Andrew Siegel MD 12/3/2016
Attribution of above image: Blaus (Own work) [CC BY-SA 4.0 (http://creativecommons.org/licenses/by-sa/4.0)%5D, via Wikimedia Commons
It was not so long ago that all prostate cancers were lumped together, the thought being that a cancer is a cancer and best served by surgical removal. Consequently, with the best of intentions, some unnecessary surgical procedures were performed that at times resulted in impaired sexual function, poor urinary control, and unhappy patients.
Fortunately, urologists have become wiser, recognizing that individual prostate cancers are unique and that a nuanced approach is the key to proper management. Some prostate cancers are so unaggressive that no cure is necessary, whereas others are so aggressive that no treatment is curative. One thing is for certain—we have vastly improved our ability to predict which prostate cancers need to be actively treated and which can be watched.
The Challenge Of Diagnosing Prostate Cancer
The vast majority of patients who have undiagnosed prostate cancer have NO symptoms—no pain, no bleeding, no urinary issues, no anything. The possible diagnosis of prostate cancer is usually entertained under three circumstances: when there is an elevated PSA (Prostate Specific Antigen) blood test; when there is an accelerated PSA (when the change in PSA compared to the previous year is considered to be too high); and when there is an abnormal prostate DRE (digital rectal exam)—a bump, lump, hardness, asymmetry, etc. The bottom line is that if you don’t actively seek prostate cancer, you’re not going to find it. When prostate cancer does cause symptoms, it is generally a sign of locally advanced or advanced prostate cancer. Therein lies the importance of screening.
The Dilemma Of Screening For Prostate Cancer
The downside of screening is over-detection of low risk prostate cancer that may never prove to be problematic, but may result in unnecessary treatment with adverse consequences. The downside of not screening is the under-detection of aggressive prostate cancer, with adverse consequences from necessary treatment not being given.
How Is The Diagnosis of Prostate Cancer Made?
When the PSA is elevated or accelerated and/or if there is an abnormal prostate DRE in a reasonably healthy man with good longevity prospects, an ultrasound-guided prostate biopsy is in order. Obtaining tissue for an exam by a pathologist is the definitive and conclusive test. The biopsy will reveal if cancer is present and its location, volume and grade (aggressiveness).
If prostate cancer is present, it is useful to determine the risk potential of the prostate cancer (“risk stratify”) by classifying it into categories based upon the following:
T (Tumor) category
T1c: cancer found because of PSA elevation or acceleration with a normal DRE
T2a: palpable (that which can be felt on DRE) cancer of half or less of one side
T2b: palpable cancer of more than half of one side
T2c: palpable cancer of both sides
T3a: cancer outside prostate, but sparing the seminal vesicles (reproductive structures that store semen)
T3b: cancer involving seminal vesicles
T4: regional spread of cancer to sphincter, rectum, bladder or pelvic sidewall
Dr. Gleason devised a system that grades prostate cancer by observing the cellular architecture of prostate cancer cells under the microscope. He recognized that prostate cancer grade is the most reliable indicator of the potential for cancer growth and spread. His legacy, the grading system that bears his name, provides one of the best guides to prognosis and treatment. The pathologist assigns a separate numerical grade ranging from 3 – 5 to each of the two most predominant patterns of cancer cells. The sum of the two grades is the Gleason score. The Gleason score can predict the aggressiveness and behavior of the cancer, with higher scores having a worse prognosis than lower scores.
Grade Group 1 (Gleason score 3+3=6)
Grade Group 2 (Gleason score 3+4=7)
Grade Group 3 (Gleason score 4+3=7)
Grade Group 4 (Gleason score 4+4=8)
Grade Group 5 (Gleason score 4/5+4/5=9 or 10)
The significance of the Gleason Grade Group can be understood by examining the PSA five years after surgical removal of the prostate, correlating survival with the Grade Group. Ideally, after surgical removal of the prostate gland the PSA should be undetectable. A detectable and rising PSA after surgical removal is a sign of recurrent prostate cancer. The five-year rate of PSA remaining undetectable (biochemical recurrence-free progression) for surgical removal of the prostate in Grade Groups 1-5 is the following: 96%, 88%, 63%, 48%, and 26% respectively, indicating the importance of the grading system with respect to prognosis.
Number cores with cancer
Generally 12 – 14 biopsies are obtained, occasionally more. In general, the more cores that have cancer, the greater the volume of cancer and the greater the risk.
