Good Health Starts with You: Men's Health Month

Good Health Starts with You: Men's Health Month

June is Men’s Health Month and is an important reminder for men to visit their primary care provider for their annual wellness exam and health screenings such as prostate cancer screening.

Prostate cancer is the second most common cancer in American men. It is estimated that 1 out of 8 men will be diagnosed with prostate cancer in their lifetime and over 3 million men have a prior diagnosis of prostate cancer. In the US, there are approximately 250,000 new cases of prostate cancer yearly and 34,000 deaths from prostate cancer. Prostate cancer is the second leading cause of death in American men - one out of forty-one men will die from prostate cancer.

Non-Hispanic Black men, older men and those with a family history are more at risk for prostate cancer and death from prostate cancer. The average age at time of diagnosis is 66 years old. However, despite these ominous statistics and seriousness of the disease, most men diagnosed with prostate cancer will not die from it, especially those men diagnosed early.

The prostate is a walnut-sized gland that tends to grow larger as men age. Many times, this growth represents non-cancerous or benign disease. However, some cells within the prostate may grow out of control and this is termed prostate cancer.

The key to prostate cancer detection is screening, because nearly all prostate cancers at time of diagnosis are “silent” or give no symptoms. The two most common components of prostate cancer screening are prostate-specific antigen (PSA) and digital rectal exam (DRE). PSA is blood test that is often times elevated in men with prostate cancer.

DRE can be helpful in detecting abnormal hard areas or nodules of the prostate. DRE can sometimes detect prostate cancers in men with normal PSA levels. This is why it is often included in prostate cancer screening. PSA and DRE are generally performed yearly.

There are a number of relatively new tests that can be used in combination with PSA and DRE to better determine which men are at highest risk for prostate cancer and, therefore, should undergo a prostate biopsy.

The question of who should be screened for prostate cancer and which men benefit most from screening has been somewhat controversial since the United States Preventative Services Task Force (USPSTF) initially published their recommendations for prostate cancer screening in 2008. Since most prostate cancer screening is being performed by a primary care provider, the AUA published Early Detection of Prostate Cancer Guidelines in 2018. In summary, the Panel recommended against prostate cancer screening in men under age 40 years. For those men 40 – 54 years old, the Panel recommended individualized prostate cancer screening for higher risk men, such as Black men and those with family history of metastatic or lethal prostate, breast, ovarian or pancreatic cancer. The Panel recognized that those men age 55 - 69 years old had the greatest benefit of prostate cancer screening. Finally, for those men greater or equal to 70 years old, the Panel does not recommend routine prostate cancer screening – except for those 70 + years old men in excellent health and those that have an estimated life expectancy of 10 – 15 years.

In most cases, the diagnosis of prostate cancer is made by performing a transrectal, ultrasound-guided prostate biopsy and sending the tissue to a lab for analysis. A prostate biopsy is a 5 – 10 minute, relatively simple procedure that is routinely performed in the office under local anesthetic block. Nitrous oxide, or “laughing gas”, can also be used very effectively in the office setting for prostate biopsy analgesia.

Once the diagnosis of prostate cancer is made, a lengthy discussion is had with the patient and their urologist regarding the biopsy findings and treatment options. The pathologist will assign a Gleason score to the positive biopsies which will describe how aggressive the prostate cancer is. For some men, further tests are performed in an effort to predict cancer behavior and determine the extent of the disease. For those men felt to have cancer confined to the prostate, many urologists utilize National Comprehensive Cancer Network (NCCN) Prostate Cancer Guidelines to help counsel their patients on treatment options. These options are:

Active surveillance (AS) – Approximately 40% of American men with prostate cancer have low-risk disease. These men are prime candidates for AS. AS is defined as prostate cancer monitoring with PSA level every 6 to 12 months, DRE and periodic repeat biopsies. Prostate MRI can also be used. If there is evidence of disease progression, or if patient prefers, definitive treatment can be done at that time.

Watchful waiting (WW) – WW is defined by deferring definitive treatment unless the patient becomes symptomatic from their prostate cancer. This is often offered to men with multiple health issues that makes them less suitable for definitive treatments.

Radioactive seed implants (brachytherapy) – Brachytherapy involves implanting radioactive seeds into the prostate during a short, outpatient procedure under general anesthesia. No incisions are required and the patient can return to normal activities the next day. Those men best suited for brachytherapy have localized, favorable risk disease.

External beam radiotherapy (EBRT) – EBRT is given to the patient via short radiation sessions several times per week. The total number of sessions typically ranges from 37 to 45. However, shorter duration/higher radiation dose treatments are gaining favor.

Radical prostatectomy (RP) – RP is defined as the surgical removal of the prostate, seminal vesicles and pelvic lymph nodes. This is commonly performed utilizing a robotic approach. Men typically stay one to two nights in the hospital. Men with localized prostate cancer are the best candidates for RP.

There are other treatment options for organ-confined prostate cancer that are designed to provide cancer treatment efficacy while minimizing adverse effects. Some of these treatments can be applied to the entire prostate and/or just the tumor within the prostate gland. High-intensity focused ultrasound (HIFU) and cryotherapy are the most common of these treatment modalities. However, it should be noted that these treatments are not generally included in most guidelines as initial treatment options.

NCCN guidelines also exist for those unfortunate men found to have advanced or metastatic prostate cancer. Common treatment options include close PSA monitoring, genetic testing (i.e. BRCA1/BRCA2), ADT, hormone therapy, chemotherapy, Radium-223, targeted EBRT to symptomatic bone metastasis and Provenge (immunotherapy).

There continues to be great interest in advancing prostate cancer detection and treatment. Over the past decade, we have seen significant improvements in our ability to predict which men most benefit from screening, which men should undergo prostate biopsy and which men may respond best to certain therapies. With appropriate screening, the aim is to avoid unnecessary prostate biopsies, yet detect significant prostate cancers early so that definitive therapies can be offered.

Dr. Todd Vandenberg is a urologist with Palmetto Urology. For more information call Palmetto Urology at 803-395-3625.