Should older men (75 and up) get the PSA test for prostate cancer?

exam table (Photo credit: Lynn Kelley Author)

Over the life of this blog, I have shared my experience with prostate cancer. I was diagnosed with the disease a few years ago. The cancer was found at an earlier stage, so I elected to have radiation treatment. So far, my PSA levels have been low, and that’s a good thing. HOWEVER, I respect the fact that cancer is a tough and sneaky foe, so I will continue with my PSA tests.

There is a study that came out in the October 16th issue of the Journal of the American Medical Association that suggests that many doctors order PSA tests for men 75 and older. Current guidelines, according to HealthDay.com, advise against PSA tests for elderly men. HealthDay reporter Steven Reinberg has the lastest information.

As I have stated many times in this blog, I am not a doctor or a health care professional. I’m simply a baby boomer trying to inspire other men to see the doctor. I certainly do not have the authority to suggest whether older men need these tests.

I do feel a guy needs to meet with his doctor to discuss prostate cancer screening, and the earlier the better. While many prostate cancers are slow growing, men 75 and older have a perfect right to discuss prostate cancer screening with their physicians.  At the end of the day, a decision needs to satisfy the doctor, the patient and the patient’s family.

Prostate cancer: A variety of treatment options

Men and Health: It’s a Guy Thing had a chance to conduct an e-mail interview with Dr. Pablo Lavagnini, a board-certified radiation oncologist.

Since prostate issues start appearing in middle age, what do men (after the age of 40) need to focus on?

Prostate cancer is the most common type of cancer found in American men, after skin cancer. But luckily it is also one of the most curable types of cancer—if caught early. Men should receive regular checkups. After the age of 40, men should keep an eye out for burning urination and a decrease in flow of urine. Men should also look out for blood in their urine. This is most likely not related to the prostate, but can be linked to kidney cancer. This is very rare, but still worrisome.

Prostate cancer primarily strikes older men, but how young can a man be diagnosed with this disease?

It’s extremely rare, but men can be diagnosed with prostate cancer anywhere after their 20’s. However, as you age, the chances of being diagnosed with prostate cancer increase. Typically, after your 50’s, it’s recommended to have a periodic (2-3 years) Prostate-Specific Antigen (PSA) and a digital rectal exam as a screening method.

I have heard….you might confirm….that even a 20-something guy can have a very miniscule (tiny) amount of prostate cancer. Is this so?

Yes, this is true. But, consider this: If you take 100 men who are 75 yrs old who would die of other causes and do an autopsy on all of them, you would find that about 75% harbor an asymptomatic cancer in their prostate. However, in the general population only 8% of prostate cancers are significant enough to become clinically relevant.

The important takeaway here is that even if there are no symptoms, men after their 50’s should take precautions and be sure to see their doctors and get screening done so when and if prostate cancer is found, your doctor will advise you whether treatment is necessary and the kind of treatment that is best for you.

When diagnosed with early stage (confined to the prostate) cancer, a man may think he needs the prostate surgically removed the next week. Generally speaking, does a man have time to think about treatment options?

Absolutely! Most newly diagnosed prostate cancer patients have even two to three months to get second opinions and make a decision about treatment. It is important for any patient facing a cancer diagnosis to take the time to find a team of cancer experts who you trust. At Cancer Treatment Centers of America (CTCA) my colleagues and I place a lot of attention on education and communication. We want our patients to understand all of their options so that they can make the choice that is best for them, based on their individual case and situation.

In early stage disease, can radiation be as effective as surgery in treating, or perhaps, curing prostate cancer?

Yes, radiation can absolutely be as effective as surgery in treating prostate cancer. At CTCA, we use several different treatment options to treat prostate cancer, all of which are equally effective. They include:

Surgery – Prostatectomies

External beam radiation – Tomotherapy and Varian’s Trilogy are two advanced radiation technologies that allow highly focused, powerful radiation beams to reach the tumor, while sparing healthy surrounding tissue

Calypso® – Called “GPS for the Body,” transponders are implanted into the prostate so that movement of the tumor is monitored while delivering focused doses of external beam radiation

HDR Brachytherapy – a form of internal radiation that includes a procedure where a series of tiny catheters are placed in and around the tumor

Chemotherapy, Hormone therapy and other types of Immunotherapies and biotherapies might also be treatment options.