Percent of tumor involvement (PTI)
The percentage of any given biopsy core that has cancer present. In general, the greater the PTI, the greater the risk.
PSA is an excellent “tumor marker” for men with prostate cancer. In general, the higher the PSA, the greater the risk category.
The relationship of PSA level to size of the prostate, determined by dividing the PSA by the volume of the prostate. The volume of the prostate is easily determined by ultrasound or by MRI (magnetic resonance imaging). A PSA density > 0.15 is greater risk.
Risk Stratification For Prostate Cancer
Based upon the aforementioned parameters, an individual case of prostate cancer can be assigned to one of five risk categories ranging from very low risk to very high risk. This risk assignment is helpful in predicting the future behavior of the prostate cancer and in the decision-making process regarding treatment.
Very Low Risk: T1c; Gleason score ≤ 6; fewer than 3 cores with cancer; less than 50% of cancer in each core; PSA density < 0.15
Low Risk: T1-T2a; Gleason score ≤ 6; PSA < 10
Intermediate Risk: T2b-T2c or Gleason score 7 or PSA 10-20
High Risk: T3a or Gleason score 8-10 or PSA > 20
Very High Risk: T3b-T4 or Gleason grade 5 as the predominant grade (the first of the two Gleason grades in the Gleason score) or > 4 cores Gleason score 8-10
Prostate Cancer Treatment
Prostate cancer treatment is based upon risk category and life expectancy and includes the following:
RALP (robotic-assisted laparoscopic prostatectomy): surgical removal of the prostate gland using robotic assistance
RT (radiation therapy): this can be used as definitive treatment or alternatively for recurrent disease after RALP or immediately following healing from RALP under the circumstance of adverse pathology report
ADT (androgen deprivation therapy): a means of decreasing testosterone level, since the male sex hormone testosterone stimulates prostate growth
AS (active surveillance): actively monitoring the disease with the expectation to intervene with curative therapy if the cancer progresses. This will involve periodic DRE, PSA, MRI, and repeat biopsy.
Observation: monitoring with the expectation of giving palliative therapy (relieving pain and alleviating other problems that may surface without dealing with the underlying cause) if symptoms develop or a change in exam or PSA suggests that symptoms are imminent.
Prostate Cancer Treatment Based Upon Risk Stratification
Very Low Risk
< 10 year life expectancy: observation
10-20 years life expectancy: AS
> 20 years life expectancy: AS or RALP or RT
<10 years life expectancy: observation
>10 years life expectancy: AS or RALP or RT
<10 years life expectancy: observation or RT + ADT 4-6 months
>10 years life expectancy: RALP or RT + ADT 4-6 months
RALP or RT + ADT 2-3 years
Very High Risk:
T3b-T4: RT + ADT 2-3 years or RALP (in select patients) or ADT
Lymph node spread: ADT or RT + ADT 2-3 years
Metastatic disease: ADT
Bottom Line: Excluding skin cancer, prostate cancer is the most common cancer type in men, accounting for 26% of newly diagnosed cancers with men having a 1 in 7 lifetime risk. The median age of prostate cancer at diagnosis is the mid 60s and in 2015 there were 221,000 new cases per year, 27,500 deaths (the second most common form of cancer death, after lung cancer) and there are currently about 2.5 million prostate cancer survivors in the USA. It is important to diagnose prostate cancer as early as possible in order to decide on the most appropriate form of management—whether it is surgery, radiation, or observation/monitoring. Risk stratification can help the decision-making process.
“Appropriate treatment implies that therapy be applied neither to those patients for whom it is unnecessary nor to those for whom it will prove ineffective. Furthermore, the therapy should be that which will most assuredly permit the individual a qualitatively and quantitatively normal life. It need not necessarily involve an effort at cancer cure. Human nature in physicians, be they surgeons, radiotherapists, or medical oncologists, is apt to attribute good results following treatment to such treatment and bad results to the cancer, ignoring what is sometimes the equally plausible possibility that the good results are as much a consequence of the natural history of the tumor as are the bad results.”
Willet Whitmore, M.D.
(Dr. Whitmore served as chief of urology for 33 years at what is now Memorial Sloan-Kettering Cancer Center. He died of prostate cancer at age 78 in 1995.)
Wishing you the best of health,
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Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com
Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health http://www.TheKegelFix.com