Delaying treatment for low-risk prostate cancer

Men monitored by their doctors had same survival rate as those who had surgery, radiation

Most men diagnosed with low-risk prostate cancer can safely delay radiation or surgery without increasing their risk of death due to the cancer, according to research presented at the European Association of Urology Congress and published last year in The New England Journal of Medicine.

The study results showed that although men on active monitoring were more likely to have their cancer advance or spread, they had the same high survival rates — 97 percent after 15 years — compared with men who had radiation or surgery.

“It’s clear that, unlike many other cancers, a diagnosis of prostate cancer should not be a cause for panic or rushed decision making,” said the lead author of the study in a press release.

“This is a landmark study that was well designed with a large number of patients and a 15-year follow up,” says Dr. Nitin Yerram,  co-director of urologic oncology and director of urologic research at Hackensack University Medical Center in New Jersey. “And it’s telling us that surveillance is a really great option for men with low-risk prostate cancer, since it resulted in the same mortality rates as surgery and radiation.”

TO TREAT OR NOT TO TREAT?
Prostate cancer is the second leading cause of cancer death in American men behind lung cancer, according to the American Cancer Society. Although prostate cancer often grows slowly and is confined to the prostate gland, some types of prostate cancer can be aggressive and spread to other areas in the body, per the Mayo Clinic.

There is evidence to support active surveillance and non-treatment of prostate cancer, and at the same time, there is evidence to suggest that some treatments for prostate cancer are important in prolonging survival, says Dr. Shawn Dason, a urologic oncologist at the Ohio State University Comprehensive Cancer Center in Columbus.

“This is really the challenge for clinicians in today’s world,” says Dason, who was not involved in the study. “After assessing the risk level, we need to make sure we’re not over-treating patients by potentially giving them treatments that could have urinary or sexual side effects. But in many cases, we will eventually need to treat with radiation and surgery.”

Low-risk prostate cancer — also called localized prostate cancer because it’s found only in the prostate — often grows very slowly or doesn’t grow at all, according to InformedHealth.org. Advancements in imaging and biopsies make surveillance even more effective.

“When somebody is diagnosed with low-risk prostate cancer and it’s decided that you don’t need to treat this right away, doctors need to very closely follow them to look for progression — that’s called active surveillance.”

“Nowadays, active surveillance for prostate cancer could include PSA (prostate-specific antigen) testing every six months, MRI testing every two years, repeat biopsies, maybe up front at a year after diagnosis, and then every three to five years,” says Dason.

WHAT DOES A HIGH PSA LEVEL MEAN?
A PSA test is one tool that doctors use to screen for prostate cancer, which is cancer of the prostate gland, the small gland located between the bladder and the penis in men. The test may be administered if you’re experiencing prostate symptoms, such as an enlarged prostate, dull pain in the lower pelvic area, frequent urination and pain or difficulty while urinating, according to the Urology Care Foundation.

Depending on your age and risk factors for prostate cancer, your doctor may also recommend a PSA test as part of routine preventative care. A PSA test is performed by taking a blood sample and measuring the level of prostate-specific antigen, which is a type of protein that’s produced by normal and cancerous cells of the prostate gland. Higher levels can be a sign of prostate cancer, according to the National Cancer Institute. But the test isn’t perfect — sometimes PSA levels are elevated when no cancer is actually present.

WHAT CAN. AFFECT PSA LEVEL
In some cases, PSA levels could be above normal for reasons other than cancer.

Even without any prostate problems, your PSA level can go up gradually as you age. For men in their 40s and 50s, a PSA score greater than 2.5 is considered abnormal. In men in their 60s, PSA above 4 is considered abnormal.

One culprit for higher PSA levels can be a type of inflammation in the gland called prostatitis, a common problem in men under 50. While it can be treated with antibiotics, the more common type, called nonbacterial prostatitis, can be harder to treat because the exact cause is often unknown — it could be due to a number of factors, including inflammation, nerve damage, pelvic muscle infection or viruses.

Another cause of elevated PSA levels is benign prostatic hyperplasia (BPH), an enlargement of the prostate gland, but it’s not prostate cancer. BPH means more cells, so that means more cells making PSA. It’s possible for a man over 50 to have an elevated PSA due to an enlarged prostate. Your doctor may be able to tell whether BPH is triggering a high PSA result.

A urinary tract infection (UTI) can cause higher than normal PSA levels. The reason that the levels rise is not clear, but infections may cause the membranes that separate the prostate from the blood supply to be more permeable. If you’ve been diagnosed with a urinary tract infection, be sure to wait until after the infection has cleared up before you get a PSA test, advises the Prostate Cancer Association.

Ejaculation can also cause a mild elevation of your PSA level, and so can having a digital rectal exam. These types of PSA elevations are usually not enough to make a significant difference unless your PSA is borderline. PSA should return to normal in two to three days.

For some men, the benefits of getting screened for prostate cancer outweigh the risks, but that’s not always the case, according to the American Cancer Society. The organization suggests having a conversation about the uncertainties, risks and potential benefits with your doctor before making a decision on whether to have your PSA levels tested.