The main differences between choosing surgery or radiation are the side effects. Your physician should inform you of the side effects of each option in order to help you make an educated decision about which treatment option is best for you.

Explain external beam radiation vs. radiation seeds?

External Beam Radiation Therapy (EBRT) is targeted to the prostate, but delivered from outside of the body. Over the last 15 years, technologies including Tomotherapy and GPS guided radiation with Calypso have significantly improved the ability of EBRT in targeting the prostate and sparing healthy surrounding tissues like the bladder and especially the rectum.

Radiation seeds, better known as brachytherapy, is performed by placing permanent radioactive seeds like iodine 125, palladium or with a temporary high dose rate Iridium implant inside the prostate. One of the major benefits of brachytherapy is that the entire treatment only takes one and a half days, as opposed to the eight to nine weeks for ERBT. This is one reason that brachytherapy has become a more popular option over the last few years.

Can a younger man (diagnosed in his 50s) be a good candidate for radiation?

Yes. Age is generally not a factor when choosing the treatment option that is best for a patient.

When is it absolutely necessary to have the prostate removed…and quickly?

Personally, I would say it is never necessary to come to that type of decision hastily. You should always take the adequate time to get second opinions and make an educated and informed decision.

Are more men choosing radiation……or is surgery still preferred?

As of right now, men are choosing radiation and surgery equally. As mentioned before, a man has to weigh his options after learning about the side effects of each treatment option. There are many factors that come into play when faced with cancer and treatment planning, and every individual is different, as is their cancer.

What are some side effects of external beam radiation?

All treatments have potential side effects. Patients receiving external beam radiation could experience a higher risk of rectal irritation, bleeding and in some rare cases, ulceration. Fortunately, many of my patients benefit because of our integrated approach to cancer care. By working with complementary care providers, including nutritionists, naturopathic doctors, oncology rehabilitation therapists and mind/body medicine therapists, the physical pain and discomfort associated with traditional treatments, as well as the mental and emotional effects of the disease, can be minimized and made a lot more tolerable.

What are some side effects of brachytherapy (seeds)?

Patients receiving brachytherapy could experience a higher risk of acute burning of urination that can sometimes take a week to a few months to resolve. Some patients also may notice blood in their urine. These side effects are common and usually temporary.

How do you see prostate cancer treatment a decade from now? Could the PSA test be a thing of the past?

There will certainly be technological advances in both surgery and radiotherapy a decade from now, but I believe that both options will still remain an equal choice for patients. While it’s unlikely that the PSA test will be abandoned anytime soon, researchers are working hard to find better ways to screen prostate cancer, for the future.

In terms of treatment options there are also some exciting things on the horizon. For example, at CTCA we recently began offering patients intraoperative radiation therapy (IORT). We are currently the only hospital in the country to offer this technique using the Novac7 technology, which allows patients to receive a single, large dose of radiation while in the operating room undergoing surgery, thereby minimizing, and in some cases, eliminating the amount of external beam radiation therapy required. Patients experience few side effects and are able to get back to their lives faster than they previously thought possible. While we have been using IORT largely to treat breast cancer, the Novac7 technology also allows us to treat additional disease types. We hope that in the near future we will also be able to use IORT at the time of prostatectomies.

What are your closing thoughts about prostate cancer? What advice do you have for the middle-aged guy with no symptoms?

Don’t hide your head in the sand (pun intended). Visit your doctor regularly and get tested when you reach middle age. It’s better to be aware of an issue and take care of it while it’s manageable, than ignore and regret it later. There have been tremendous advancements in technology and treatment options, so find a doctor who you trust and who takes the time to explain them to you. Also, be aware of complementary therapies that can help improve quality of life and keep you feeling and acting like you!

Dr. Lavagnini serves as the Director of Radiation Oncology at Cancer Treatment Centers of America at Eastern Regional Medical Center.

