Prostate Cancer – Separating Diagnosis From Treatment

Making progress against over treating prostate cancer

/ Author:  / Reviewed by: Robert Carlson, M.D

September is National Prostate Cancer Awareness Month, and dailyRx News wanted to learn about the state of the disease, its diagnosis and treatment. 

What's common knowledge is that prostate cancer screening is rife with controversy. Why?

The controversy

The PSA test, approved by the U.S. Food and Drug Administration in 1994, measures the level of an enzyme the prostate makes - the prostate-specific antigen (PSA). 

PSA levels are affected by all sorts of things - mostly change in the size of the prostate called BPH - Benign prostatic hyperplasia. Infection and even over-the-counter drugs can make the PSA go up.

This test is only a marker - it doesn't say a man has prostate cancer. Period. 

The test also can't say anything about the cancer that may or may not be present.

But a typical scenario has been that a doctor interprets the PSA as too high - and what's high to one doctor could be low to another. A biopsy is ordered to find out what's going on.

Most of the time - about 75 percent of the time - no cancer is found. Or, maybe a low-risk cancer - that may never cause him harm - is picked up.

Fear sets in, the doctor pushes treatment and then the prostate might be removed or radiated.

The man has to deal with temporary or permanent sexual problems and/or incontinence. All for a slow-growing cancer that could have just been watched over the years.

This is why the United States Preventive Services Task Force has recommended against routine prostate cancer screening in healthy men.

Ask an oncologist

dailyRx News held a telephone interview with nationally known prostate cancer expert, E. David Crawford, MD, to get his thoughts on what men need to know about prostate cancer.

Dr. Crawford is professor of surgery, urology, and radiation oncology, and head of the Section of Urologic Oncology at the University of Colorado Health Sciences Center in Denver.

He is also one of the founders of Prostate Conditions Education Center, a non-profit organization that's dedicated to educating men about diseases and conditions of the prostate.

We asked Dr. Crawford to speak from his own experience as someone who diagnoses and treats men with this disease.

dailyRx: What's the age range of men you see who have been diagnosed and treated for prostate cancer?

Dr. Crawford: We started doing the screens in 1989 – early detection is a better name - and quickly realized that a lot of guys would walk in at age 50 to get their first PSA (prostate-specific antigen) test - they had PSAs of 100 and they had disease in their bones.

So we lowered screening recommendations to age 45. But again, we were still seeing some people come in with advanced disease. What we’re now suggesting is that men come in for screening early in life to try and avert them coming through the doorstep at age 50 and having incurable disease.

dailyRx: How common is prostate cancer in men under the age of 50?

Dr. Crawford: I see a lot of men in their 40s with prostate cancer. I would say the average age is 60-70, but that’s a bell-shaped curve. People in their 40s are about 5-7 percent of the people we take care of.

dailyRx: What is considered an elevated PSA?

Dr. Crawford: It really depends somewhat on age. There are three things that will elevate your PSA:

  1. Size (enlargement) of the prostate – which is the most common.
  2. Prostate cancer
  3. Inflammation

As men get older their PSA goes up. Not a lot, but once it gets to 1.5 – that’s kind of the danger zone. And there’s a linear relationship between the size of the prostate and PSA.

What I say is that guys between 40 and 50 should have PSAs of less than 1.

dailyRx: With all the concern about the unnecessary testing and treatment, what do you consider to be the trigger points to do more testing?

Dr. Crawford: A 41-year-old man who has a PSA of 1.5 or 2, in my opinion is abnormal, and I would do a biopsy. But I would also use some of these new biomarkers – that can indicate that prostate cancer is present – to help us make that decision.

The other thing is looking at what we call velocity, which is the change in PSA levels over a year’s time. If it’s going up, it doesn’t always mean you have cancer, but it is a red flag that you need to worry about something.

dailyRx: What percentage of men have you biopsied based on PSA levels who ended up being a false positive?

Dr. Crawford: Well that’s the problem. About 3/4s of the people you biopsy will not have prostate cancer.

dailyRx: A better test is needed to see what an elevated PSA really means, right?

Dr. Crawford: PSA is not perfect and it’s not protective. PSA is a good marker, but there’s no marker that's perfect. That’s why we need to have other ones – like these biomarkers – to help us determine who with an elevated PSA might have prostate cancer.

