The latest in prostate cancer screening and treatment

The latest in prostate cancer screening and treatment

Diagnosis and treatment of prostate cancer continue to improve.

There's now more emphasis on monitoring progression of the disease before moving to treatment for cancer that hasn't spread beyond the prostate, and some older men may elect to skip treatment altogether, said Timothy K. O'Rourke, MD, of Urology Associates of Cape Cod in Yarmouth Port.

According to the American Cancer Society (ACS), prostate cancer follows only lung cancer as the leading cause of cancer death for American men, and about one in eight men will get the diagnosis, with 60 percent of those men aged 65 or older.

However, a diagnosis isn't a death sentence for most. Prostate cancer first detected as confined to the prostate or the immediate surrounding tissue and lymph nodes has a greater than 99 percent five-year survival rate, says the ACS. Cancer that's spread to distant sites in the body has a 38 percent five-year survival rate.

Screening Methods Have Changed

Use of a PSA (prostate specific antigen) blood test and a digital rectal exam at men's annual physicals fell off following the U.S. Preventive Services Task Force recommending against routine PSA tests for all men in 2012, amid concerns of excess diagnosis and overtreatment, according to a March 14, 2022, article in JAMA Network Open. The task force earlier had recommended against testing men 75 and older.

The 2012 USPSTF recommendation has since been rescinded, noted Dr. O'Rourke, and now focuses on shared decision-making between patient and physician, rather than rejecting screening entirely.

Emphasis is now on a more risk-based approach, he said. American Urological Association guidelines state that PSA screening should be initiated in men aged 40-45 with risk factors and men 45-50 at average risk for prostate cancer. Men over 50 years old at average risk, and who will likely live for 10 more years, also should be screened after being told of pros and cons of testing, says the American Cancer Society.

According to a National Library of Medicine StatPearls article, risk factors include:

• Being black or having African ancestry
• Family history of several malignant cancers
• Lynch syndrome
• Testing positive for BRCA1 and BRCA2 genetic mutations

Dr. O'Rourke said PSA levels don't directly correspond to whether a man has cancer or not.

"It's not a perfect test. It can be elevated for things other than cancer," said Dr. O'Rourke.

The prostate enlarges with age, which generates more PSA, causing levels in the blood to go up, so Urology Associates of Cape Cod uses an age-adjusted scale for blood levels, he said. If PSA is elevated, but a subsequent MRI (magnetic resonance imaging) of the prostate doesn't find any suspicious areas, blood tests for other biomarkers may be used before making a decision to proceed to sampling prostate tissue via a biopsy procedure.

Biopsies and Treatment

Biopsies access the prostate from either the rectum or the perineum, the area directly behind the scrotum. Both procedures are guided by an ultrasound device placed in the rectum, according to Dr. O'Rourke, and both have similar risks of infection. Transrectal biopsy can be done under local anesthesia in the Urology Associates Yarmouth Port office, he said.

There are multiple clinical variables that determine an optimized approach for biopsy in each patient, he said. Each patient's case is considered and both transrectal and transperineal options are available to patients on Cape Cod, he added.

If cancer is found and it's slow-growing, active surveillance may be used. This entails not proceeding to surgery, but monitoring PSA levels two to four times annually, and a digital rectal exam once a year, according to the American Cancer Society. In addition, genomic testing can help define characteristics of a patient's cancer and thereby better guide effective treatment, Dr. O'Rourke said.

If cancer progresses or is fast-growing, options include radiation therapy (external beam radiation or implantation of radioactive "seeds" (brachytherapy) into the prostate, surgical removal of the prostate and the seminal vesicles that are attached to the gland (prostatectomy), and androgen-blocking drugs to reduce production of the male sex hormone testosterone, which feeds prostate tumor growth.

Brachytherapy is not utilized as often as in years past, said Dr. O'Rourke, due to cutting-edge technology/capabilities of external beam radiation at Cape Cod Hospital's new radiation center at Cape Cod Hospital's Davenport-Mugar Cancer Center and the Clark Cancer Center at Falmouth Hospital and the hospital's da Vinci robotic-assisted surgical machine that make prostatectomies less invasive and limits bleeding.

At every step of the way, Dr. O'Rourke said he discusses the pros and cons with patients, who are the ones who make the decisions whether to proceed. A patient's age, general health and any chronic illnesses factor into the process, as well as how much a patient might tolerate side effects, such as urinary, bowel and sexual problems.

"We try to give a very personal approach," he said.