Dr. Stephen Hardeman on Prostate Cancer Diagnosis
Dr. Stephen Hardeman on Prostate Cancer Diagnosis
Dr. Stephen Hardeman: Hi, I'm Steve Hardeman, and I'd like to talk to you about prostate cancer with the emphasis on diagnosis and treatment.
One of the questions I'd like to propose is: Are we over diagnosing and over treating prostate cancer? Do we need to find and treat every case of prostate cancer?
There's been a lot of controversy lately about the PSA blood test. Is it an accurate test, and should we even continue to use it to screen for prostate cancer?
Richard Ablin, the researcher credited with discovering PSA, recently came out with a scathing criticism about the way the medical community has used or misused PSA blood tests. Now this and other evidence ought to cause us to pause and reconsider the way we screen for prostate cancer and how respond when we find the disease.
So, how does prostate cancer compare with other malignancies? For instance, for every 1.2 cases of lung cancer diagnosed each year, there is one death. That's a pretty high ratio. And for every 2.1 cases of colon cancer, there is one death. Again, a pretty high ratio. But for every eight cases of prostate cancer diagnosed every year, there is only one death, and that's a pretty low percentage.
There's a new approach that's been proposed and researched over the last few years that's a good answer to those questions about over diagnose and overtreatment of prostate cancer and it's called Active Surveillance. Before I say anything more about active surveillance, I think it's a good time to stop and answer the question of what's wrong with over diagnosing and over treating prostate cancer? Cancer is bad. Why not go after it full force?
This is an example of why you need to weigh the good versus the bad. Prostate cancer is very common. We know that 30% of the men over age 50 have it. But we also know that 50% of those men would not die of prostate cancer, even if it was left untreated.
If we diagnosed and treated every man with prostate cancer, the cost of medical resources would be enormous. And about half of the men being treated wouldn't even need it. Plus, the toll and side effects, such as impotence, which is erectile dysfunction, and incontinence, which is leakage of urine, would rise sharply.
So the question becomes how do we select that and separate those men who need to be treated from those men who could be watched conservatively? Let's talk about PSAs and prostate biopsies before we get to the criteria for active surveillance.
What's PSA? Well, PSA stands for Prostate Specific Antigen. It may not be the most accurate test we have, but until we get a more precise instrument for identifying prostate cancer, and more specifically, the dangerous cases of prostate cancer, I think we need to continue using PSA.
Some physicians argue that drawing too many PSAs results in too many prostate biopsies. So what's involved in a biopsy? It's a relatively simple, and because of recent techniques we've recently developed, a relatively painless procedure. We do it in the office. Preparation is minimal. Turnaround time is about an hour. The discomfort level is similar to what you would experience in a routine visit to the dentist. And complications are rare.
So what happens is the biopsy shows tumor? Well according to the Active Surveillance protocol, if only one or two of the cores of the 12 that are obtained shows tumor, and the Gleason Score is 6 or less, then you can choose Active Surveillance. The Gleason System or the Gleason Score is a way of assessing the aggressiveness of the tumor, and a Gleason 6 or less is considered slow growing.
Even if you meet the criteria for Active Surveillance, you can go ahead and choose to be treated, it's just that you have the opportunity to be monitored and avoid the risks of treatment such as impotence and incontinence.
If you do choose active surveillance, the recommendations are to repeat the PSA every three or four months. And you need to count on having another biopsy after your initial diagnosis. If the biopsy shows progression, then you proceed to treatment. But if it does not show progression, you can continue with Active Surveillance.
So far, results have show that this approach, Active Surveillance, offers the same results as were obtained with previous early intervention with surgery or radiation. Obviously, some patients with low-grade, low-stage prostate cancer will progress. And with careful monitoring, they can be treated appropriately with no detriment to their overall survival.
Prostate cancer is a very common malignancy. About 30% of the men over age 50 have it. And Active Surveillance offers the best answer we have at this time for those questions I asked earlier about over diagnosing and over treating prostate cancer.
We may be over diagnosing prostate cancer, but there's no good way of avoiding it without missing those dangerous prostate cancers, and I don't want to do that. But if you are found to have a low-grade, low-stage prostate cancer, at least you have the opportunity to avoid the complications of therapy such as impotence and incontinence. And, if you do progress, we can catch it in time and still cure you. In my opinion, that represents a major advancement in the way we manage prostate cancer.