Dr. David Samadi, prostate cancer expert, shares latest PSA test recommendations based on 10-year life expectancy and a man's right to choose. You have two choices:
1 Live ten years happily without treatment for prostate cancer
2 Live ten years with more side effects and problems (after treatment)
What is prostate cancer?
Prostate cancer is a disease which only affects men. Cancer begins to grow in the prostate - a gland in the male reproductive system. The word "prostate" comes from Medieval Latin prostate and Medieval French prostate. The ancient Greek word prostates means "one standing in front", from proistanai meaning "set before". The prostate is so called because of its position - it is at the base of the bladder.
Prostate cancer is mostly a very slow progressing disease. In fact, many men die of old age, without ever knowing they had prostate cancer - it is only when an autopsy is done that doctors know it was there. Several studies have indicated that perhaps about 80% of all men in their eighties had prostate cancer when they died, but nobody knew, not even the doctor.
What is the prostate?
The prostate is an exocrine gland of the male reproductive system, and exists directly under the bladder, in front of the rectum. An exocrine gland is one whose secretions end up outside the body e.g. prostate gland and sweat glands. It is approximately the size of a walnut.
The urethra - a tube that goes from the bladder to the end of the penis and carries urine and semen out of the body - goes through the prostate.
What are the symptoms of prostate cancer?
During the early stages of prostate cancer there are usually no symptoms. Most men at this stage find out they have prostate cancer after a routine checkup or blood test. When symptoms do exist, they are usually one or more of the following:
The patient urinates more often
The patient gets up at night more often to urinate
He may find it hard to start urinating
He may find it hard to keep urinating once he has started
There may be blood in the urine
Urination might be painful
Ejaculation may be painful (less common)
Achieving or maintaining an erection may be difficult (less common)
What is the Prostate-Specific Antigen (PSA) test?
The PSA test is a blood test that measures the amount of PSA in the blood. PSA is produced by the prostate and is normally present in a man’s blood in small amounts. An elevated PSA level may be an indication that cancer is present. Men who have a prostate infection or prostate growth that is not cancerous (like benign prostatic hyperplasia - BPH) may also have high levels of PSA.
What causes prostate cancer?
We don't yet know what causes prostate cancer, but we do know that it's more common in :
•men over 50
•men with a family history of prostate cancer (one or two "first-degree" relatives, such as a father or brother) men of African ancestry
•We also don't know the effect that other factors (such as diets low in fibre or high in fat, or low levels of physical activity) have on the likelihood of developing prostate cancer.
How is prostate cancer treated?
To treat localized prostate cancer (cancer that has not spread), doctors use one of three methods
•Surgery (prostatectomy)
•Radiation therapy (including brachytherapy)
•Watchful waiting (expectant management)
Generally, prostate surgery is preferred for younger men if they don't have other significant health problems. Radiation therapy is is an alternative to surgery and in particular for men who are at greater risk for complications from a major operation. Watchful waiting is most appropriate for older men with less aggressive, low-grade, slow-growing cancers as these men are likely to die from other illnesses before needing treatment for their cancer.
New report – You have 10 Years to Live? Get the PSA Test for Prostate Cancer
Life expectancy is the new metric for PSA testing and prostate cancer, according to the American Society of Clinical Oncology (ASCO). Dr. David Samadi, SMART robotic prostate cancer surgeon, explains how newly released ASCO guidelines put into writing what leading prostate cancer treatment experts have been espousing for years. The ASCO advises men with a life expectancy of less than ten years to forgo routine PSA screening, suggesting the potential side effects of treating prostate cancer may outweigh the benefits. For men with a life expectancy of ten years or more they support a man's right to choose, encouraging a thorough discussion of the benefits and risks of testing.
It's personalized medicine, plain and simple," says Dr. Samadi. "Whether ten years is the magic number for PSA screening depends on the patient, but the recommendation that men have a choice gets us back on track. The PSA debate came to a head in 2012 fueled primarily by concerns over whether a man should expose himself to the potential side effects of prostate cancer treatment, chief among them problems with urinary control and sexual potency. Dr. Samadi breaks down the crux of the issue. "Is it worth it? That's what they're asking. But that's a choice each man must make for himself. As experts, our role is to provide an accurate picture of their health and an education about the pros and cons of prostate cancer testing and treatment."
