Prostate Cancer

Prostate cancer is a unique but common medical problem and a very difficult one for the layperson to fully comprehend. The greatest challenge to the patient first diving into the topic, especially on the internet, is what Dr. Jason Engel calls the great paradox. On the one hand, prostate cancer is now often presented as always slow growing, not particularly dangerous or harmful, and eventually every man gets prostate cancer. On the other hand, the fact remains that prostate cancer can be as aggressive and as deadly as any other cancer, as it is indeed the number two cause of cancer mortality in men in the United States today. So, which one is true?

The answer is that both are true. The treatment of prostate cancer and PSA screening in general has come under fire in recent years, particularly around the time of the Affordable Care Act debate and passage. Data from the US Preventative Task Force, data that was presented five years before that time, suggested that PSA screening in America was more harmful than good, even to the degree that guidelines for screening were changed and some primary care physicians stopped PSA screening altogether. This was a very dangerous message and was a one sided telling of the story that in some ways was politically influenced.

For the first 20 years of widespread PSA screening, PSA was used as a true screening test, one where if a man’s PSA was above a certain level (4 ng/dl) a man underwent a biopsy. This lent itself to extreme over-testing and extreme over-treatment in America. It is estimated that almost half of all cancers treated in the 1990s through 2005 or so were very minimal and low grade and thus not harmful. These cancers would now be deemed insignificant and perhaps not treated at all. Aggressive PSA screening found a lot of prostate cancer, but not cancer that always needed to be treated. It took 20 years of research and follow up to learn this. Thus, PSA back then was in some ways hurtful to American society more than helpful and ushered in an era of overdiagnosis and overtreatment. It was this era that was presented and not contemporary usage that led to the guideline changes.

Most Urologists now do not use PSA as a single point screening test. PSA is now properly used as a trend test, especially with the doctors at USW. If used this way, PSA moves from perhaps the worst performing screening test in contemporary medicine to possibly the best of all screening tests available today.

The part that was not told to the lay press however is that most Urologists now do not use PSA as a single data point screening test. PSA is now properly used as a trend test, as substantiated very clearly in the literature, especially with the doctors at USW. If used this way, PSA moves from perhaps the worst performing screening test in contemporary medicine to possibly the best of all screening tests available today. The philosophy most commonly employed now is one where the goal of screening for prostate cancer is to find only aggressive cases, the ones responsible for the deaths in America. We call these significant cancers. Thus, the old adage that all men will eventually get prostate cancer if they live long enough may be true if one includes low grade cancers that are not harmful as well as cancer grades that are now not even called cancer. We don’t look for those anymore, and if found we try not to treat them. So, the first step in understanding prostate cancer is to first understand these points about PSA screening and how it has evolved.

Please learn far more by watching Dr. Engel’s webinar regarding up to date prostate cancer screening on our site, found on the homepage. Now let’s move to the concept of significant versus insignificant prostate cancer.

To avoid finding insignificant prostate cancer in the first place, Dr. Engel generally will not offer a biopsy until at least two, or perhaps even three successive rises of the PSA are seen in a patient. It is only a consistent trend, not singular peaks in a bouncing PSA pattern nor any particular set number that will be deemed suspicious. These days, there is much interest in non-invasive tests such as 3-D Ultrasound, MRI, and others to see if these technologies can be sensitive and specific enough to supplant an actual biopsy to look for prostate cancer. There also is an ever growing and evolving list of risk stratification tests also designed to guide us as to whether a biopsy is necessary or not. Dr. Engel has not found any of these tests to be particularly helpful in his practice yet and feels that the philosophy of demanding successive rises of the PSA before biopsy when applied to the individual patient circumstances is far more specific for finding aggressive cancers and excluding insignificant ones. In the same light, Dr. Engel is generally not an advocate for MRI targeted/fusion biopsies as an initial step. Using all of these extra steps seems to take a step backward into the days of overdiagnosis and overtreatment – a place best not to go. We try to protect our patients from that.

What is (Prostate) Cancer?

