Too many men are discovering their prostate cancer when it’s already at an advanced stage, one expert says, and confusing advice – and embarrassment – appear to be to blame.
Dr. Deborah Bradley , an oncologist with Novant Health Cancer Specialists in Charlotte said the disturbing trend carries serious consequences for men.
Q: Why is it so important for men to be diagnosed early with prostate cancer, in particular?
A: Being diagnosed with early stage disease is the only opportunity for cure. However, men who present with advanced stage disease can still benefit from treatments to help them live longer and better. Back when prostate cancer screening was common, men were presenting with early disease. We are now seeing more men present with advanced disease. These men have higher morbidity and mortality.
Q: What caused the shift of more patients coming in at a later stage of the disease?
A: In the early 1990s, prostate cancer screening was widely adopted. Professional societies had issued guidelines supporting routine screening with public service announcements. This led to a dramatic increase in incidence of prostate cancer. The majority then were confined to the prostate itself. This led to a lot of men being treated aggressively. However, studies did not, at the time, show screening and early aggressive treatment saved lives. So brakes were put on and professional societies changed their recommendations.
Prostate screening is now controversial due to conflicting data regarding saving lives. The recommendation is now “informed decision making” or “shared decision making,” which is a conversation with your doctor of risks versus benefits of undergoing testing. However, what I am seeing is this just does not happen as often as it should. This takes time and many providers feel the area is very gray. The fact is that we are now seeing more men present with more advanced disease that is not curable.
It is OK and correct to diagnose men with prostate cancer. But we have to be very thoughtful about who needs treatment and who can just be observed. There are certainly men we will diagnose that may not need to be treated immediately, if at all.
Q: What do you tell patients who are diagnosed?
A: When diagnosed with prostate cancer, men usually have several acceptable options for management.
Treatment recommendations are made based on characteristics of the patient and the aggressiveness of the cancer itself. Based on a few factors, patients are given a risk category. Depending on whether their disease is high, intermediate or low risk disease, options can include active surveillance, surgery and radiation alone or in combination with suppression of testosterone for localized disease.
Making a decision is often hard for patients. In medicine, it is more common for the doctor to come in and recommend a specific pill, drug, procedure, etc. To hear you have several good options can be hard for patients in that they ultimately have to make a decision.
Q: What’s the biggest misconception about prostate cancer?
A: The misconception I hear a lot is that prostate cancer is slow-growing and you will die with it − not because of it. That is true in many cases. However, many men each year die of prostate cancer. An estimated 26,700 men will die of prostate cancer in 2017. Prostate cancer, just like others cancers, can metastasize and lead to death in men.
The cells of the prostate gland make the protein called PSA. Men normally have low levels of PSA. If your PSA levels start to rise, it could mean you have prostate cancer, benign prostate conditions, inflammation or an infection. PSA values can also be misleading to patients. The fact is that there is no value that rules out or rules in prostate cancer. Therefore, a rectal exam and discussion of symptoms is important with interpreting PSA values. Trends in the number can also be helpful. Unfortunately, in my opinion, there are authorities who continue to argue.
Q: Are patients sometimes uncomfortable talking about prostate cancer or getting tested?
A: Absolutely! Breast cancer has been a brand. We hear about mammograms. The White House turns pink. I believe one reason we are so far behind in prostate cancer is men are embarrassed to talk about their prostate.
I feel another big reason men are reluctant to talk about their prostate, and undergo screening, is the stigma around incontinence and impotence with treatment. These are real issues. It is true that with treatment, many men experience these side effects at least for a short period of time and some indefinitely. However, the risk varies depending on age and other medical problems men may have as well as their specific treatment.
My recommendation is to talk about your concerns not to avoid what you fear. There are treatments that can help. And in reality, it is extraordinarily rare to meet men who wish they would not have been screened or treated. However, I have met many men who wish they would have been more proactive leading to earlier diagnosis.
Q: Are there any groups of people who should especially be made aware of prostate cancer?
A: We know that there are groups of men who are higher risk for development of prostate cancer. This includes African-American men and men with a family history of prostate cancer.
Q: When should someone get tested? Is there an age when that should happen for everyone?
A: When and if to get tested is always an important discussion for men to have with their primary care doctor.
Q: Are there any recent trends in terms of treatment options going on now that you’ve used to treat prostate cancer patients? I know this question gets a bit technical.
A: Six new therapies have been approved since 2010. These range from further manipulation of the androgen receptor and androgen signaling to chemotherapy (Zytiga, Xtandi), chemotherapy (Jevtana), “bone-seeking” radiation (Xofigo), bone-modifying agents (Xgeva) and immunotherapy (Provenge), where patients’ own cells are “taught” to recognize prostate cancer. A focus now is not only on identifying other drugs with different mechanisms of action that may be helpful but also understanding how to best sequence and use these drugs in combination, as well as identify what patients may most benefit from each drug.
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