At 90 years old, Jesse Seligman, facilitator of the Cancer Support Group at Wellington Regional Hospital, is one of many success stories when it comes to curing prostate cancer (according to the American Cancer Society the relative 5-year survival rate is almost 100%). Diagnosed at the age of 73, Seligman initiated routine diagnostic blood tests in his 50s as a preventative measure because his father had succumbed to the disease in 1946. While obvious symptoms include changes in sexual and/or urinary function (erectile difficulties, painful or interrupted urination) most prostate cancer is first detected through routine diagnostic methods; the majority of men are asymptomatic.
The diagnostic controversy
For many years, the prostate-specific antigen (PSA) blood test was the litmus test for cancer. A small gland located below a man’s bladder, the prostate ordinarily secretes PSA, which is mostly found in semen although small amounts appear in the bloodstream. High blood levels of PSA may indicate the presence of cancer. However, high PSA can also occur due to other conditions (age or an inflamed/enlarged prostate) leading the PSA test straight into the jaws of controversy: In recent years there’s been a significant shift away from PSA as the most reliable prostate cancer diagnostic tool.
While its use statistically coincided with a reduction in prostate cancer mortality there has also been an increase in over-diagnosis and unnecessary treatment: Men who did not have prostate cancer or forms of the disease that needed treatment were undergoing harsh programs of eradication.
Today, the PSA test remains controversial and organizations like the American Neurologic Association and U.S. Preventative Task Force recommend a different approach to diagnosis: “shared decision-making.” According to Dr William Gans, urology specialist at Cleveland Clinic Florida, “Regarding the question when to get tested or not to get tested there’s really been a major shift. There’s no absolute requirement. As opposed to the physician saying ‘You have to get this done,’ the physician and the patient discuss what are the benefits of doing a digital rectal exam and the blood test, plus what are the potential harms, then make the decision together.”
Inviting patients into the diagnostic process has important benefits, especially in light of the fact that test results can yield three categories of diagnosis: 1) elevated PSA but no cancer, 2) cancer that doesn’t require treatment, 3) cancer that requires treatment.
An approach to treating prostate cancer
Upon diagnosis it’s easy to begin catastrophizing the treatment process. Dr Gans suggests making decisions slowly, counseling patients to research alternatives, meet with radiation oncologists and surgeons, and take time gathering information. “Research the pros and cons of each option,” he encourages. “Ask specialists to share statistics of the risks and potential harms. Speak to different doctors and get different opinions.”
Having a comprehensive interpretation of diagnostic data, plus an overview of treatment choices from “active surveillance” (a form of watchful waiting) to radiation, surgery or hormonal therapy offers patients an opportunity to make informed decisions that feel comfortable.
According to David Most, Executive Director of Health Information Research and a 20-year survivor of the disease, “It gets to be very complicated because whoever is practicing one or another methodology is going to push that methodology. The poor patient doesn’t know enough to sort out the effects from the different approaches so he’s left scratching his head trying to figure out, ‘What do I do now?’ This is one of the things we’ve offered guys over the years: to counsel them on the consequences of each approach.”
Having a support system, Most recommends, is critical. For patients, and also especially caregivers, he suggests finding a local prostate cancer support group (hospitals and cancer centers are good sources) for emotional sustenance and experiential information.
The future of prostate cancer diagnosis
Unlike other forms of cancer that have strict protocols prostate cancer has a lot of wiggle room. From diagnosis through treatment developing prevention and management strategies happen most effectively through a combination of preferred personal and recommended medical approaches. Most remains adamant about the importance of the PSA test and suggests that the shift away from it has a lot to do with the costs that testing and treatment incur. “Don’t listen to people who say to ignore the PSA test,” he cautions. “It starts you on the journey and tells you if you are at risk or not.”
Seligman agrees. “We still need the PSA test,” he affirms, “at least after 50 years of age, and then periodically following up every one to two years. If you wait any longer than that it doesn’t take long for the cancer to grow and metastasize.” Seligman feels optimistic about advances in diagnosis (including new MRI and MRI directed biopsies) that make detection less dangerous and more accurate. “The secret to prostate cancer is to catch it in time,” he advises.