive tests include cytoscopy, trans-rectal ultra-sonography and direct rectal examination (DRE). Ultrasound (US) and magnetic resonance imaging (MRI) are also common imaging procedures for detecting the cancer of the prostrate.

How is Prostate Cancer DiagnosedUsing tumor markers such as PSA to detect prostrate cancer and malignant cells that are in metastasis is a common practice. However, the tumor markers cannot help to detect small cell carcinoma which takes around 1% of all cases of prostrate cancer. Small cell carcinoma is diagnosed by protein capture immunoassays, immunized antibodies, and a combination of chromatographic methods with mass spectrometry.

Prostrate Cancer Treatment

Depending on the severity of the cancer, various treatment decisions can be made. Usually, surgery, radiation therapy and cryosurgery (rarely) are the choice curative procedures. In more severe cases, chemotherapy and hormonal therapy are preferred. Studies reveal that masturbation, and the use of Finasteride and Dutasteride after screening will reduce the chances of having prostate cancer.