What we’re trying to do is be more specific with the diagnosis and not have so many false positives. And then once a diagnosis is made, help determine who needs to be treated.

dailyRx: Talk about these biomarkers.

Dr. Crawford: I would bundle these markers into a couple of different bins.

Diagnostic markers help us identify who has prostate cancer. This includes Progensa PCA3 – PCA3 for short – a urine test approved by the FDA that detects the over-expression of the PCA3 gene – which is a marker for prostate cancer.

Another set of markers helps us identify who might have an aggressive type of cancer that needs to be treated. And that’s one of the big controversies – over-treatment of men with prostate cancer.

This includes the Prolaris test, which predicts 10-year survival rates and can help determine the best treatment options.

dailyRx: From your experience, what percentage of men do you see who need to be treated?

Dr. Crawford: Therein lies the problem and all the controversy because a lot of times once the diagnosis of prostate cancer has been made, the train has left the station so to speak.

The guys are diagnosed with what appears to be a low-grade cancer – not an aggressive cancer. The doctor pushes them to be treated, and they want to be treated. And that’s why many get over-treated.

As many as 30-40 percent of people may be over-treated for prostate cancer.

And people will say to me, “Doc, are you sure if you don’t treat me and that you watch me, I’m going to do okay?” And you can’t say that.

That’s why we’re doing these mapping biopsies – we call them 3D biopsies. These can tell us more about who you can watch and who you should treat.

Most men will get a biopsy and find they have a low-grade cancer that may not be a threat to them. And that’s the basis of all the concern of the United States Preventive Services Task Force.

The fact is, though, once someone is diagnosed, 85-90 percent of them are treated.

dailyRx: Why are so many men treated for what could be a slow-growing cancer?

Dr. Crawford: It’s fear; people want to get it out; they want to get on with their lives; they don’t want to take any risks. And then doctors push for treatment because they might have some type of equipment they need to use to pay for.

dailyRx: What can a guy do to take care of himself once he’s been diagnosed with prostate cancer?

Dr. Crawford: What I tell a guy is. ‘There’s bad news and good news. The bad news is you have prostate cancer. The good news is it’s been found early and it’s treatable. You’ve got lots of options – from doing nothing to surgery, to radiation. Take your time, get some second opinions and don’t rush into any treatment.’

And then I tell him, ‘There’s no treatment that’s going to make you a better man than you are right now. All the treatments to get rid of the disease have side effects.'

The next thing is to decide on a treatment that’s best suited for him and his lifestyle.

dailyRx: Are there new kinds of treatment?

Dr. Crawford: Right now, we’re doing a lot of what we call a male lumpectomy.

This is targeted therapy. If we know where the cancer is, we don’t have to treat the whole prostate, with all its risks of impotence, incontinence and all the rest of what can happen.

dailyRx: What do you want men to know about prostate cancer?

Dr. Crawford: I would say ‘why should they care about prostate cancer?’ They should care about prostate cancer because a man has a one in six chance of getting the disease. It’s still the most common cancer in men [outside of skin cancer] and the second leading cause of cancer death.

What they should know is:

  • What’s heart healthy is prostate healthy.
  • When you eat healthy and stay in shape, this actually reduces your risk of a lot of prostate conditions.
  • Taking saw palmetto and all this other stuff shows no benefit.

Unfortunately, a healthy lifestyle doesn’t work for some men and they still get it. Early detection is still important, but there’s controversy about this.

What men need to do is separate diagnosis from treatment. Not everyone who is diagnosed needs to be treated.

We are making progress with the biomarkers, sophisticated technology for the 3D biopsies and other tests that help us identify an aggressive cancer and who might need to be treated.

Finally, we’ve made a lot of progress in the last couple of years in treating even advanced disease with a number of new drugs that have come out that are making an impact.

[These include Jevtana (cabazitaxel), Xgeva (denosumab), Provenge and Zytiga (abiraterone). And Xtandi (enzalutimide) is the latest to be approved.]

In the future, it’s reasonable to assume that we may turn this into a chronic disease – much like diabetes or heart disease.

Review Date: 
September 11, 2012