September is Prostate Cancer Awareness Month so it’s an opportune time to discuss one of the most common cancers in men. UConn Health urologists, Drs. Peter Albertsen, Brooke Harnisch and Benjamin Ristau, answer questions about the latest information concerning diagnosis and treatment.
How much of a factor in prostate health is the PSA test today, and how has that changed over the years?
PSA was originally developed as a blood test to detect prostate cancer recurrence after treatment and received its initial FDA approval for this purpose in 1986. In this setting, it is one of the best biomarkers across the entire cancer landscape. In 1994, PSA was approved as a test for prostate cancer screening. It is in this arena where the majority of controversy exists.
PSA screening has undoubtedly reduced the incidence of prostate cancer cells spreading outside the prostate. By doing so, death from prostate cancer has declined since PSA-based population screening began the mid-1990s. However, PSA screening has also led to an increase in the detection of low grade prostate cancers. Most of these low grade cancers do not require immediate treatment and many will never negatively impact a man’s life. Fortunately, we now have high level data from clinical trials to support watching most low grade cancers over time – a concept called active surveillance. The goal of active surveillance is to carefully monitor a man’s prostate cancer so that we maintain the ability to cure if cure becomes necessary. At the same time, active surveillance allows us to avoid treatment and its inherent risks when a prostate cancer is unlikely to have a negative impact on a man’s life.
The most recent guidelines state that men should have discussions with their doctors about PSA screening and decide together on the best course of action for an individual patient. This concept is called shared decision-making.
How do you determine what course of action to take when you diagnose a man with prostate cancer?
There are two major considerations at play when a man is diagnosed with prostate cancer. First, how aggressive is the cancer? The vast majority of low grade grade cancers can very safely be watched over time. High grade cancers and some intermediate grade cancers, on the other hand, may require treatment. This brings us to the second consideration; how long do we expect a man will be living with prostate cancer. The interplay between these two considerations is individualized and requires a nuanced discussion between a patient and his urologist.
Explain the concept of “watchful waiting” or “active surveillance”?
Watchful waiting and active surveillance sound similar, but describe management options with different priorities in mind. With watchful waiting, the goal of cure is not front and center. Rather, treatment begins when prostate cancer starts to cause symptoms. Typically, this happens several years after the initial diagnosis, and often, the cancer has spread outside of the prostate gland by the time it starts to cause these symptoms. As such, it is a strategy used mostly in men with a limited life expectancy. Hormone therapy is commonly used to reduce the symptoms, and men can live for many years without symptoms from advanced prostate cancer when they are on hormone therapy.
In contrast, the goal of cure remains front and center with active surveillance. However, this is contextualized by a desire to avoid the risks of prostate cancer treatment until it becomes clear that a prostate cancer may negatively impact a man’s lifespan. Active surveillance is an option for the vast majority of men with low risk prostate cancer. It is characterized by active monitoring through periodic PSA blood tests, use of MRI, and occasional repeat prostate biopsy to ensure that a low risk cancer doesn’t become more aggressive. By so doing, the window of opportunity for cure is maintained while avoiding some of the undesirable side effects of treatment.
In Connecticut, we are extremely fortunate to have one of the pioneers of active surveillance – Dr. Peter Albertsen – who wrote the initial research studies demonstrating that most men with low risk prostate cancers are not at risk of dying from their cancer. Nearly 15 years later, active surveillance is a widely accepted management strategy for low risk prostate cancer. With his seminal work, Dr. Albertsen laid the foundation that has prevented unnecessary overtreatment for countless men.
At what point do you decide to intervene, what are today’s most effective treatments?
Unfortunately, not all prostate cancers are low grade; there are some bad actors. After discussion with the individual, a surgeon usually recommends intervention if there is a significant risk of shortened life span or significantly decreased quality of life due to advanced prostate cancer.
Intervention can be divided into two basic categories: surgery and radiation therapy. Both options are available at UConn Health. Surgery can be done as either an open procedure or a minimally-invasive approach using small key-hole incisions (robotic surgery). Radiation therapy involves several prostate-focused radiation treatments typically accompanied by hormonal therapy. Generally speaking, surgery tends to be offered to younger patients and radiation to older patients as a primary treatment; though, there are no hard and fast age limits for either. Cancer outcomes and treatment side effects are comparable between the two approaches. Advances in surgical technique and radiation therapy technologies have led to a reduction in the frequency and severity of adverse side effects.
What can men do to reduce their risk of prostate cancer?
Currently, there are no known modifiable risk factors specific to prostate cancer. General recommendations are to engage in moderate regular exercise, increase fruit and vegetable intake, and minimize consumption of red meat. As Dr. Albertsen often says to men who inquire, “what is good for your heart, is good for your prostate.”