Going forward, it is unlikely that a man's general physician will automatically lump the PSA blood test in with their annual cholesterol and blood pressure screenings. The ASCO's step-by-step patient guide is another tool in what Dr. Samadi refers to as "personalization and collaboration" regarding the PSA decision. Choosing the PSA test means having a thorough understanding of the options your outcome will present. It's a good idea for men to determine what actions they might take should their results signal the possibility of prostate cancer," Dr. Samadi advises, "The counsel of an experienced prostate cancer expert should be central to the PSA decision.
Beyond life expectancy, Dr. Samadi knows firsthand that quality of life is a stronger factor for many. "I have performed successful robotic prostatectomy surgery on many patients in their late 70's. While some experts might suggest they had a medical life expectancy of less than ten years, these men chose peace of mind," he says, "For most patients, my robotic SMART (Samadi Modified Advanced Robotic Technique) surgery can deliver that and quality of life at any age."
Dr. Samadi and a great number of his colleagues are encouraged by the ASCO's expression of support for the PSA test and a man's right to choose. As prostate cancer screening tools improve, men will have even clearer results on which to base their prostate cancer treatment decisions.
You've been diagnosed with prostate cancer and after the shock come confusion.
Should you treat it fast with surgery but face an immediate risk of sexual and urinary problems? Or should you opt for weeks of daily radiation treatments and side effects that set in more slowly? Should you also use hormone therapy that may shrink the cancer -- and your sex drive along with it? Or should you just monitor your cancer and hope you'll catch it if it starts to spread out of control?
Some 185,000 men will be diagnosed with prostate cancer this year in the U.S., and many will get conflicting advice. There's little consensus on how or even whether to treat prostate cancer, which can be slow-growing and harmless or aggressive and lethal.
But every man's cancer is different, as is his general health, family history, life situation and mindset. Make sure you understand your own priorities. Some men want the cancer out as fast as possible; others want to avoid surgery at all costs. Some want the best chance for a long-term cure; some care as much or more about avoiding incontinence or erectile dysfunction.
Here's a look at the options:
Surgery:
Men diagnosed with prostate cancer in their 40s and 50s are often steered toward surgery (called a radical prostatectomy), since it's thought to offer the best chance for long-term survival. What's more, removing the prostate and examining it in a lab is the only way to know for sure how much cancer was there and how likely it is to return.
Surgeries using the daVinci Robotic System now account for over 50% of prostatectomies. The surgeon sits at a console about six feet from the patient and, while watching on a video screen, manipulates miniature, flexible tools that perform the surgery through small incisions. It's minimally invasive, which reduces pain, recovery time and blood loss. Most patients go home the next day.
"If you have a well-trained robotic surgeon, there's absolutely no reason to filet patients open and go through all the mess we used to have," says David Samadi, chief of robotic and minimally invasive surgery at Mount Sinai Medical Center in New York City who has performed over 1,800 robotic prostatectomies.
Radiation:
Men over 70, those with other health problems or those whose cancer has spread beyond the prostate are usually counseled to have radiation. External-beam radiation therapy, or EBRT, requires no incisions, no hospitalization and no anesthesia. But it can be inconvenient: Patients generally undergo 40 or more treatments over six to eight weeks. High-energy beams damage the ability of cancer cells to replicate. The entire prostate slowly withers as well.
Radiation has fewer immediate side effects than surgery, but urinary discomfort and loss of sexual potency often set in gradually.
In one form of radiation called bracytherapy, doctors insert 70 to 80 tiny radioactive pellets into the prostate that gradually dissolve and destroy cancer cells internally. Many patients like the convenience: It requires just one minimally invasive procedure that lasts about an hour.
One downside is that patients are advised to avoid prolonged contact with pregnant women and children to minimize a slight risk of radiation exposure to them. In high-dose bracytherapy, a radioactive source is placed in the prostate only temporarily, with no risk to others. Studies have shown that bracytherapy carries a higher risk of urinary problems than other therapies.
