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Ask the Expert

What Men Need to Know About Prostate Cancer Screening and Treatment

Mark Rosenblum, M.D.
Prostate cancer is a topic that you may have seen in the news lately, as there is disagreement regarding the benefits versus the harm of screening and treatment. The fact is that prostate cancer is the most common cancer among men after skin cancer, and the second most common cause of death from cancer. Thanks to earlier detection and treatment, however, the five-year survival rate for all stages of prostate cancer combined is nearly 100 percent, according to the American Cancer Society. Suburban Hospital urologist Dr. Mark Rosenblum discusses what men need to know about prostate cancer screening and treatment.

Who is at risk for prostate cancer?

Certain groups of men are at higher risk for prostate cancer, including men over the age of 50, men who have a family history of the disease, and African American men.

What are the symptoms of prostate cancer?

Symptoms of prostate cancer include:
• Weak or interrupted flow of urine
• Urinating often (especially at night)
• Inability to urinate or difficulty urinating
• Pain or burning when urinating
• Blood in the urine or semen
• Nagging pain in the back, hips, or pelvis
• Difficulty having an erection and/or painful ejaculation

It’s important to note that these symptoms may be caused by other conditions, and that early prostate cancer usually does not cause any symptoms at all.

What screening tests are most often used to detect prostate cancer?

The two most common tests used to detect prostate cancer are the digital rectal exam (DRE) and the prostate-specific antigen (PSA) blood test. PSA is an enzyme made by the prostate that helps in reproduction. The PSA test measures the PSA level in your blood.

The U.S. Preventive Services Task Force has issued recommendations against screening for prostate cancer. What was the reasoning behind this recommendation and what do patients need to know about prostate cancer screening?

The Task Force looked at the risks of over-diagnosis of prostate cancer and it is true that by performing routine, indiscriminate screening, we may be over-diagnosing this disease. The Task Force also looked at the risks versus the benefits of prostate cancer treatment. For slow-growing cancers, for example, the cancer may not cause symptoms or health problems. Given the potential side effects associated with some treatments, an important factor to weigh when deciding who to screen is whether or not the patient would benefit from treatment if he is diagnosed with clinically significant disease. We have to look at such factors as the patient’s age and other co-morbidities.

The fact remains, however, that early detection and better treatments have contributed to a dramatic decrease in prostate cancer mortality. That is why the Task Force recommendations do a disservice to patients. If we stop utilizing screening techniques such as the PSA test, we will no doubt see these positive trends reverse.

How do I decide if I should get a PSA test?

The question regarding whether or not to get a PSA test should be an informed decision between a patient and his physician based on such factors as the patient’s age, race, family history, possible symptoms, etc. The fact is that the PSA test remains one of the best tumor markers we have for the detection of prostate cancer. It’s a fantastic tool and it should continue to be used appropriately.

How is the PSA test used by the doctor?

The PSA test can be done for many reasons. We use the PSA test in our practice as part of an overall evaluation of patients who have benign prostate disease, such as an enlarged prostate, as well as patients we suspect of having prostate cancer. The PSA is a tool for diagnosis, prognosis, and the management of prostate cancer as well as other conditions of the prostate. We also use the PSA test in the evaluation and treatment of acute conditions, such as acute prostatitis, an infection of the prostate gland.

It should be noted that we almost never use the PSA test in isolation. The absolute value of a PSA at one specific point in time is not that significant. What we look at is the PSA velocity, or rate of change in the PSA level, over time. We also use the ratio of free to total PSA and PSA density, which is the relationship of PSA to the volume of the prostate gland.

Have there been any advancements in prostate cancer screening and detection?

There are other markers on the horizon. For example, the PCA3 gene, which can be measured in urine samples, is over-expressed in prostate cancer cells. This test is currently used in patients who have an elevated PSA but a negative biopsy. It may play a role in future screening as well. Imaging is the holy grail when it comes to prostate cancer diagnosis and prognosis. Both ultrasound and MRI scans are changing the way we manage patients by helping to direct biopsies and to decrease false negative biopsies.

