Vail Daily health feature: The ins and outs of prostate cancer
June 24, 2014
The most common cancer among American men, prostate cancer, is not the deadliest one out there — lung cancer is. But when it comes to testing for prostrate cancer and treating it, it is one of the most complex and controversial.
Because the prostate is a gland in the male reproductive system (located below the bladder), prostate cancer is unique to men, although it is often compared to breast cancer in women.
"As far as incidence rates, prostate and breast cancer are similar in men and women," said Dr. Alec Urquhart, medical oncologist at Shaw Regional Cancer Center. "Women can't get prostate cancer, but men can get breast cancer. Androgen plays an important role in both."
Whereas a significant portion of breast cancer cases (about seven percent) occur in women younger than 40 years, the risk for prostate cancer doesn't increase significantly until after age 50.
“Of all cancers, prostate cancer is definitely one of the most treatable and slowest.”
Dr. Michael Glode
Medical oncologist and nationally renowned prostate cancer specialist
Similar to women getting mammograms to screen for breast cancer, the screening process for prostate cancer in men begins with a PSA test (prostate-specific antigen), which simply involves testing a blood sample. Elevated levels of PSA may indicate prostate cancer. The catch is that certain harmless conditions or circumstances such as benign prostate enlargement (BPH) or inflammation (prostatitis) can also lead to high levels of PSA that don't indicate a presence of prostate cancer, meaning that PSA screening is a matter of significant contention in the medical world.
Screening: Yay or nay?
"I could speak ad nauseam about the pros and cons of PSA screening," said medical oncologist and nationally renowned prostate cancer specialist Dr. Michael Glode, who also happens to be a recent prostate cancer survivor. "The more you screen for it, the more you find it. What's happened with PSA testing is that more men were discovered to have elevated PSAs. But some have that because their prostate enlarges. There are some men who have cancer with normal PSA values, too, but when you start biopsying, as one of my colleagues puts it, 'If you drill more holes, you find more oil.'"
The thing is, there are types of oil, or rather, prostate cancer, that are indeed unveiled in biopsies following PSA screening, but they are low-grade and potentially not much of a threat.
"In the last 10 years, there was a flurry of cases when PSA screening became available," Glode points out. "People said 'Oh my God, you can find cancer, it needs to be treated.' But as with breast cancer, we started wondering are we finding too many? Are we putting too many women and men through biopsies when many are low-grade cancers that may have never bothered them?"
As you may imagine, a prostate biopsy is an unpleasant undertaking. It is done by inserting a large ultrasound device into the rectum where two cameras take pictures of the prostate and a needle extracts a thick thread of material for microscopic examination. If the sample shows cancer, even a low-grade variety, it typically leads to a fair amount of alarm among patients and their loved ones.
"All the screening has changed the biology and clinical behavior of prostate cancer, but it has only had a small effect on death rates," he said. "It has caused a lot of anxiety. It makes sense to go through the side effects (of treatment), if a patient has more than a 15-year life expectancy. But more than half of the men diagnosed at age 70 will be dead from another cause by 85."
Dr. Connie Wolf, urologist at Colorado Mountain Medical, believes that screening is advisable for younger men, but only after an extensive exchange of information.
"I do believe that it should be offered to certain men after a discussion of the benefits and risks surrounding prostate cancer screening and treatment," she said. "Entire clinic appointments are sometimes spent discussing this."
The upside of PSA screening is that if the cancer discovered in a biopsy is more advanced, it can be treated in a number of different ways and prolong a patient's survival, which is the popular choice among younger men diagnosed.
"The good news is that even for men with metastasized forms there are five new drugs approved in the last few years that have been shown to treat it effectively," Glode said. "Of all cancers, prostate cancer is definitely one of the most treatable and slowest."
Symptoms of advanced or metastasized (cancer outside of the gland) prostate cancer include bone pain similar to arthritis but more severe, blood in the urine and semen and trouble urinating.
Prostate cancer is uniquely dependant on androgens for surviving and spreading. The new drugs block testosterone and target abnormal proteins in the blood but also come with side effects such as swollen breasts, impotence and urinary incontinence.
For non-metastatic (not spread beyond the gland) prostate cancer, surgically removing the prostate is a frequently employed treatment option.
Some men with higher grades of prostate cancer choose to have radiation, which is done by external beams or radioactive "seeds" placed in the prostate tissue.
Chemotherapy is reserved only for patients with the most advanced forms of the disease. Unlike chemotherapy however, hormonal treatments don't typically cause sickness or hair loss. Androgen deprivation therapy (ADT) can control the disease for years, sometimes leading to remissions lasting 15 to 20 years.
"That's what's exciting about prostate cancer now, there are new therapies coming out," Urquhart said, adding that in spite of the cons of screening, the Shaw Center generally advocates it. "We are on the pro-screening side for mammograms, starting at a younger age — at 40. As far as the PSA, it's much less clear. There has been increasing debate on that. I still recommend it."
Some men who undergo PSA tests discover high levels, are biopsied and find the presence of cancer, but simply decide to wait and watch because the tumor is low-grade and non-threatening. Still others live under the philosophy that ignorance is bliss and opt to never be screened.
"If you talk to men in a prostate cancer support group, none of them feel like they shouldn't have been screened," Glode said. "But there is a big physiological burden of surgery, so you want to make sure it was worth doing."
Ultimately, it comes down to personal choice and talking to your doctor about the options.
"You can download thousands of pages of very confusing information about prostate cancer," Glode said. "This is what newly diagnosed people usually do. After they've done that, they like to talk to somebody who has experience treating it."
In his 30-plus-year medical career, Glode has treated more than 3,000 cases of prostate cancer and was Harvard-trained. The Associate Director for Outreach at the University of Colorado Cancer Center, Glode has led the charge on a multitude of medical and pharmaceutical research projects and investigations on cancer treatments. Although he is on the road to retirement, he serves patients twice per at week at the university and once per week at the Shaw Center.
"Now I'm one of the grand old men on prostate cancer nationally," Glode said. "I guess I'm one of the local guys with a national reputation."
He is also a guy who has experienced prostate cancer first-hand. This in itself speaks to the necessity of a personal decision when facing prostate cancer, beginning with the controversial decision to get screened and if so, when, what measures to take if a biopsy turns out malignant and how to choose and/or deal with treatment.
"I made up my mind to be screened until age 70," Glode said of his own choices. "A couple years ago my PSA crept up and I got biopsied. Last year, it was up again and I had a second biopsy. That found a small tumor, an intermediate grade."
Glode opted for surgery about a year ago. Like most prostate surgery patients, he was in and out of the hospital in about 24 hours. The recovery wasn't particularly difficult — within a week he was out hiking — and he said he is doing well.
"That was my choice. That's how the cards fell," he said.
At the time, it's what felt right to him, and he said it always needs to be a personal choice.
"I'm always helping men make decisions talking about their personal preferences," he said.
Not only is he one of the most qualified prostate specialists in the world, but Dr. Glode also has access to experimental treatments that are not yet FDA approved and knows patients have access to the best treatment in the world at Shaw Regional Cancer Center.
"We have a state-of-the-art radiation facility. My feeling is we can deliver radiation therapy as well as anyone in the country," he said.
"I can be a conduit to research drugs available. (Patients) can go through standard care here, and we can make it seamless to be put on research trials at the university."