Lumpectomy:
About 20% of prostate cancer patients have very small localized tumors. One new option for them is focal ablation, in which doctors destroy the individual tumor while leaving the rest of the gland intact, much like a lumpectomy for breast cancer. Of several ablation techniques, cryotherapy has been in use the longest. Doctors insert metal prongs into the prostate to surround the tumor and freeze it with liquid nitrogen. Critics argue that prostate tumors that are small and localized enough for focal therapy could be safely watched instead.
Watchful Waiting:
At least 50% of men diagnosed with prostate cancer in the U.S. have a low-grade form of the disease that experts say doesn't need immediate treatment and may never. But less than 10% opt to put treatment off and just monitor their cancer. That's in part because it can be psychologically difficult to live with untreated cancer, and in part because the medical system is geared toward active treatment. The big risk with watchful waiting is that a cancer will spread from a highly curable early stage to a more advanced stage, growing outside the prostate, that is far more difficult to treat. Some tumors that have been stable for years can suddenly start to spread. That's why patients and doctors alike need to do active monitoring, with PSA tests every three to six months, digital rectal exams annually, and repeat biopsies if the PSA starts to rise. "You can't have a patient who will disappear on you. If the guy moves to Florida and five or six years from now his PSA hits 90, then it's over," Dr. Samadi says.
WDiet and Exercise:
Besides being conscientious about followup exams, patients can help their own cause by maintaining a healthy diet and lifestyle. Getting exercise and minimizing stress can go a long way as well. Stress hormones epinephrine and norepinephrine help prostate-cancer cells grow and impair the immune system.
Late-Stage Cancer:
Not all prostate-cancer patients can control their cancer with diet and exercise. For those whose cancer has metastasized, a variety of hormone therapies that block testosterone can often stop the progression very successfully, at least for a while. The downside is a high risk of osteoporosis, hot flashes, depression, breast enlargement, diabetes, obesity and high blood pressure. Using hormone therapy intermittently can help reduce such side effects.
Conclusion:
Experts urge men with prostate cancer -- at any stage -- to join clinical trials if possible. "That's how we made all the progress in breast and colon cancer," says Jonathan Simons, president of the Prostate Cancer Foundation, which funds clinical research. "We have some very important ideas to test that might lengthen your life."
How Prostate-Cancer Treatments Compare
TREATMENT RECOMMENDED FOR PROS CONS
Active Surveillance: Also known as watchful waiting; no treatment, but continued monitoring via PSA, biopsies, scanning Gleason score below seven, PSA below 10; small, localized tumors; men with less than 10 years' life expectancy 85% of prostate cancers don't cause problems; no surgery, no hospitalization, no side effects; new imaging techniques allow close monitoring 15% of prostate cancers do spread, requiring more aggressive treatment later; requires regular follow-ups; psychological stress
Robotic Prostatectomy: removal of the prostate gland using da vinci robotic surgery Cancer confined to the prostate, men under 65 and healthy enough for surgery High cancer cure rate with minimal post operative complications when performed by a skilled robotic surgeon; nerve sparing procedure that preserves sexual function and continence; one-two day post operative hospitalization with removal of catheter in 5-7 days Potential erectile and urinary side post operative effects when the procedure is performed by an inexperienced robotic surgeon
External-Beam Radiation: Prostate is bombarded from outside the body with X-rays or proton beams Cancer outside the prostate; men over 70 and those who can't have surgery No incisions, hospitalization or anesthesia; few immediate side effects Requires multiple treatments that are uncomfortable and inconvenient; high probability of erectile and urinary problems that develop and worsen over time; can cause rectal soreness
Brachytherapy: Tiny radioactive seeds are implanted in prostate and kill the cancer cells gradually Low and medium-grade cancers One-time, minimally invasive procedure; no hospital stay High probability of urinary and erectile problems that develop and worse over time
Drug Therapies: Hormone medications block androgens that fuel cancers; can be combined with radiation or chemotherapy Advanced, high-grade or recurrent cancers Can help halt spread of cancer, shrink enlarged prostate Loss of libido and erectile function; osteoporosis; decreased muscle mass; hot flashes; breast enlargement; diminished mental acuity
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