By Dr. David Oubre
Is there a prostate-specific antigen? Well, prostate cancer is one of the most common cancers in senior men. There are a lot of controversies in this disease, partly because there are a lot of options. I’d like to give a basic explanation of the most common options for the diagnosis and management of prostate cancer.
The most commonly used test to screen for prostate cancer is the PSA, or prostate-specific antigen. Many physicians advocate an annual PSA for men between the ages of 50 and 74. However, this is controversial. The American Cancer Society’s (ACS) guidelines do not support routine use of the PSA in all patients. Instead, the ACS recommends physicians discuss the pros and cons of the test with their patients. Without question, a prostate cancer diagnosis is easiest to make with PSA screening. However, an elevated PSA is often seen in other diseases of the prostate, such as benign prostatic hyperplasia (BPH.)
A positive PSA can lead to more tests, procedures and anxiety. Furthermore, prostate cancer is often a slow growing malignancy, so early detection is not as critical as in other diseases, like breast or lung cancer. My recommendation is to have the screening if you are at high risk (family history of prostate cancer, African-American) or in any man over 50, in good health, who doesn’t mind going through a few extra tests. PSA screening may not be as effective as mammograms, but it has saved many lives.
The other screening test used to detect prostate cancer is the digital rectal examination (DRE). This detects more advanced cases of prostate cancer. Although not nearly as effective as a screening tool as the PSA, the DRE is quick, easy, and inexpensive.
Once prostate cancer is suspected, the physician will generally recommend a prostate biopsy. If the biopsy is positive, then treatment decisions are considered. If the disease has not spread to other organs, the main options for treatment are surgery and radiation therapy. There are several surgical and radiation options available.
Surgery to remove prostate cancer is performed by a urologist. The urologist will usually perform a procedure called a Radical Prostatectomy which can be done through a standard open incision or with laparoscopic assistance. Within the last 10 years, robotic prostate surgery has gained in popularity. Patients notice little difference in these techniques. As far as outcomes are concerned, the robotic technique has not been around long enough to know if it is better. If you have prostate cancer and have elected surgery, I would recommend finding a urologist that you trust, and ask that doctor to perform the procedure with which he or she is most comfortable.
The main side effects associated with surgery are urinary incontinence and erectile dysfunction. Thirty to 40% of men will have some form of incontinence after surgery and require wearing pads to stay dry. Post-operative erectile dysfunction, or impotence, is more likely to occur at advanced ages. Incidence rates for a 60-year-old man are about 30%. There are a variety of procedures and medications available to help deal with these situations. Most physicians consider surgical removal of the prostate to be the most effective way to cure the cancer while recognizing that the side effects are not insignificant.
Radiation therapy can also be a primary treatment of prostate cancer, or post surgery especially if all of the tumor could not be removed. External beam radiation, the most frequent type, is given repeatedly over several weeks. Alternatively brachytherapy, a technique where seeds are implanted in the prostate gland (treating the tumor inside out) can be used. This technique is generally only for smaller, less risky cancers.
Radiation seems to be as effective as surgery. The side effects are also comparable between the two. Incontinence is more frequent with surgery, rectal bleeding and irritation is more frequent with radiation, and impotence rates are the same.
Since prostate cancer usually is a slow growing tumor, often not spreading for years, observation may also be considered. Patients with other medical problems like heart disease, strokes or emphysema may have a lower risk of death from prostate cancer compared to their other diseases. Thus it may be best to watch and wait.
If the cancer has already spread to other organs several options exist. Hormonal therapy, designed to cut off the effect of the male hormones on the cancer, is one. Chemotherapy can also be effective at delaying the progression, and prostate cancer vaccines have been developed as well.
Know your options and talk with your doctor should you be diagnosed with prostate cancer.