Dr. Engel and his partners have delivered the diagnosis of prostate cancer or educated patients on the topic well over 5000 times. What has always impressed him from patients diagnosed elsewhere is how little the patient has been educated on the topic. This is a stressful and confusing time for the patient and his spouse and family, and the first step that should be taken is education. Dr. Engel takes that very seriously; Perhaps you have been instructed to read this essay before your next visit for this very purpose. Perhaps you are with another Urologist and hopefully, you will find this education helpful as you move along on your journey.

After understanding first whether a biopsy is indicated, it is important for a patient to then understand what cancer is in general. Cancer is the uncontrolled growth of cells in an organ or the blood. When enough of these cells are present, this is called a tumor. Unlike cells in a benign tumor which also grows in an uncontrolled manner, malignant (cancer) cells can spread throughout the body. This process is called metastasis, and it is metastasis that can lead to death and thus should be seen as the real enemy. It is worth noting that all cancers have a specific pattern of where cancer tends to spread. With prostate cancer, it is to bones and lymph nodes primarily.

The challenge with all cancers is to catch them early before they have spread, which is of course what PSA seeks to do. If found and treated at that early stage, cancers are not much different than benign tumors. The term prostate cancer refers to the malignancy transformation happening in the prostate. When cancer spreads, let’s say to a bone, it is not called bone cancer but rather a metastasis from the originally named cancer. Patients will often see the term adenocarcinoma in their biopsy/pathology report. This just refers to the cell type that transformed into prostate cancer. In the case of prostate cancer, well over 95% of cases are this cell type.

Risk Stratification & Treatment

Patients must then understand the details of their prostate cancer and really should do their best to be educated which includes obtaining their pathology report and being conversant about it. One of the most important concepts to first understand is that prostate cancer, like breast cancer, exists over a wide range of how aggressive each case is. So first, one needs to get a sense of where they stand on this range, and this process is called risk stratification. One’s risk stratification determines if a cancer needs to be treated at all, and if so, what treatments are best suited for their particular case.

Several variables contribute to risk stratification. These include parameters such as how much cancer was present on their biopsy (number of needles), the percentage of each needle or core that contains cancer, the PSA pattern and velocity of rise (much more important than just the latest PSA), and the highest grade of cancer seen on the biopsy report (Gleason grade). One thing to note regarding PSA is that patients found before their PSA gets to 10 ng/dl are considered to have been caught early, with a far lower risk of metastasis. In terms of Gleason’s score, Dr. Engel tries to explain this as four grades, just like most other cancers have. The lowest grade is a 6(3+3). All Gleason grades lower than this are no longer called cancer. There are two grades of seven, 3+4 and 4+3, in order of aggressiveness, and finally, Gleason scores 8-10, the most aggressive. So, he will discuss these grades as grade groups one, two, three, and four with four being the most aggressive. Most pathologists have started to present things this way as well on pathology reports.

So, now you and see that just to be told one has prostate cancer does not say much. We will learn about all of these variables and then we will assign a risk stratification. Dr. Engel often uses the terms:

• No risk
• Low risk
• Moderate risk and
• High risk

Learn more about risk stratification and treatment for prostate cancer

Treatments for prostate cancer may include:

• Watchful Waiting
• Active Surveillance
• Radiation Therapy Delivered Via Different Protocols
• Brachytherapy
• Cryotherapy
• Surgery (Robotic Prostatectomy)

Learn more about treatment for prostate cancer

Next Steps

If you have been diagnosed recently with prostate cancer, Dr. Engel (robotic prostatectomy, cryotherapy) would be happy to have a consultation with you in our office. We will make sure we review your case with you, make sure you understand the problem first thoroughly, and will then go over all treatment options before zeroing in on the right one for you.

Decision Making Once Diagnosed with Prostate Cancer

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When coming for your consultation, please bring all pathology, radiology, and lab reports with you. Also, we encourage you to bring your spouse, family, or significant other as usually these people are also integral to your education and decision process.