If the PSA test indicates there may be a problem, what is the next step?

A biopsy offers the definitive diagnosis for prostate cancer. The biopsy is done to determine if cancer is present and, if so, the type of cancer. Prostate cancer is classified according to the Gleason score, which indicates how likely it is that the cancer will spread. Tests are also performed to determine if the cancer cells are contained within the prostate (localized); if they have spread to the region outside the prostate; or if the cancer has metastasized, meaning it has spread to other areas of the body. All of these factors will help the physician determine what type of treatment should be considered.

What are the treatment options?

There are three main forms of treatment for prostate cancer: observation; surgery, including open surgery or robotic surgery; and radiation, including external beam radiation and the implantation of radioactive seeds directly into or near the cancer. For localized or regional prostate cancer, surgery and/or radiation are the most widely used treatment options if active surveillance is ruled out. There are nuances to each treatment and specific side effect profiles that should be considered.

Laparoscopic robotic assisted surgery is becoming the standard surgical treatment. It has benefits over open surgery in that it’s less traumatic for the patient, including less pain, less blood loss, a quicker recovery time, and a faster recovery of sexual and bladder function. When it comes to deciding which type of surgery is best for the patient, however, it’s always better to have the surgeon do whatever procedure he or she does well. Trust your surgeon. When we measure surgical outcomes six weeks after surgery, there isn’t a huge difference between patients who have had an open procedure and those who have undergone robotic surgery. The difference really is that the robotic surgery is a milder procedure for the patient.

How do I decide the right prostate cancer treatment (if any) for me?

We utilize a multi-disciplinary, patient-centered approach for all our patients. Our patients make their decisions based on the information provided by the surgeon and the radiation therapist. For localized cancer that is slow growing and not causing symptoms, a decision not to treat is often the correct choice. Active surveillance plays a significant role with prostate cancer.

The likelihood that men with low-stage disease will die from the disease is extremely low, so, again, it’s important to look at a number of factors when considering whether or not to treat prostate cancer, including the patient’s age, co-morbidities, and personal preferences.

What happens if I receive treatment for prostate cancer but the cancer returns?

If a patient has previously received treatment for prostate cancer, it is possible to treat a recurrence of the cancer, depending on the initial form of treatment. In cases of advanced cancer, where the cancer has spread beyond the prostate and surrounding tissues, hormone therapy is the mainstay of treatment. For recurrent cancers in patients who have previously undergone surgery and/or radiation, we would move to hormone therapy or chemotherapy.

The management of advanced prostate cancer involves multiple physicians and multiple specialties. We find that this multi-disciplinary approach to treatment makes our patients’ experience more tolerable and, ultimately, leads to better outcomes.

What can I do to lower my risk for prostate cancer?

You can lower your risk for prostate cancer by doing the same things you would do to lower your heart disease mortality risk: Eat a low-fat diet; decrease your consumption of red meat; consume more fruits and vegetables and antioxidant-rich foods, including foods that contain lycopene such as tomato products and watermelon; and live a healthy lifestyle that includes being physically active and maintaining a healthy weight. If you experience any worrisome urinary symptoms, see your doctor.

About Dr. Mark Rosenblum
Dr. Rosenblum is a board-certified urologist. He is a graduate of Anahuac University Mexico City, Mexico. He performed a surgical internship and a urology residency at Washington Hospital Center, and a fellowship in urologic oncology at the University of Colorado Health Sciences Center. Dr. Rosenblum has a special interest in urologic oncology, robotic/laparoscopic surgery, minimally invasive therapies for benign prostate disease, and kidney stones.

Dr. Rosenblum has offices at 6410 Rockledge Drive, Suite 503, in Bethesda, and 20528 Boland Farm Road, Suite 202, in Germantown. The phone number is 301-530-1700.

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