Getting Smarter With Prostate Cancer

Author: R. James Yu, MD, Urologic Oncologist

The quandary of prostate cancer screening has been long debated even before the United States Preventive Task Force issued recommendations against PSA (prostate specific antigen) testing in 2012. Without question, prostate cancer deaths have experienced a tremendous decline since the introduction of the PSA blood test in the 1980’s. However, PSA screening also identified non-lethal cancers that never posed a health risk to the patient in the first place. Their treatment with radiation, surgery or hormone therapy often led to problematic side effects such as urinary incontinence, erectile dysfunction or bowel dysfunction. In 2015, while this debate is far from over, new advances in screening, patient selection, and treatment options allow more men to realize the benefit of prostate cancer screening while minimizing the harm.

To improve the screening process, urologists have new tests in their armamentarium to better identify patients at risk of having deadly prostate cancers. These tests, including the 4KScore and PHI (Prostate Health Index) test, are more specific for high-grade prostate cancers and help determine those who need additional workup for elevated PSAs. In doing so, we are able to avoid biopsying every patient with a high PSA. A recent prospective study showed that using 4KScore reduced the number of biopsies performed for high PSAs by 40-50%, while missing only 2% of high-grade cancers. Less biopsies means less non-lethal cancers diagnosed, and less people harmed by the diagnosis of prostate cancer. While still early in their utilization and evaluation, these tests hold promise to potentially replace PSA for screening.

If prostate cancer is indeed identified, new tests are routinely used to clarify the need for treatment, thereby avoiding overtreatment. These breakthroughs include genomic tests (Oncotype DX and Prolaris) to evaluate the cancer’s genetic aggressiveness, and prostate MRI to better visualize the extent of disease and assess if there are unidentified lesions elsewhere. If deemed to be low risk, many patients can avoid treatment and enroll in active surveillance programs to track the cancer over time. If the cancer shows any sign of progression, intervention can then be undertaken. Currently, more than 50% of prostate cancer patients diagnosed in Marin County are enrolled in the active surveillance program at Marin General Hospital, of which only 30% progress to treatment while on the program. Therefore, treatments are reserved only for patients that truly need to be treated.

Finally, if treatment is truly needed, localized prostate cancer treatments have undergone a tremendous evolution in the past decade. The advents of robotic surgery and sophisticated radiation technologies have allowed more patients to enjoy excellent cancer outcomes with easier recovery, and improved preservation of urinary, bowel and sexual function. Focal therapies with cryotherapy or ultrasound are the next frontier, soon to be better understood. The perfect treatment is yet to be discovered, however, men have better-than-ever chances of achieving cure without detriment to their daily function in 2015, and the landscape is continuing to transform.

Of course, as more evaluation and research is performed on these exciting fronts, emphasis must be placed on the importance of the patient and physician to share the decision making process in the diagnosis, workup and treatment of prostate cancer. Patients should be fully informed of the pros/cons of proceeding down the path of cancer screening, AND, the pros/cons on NOT proceeding down that path, and make a decision for themselves. But be aware that this debate is constantly changing. The devastation seen in the past without any screening may have swung the prostate cancer pendulum towards over-diagnosis and overtreatment. However, with ongoing development of personalized tests and less aggressive treatments, the hope is the pendulum swings back to the point where we only target the men that truly need to be saved, while minimizing the collateral damage during that process.