Visit: www.cancercenter.com

 

 

 

Book review: “Invasion of the Prostate Snatchers: No More Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency”

By Ralph H. Blum and Mark Scholz, MD

Review by Scott Keith

As a man gets older, he has a greater chance of getting prostate cancer. It’s a scary moment. The man may wonder if his cancer is fatal. Not too many years ago, a cancer diagnosis was thought of as an automatic death sentence. Unfortunately, some cancers are diagnosed at a late stage, but evolving technology is making it easier to treat early-stage cancer.

Prostate cancer is a strange breed of disease. Long-term survival is a very good bet if the tumor is low-grade and confined to the prostate. In many cases, there is no need for a man to panic and schedule a prostatectomy the following week. You could almost say that if you had the misfortune of getting cancer, the prostate variety would be the choice. The newly-diagnosed man would be well served to read a fascinating, engaging book on prostate cancer, written by a doctor who is board certified in medical oncology and internal medicine and a patient who has spent a couple of decades living with the disease.

Ralph H. Blum and Dr. Mark Scholz have co-written “Invasion of the Prostate Snatchers: No More Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency.” Blum should know. He has avoided surgery to remove his prostate and today concentrates on carefully monitoring his disease.

The book is riveting and instructional on many levels. Blum and Scholz write alternating chapters. In chapter one, Blum introduces the reader to Prostate Country. Blum writes, What follows is a two-man show-and-tell, the result of an alliance between a prostate oncologist and his Refusenik patient. We will have accomplished what we set out to do if this book informs you, calms your fears, entertains you and leaves you with good reasons for hope. And that’s the focus of this remarkable book: To allow the newly-diagnosed prostate cancer patient to think through the disease and treatment options, minus panic and anxiety. In an interview with Men and Health: It’s a Guy Thing, Blum, a cultural anthropologist and author, who has written for a number of nationally-recognized magazines, says he went in for a regular check-up around 1990. “It was time for the infamous DRE (digital rectal exam) where he just said ‘drop ‘em and bend over,’”recalls Blum. The doctor found a palpable lump and Blum’s PSA had been a little high. After a prostate biopsy, they could not read the results. Blum turned down a repeat biopsy. In what he later called a risky move, he didn’t have another biopsy for nine years, although he continued monitoring his PSA blood level.

During this time, a friend suggested Blum touch bases with Dr. Scholz. “We started a relationship that eventually turned into a partnership. It’s an interesting kind of “no man’s land” to operate in where you are both the writing partner and the patient,” says Blum.

Chapter two delves into an area men constantly struggle with. Do I remove the prostate, even if the cancer is low-grade, or not too aggressive? Scholz, also interviewed by Men and Health, says the book has some fairly straightforward messages. One is that there are different types of prostate cancer. Scholz makes the argument that, “specialists that run this business are surgeons, so the default recommendation is an operation.” He adds that quality of life is an issue. “Even the “quote” bad types of prostate cancer generally are not fatal, so people usually live a normal life expectancy. They have to live with the consequences of the treatment that they pick. For us guys, surgery causes impotence. Even if you go to the finest surgeons, you’re going to be impotent more than half the time,” says Scholz.

Scholz stands by the statement that low-risk prostate cancer “can be watched, period.” The contention for that point of view, according to Scholz, is based on science published by urologists. “The idea of active surveillance, at the academic level, is really not controversial. But when you get out into the back alleys of prostate cancer treatment, there are a number of doctors that haven’t bought into the concept,” says Scholz.

“The book also makes the point that if you have intermediate or high-risk (disease), and you need treatment, modern state-of-the-art radiation technology is both less toxic and more effective at controlling cancer than surgery,” says Scholz. “We’re not a one-trick pony saying everyone should just watch their cancer. We know that some types do need treatment. When treatment is required, we believe there are better ways than surgery to treat it.”

The idea is for men to take personal responsibility and learn all they can about the disease and treatment options, then talk it out with medical experts. Scholz says, “In the book, we want to provide a map, or a way to empower patients…there’s a need for unbiased information that people can peruse in the privacy of their homes…and reflect on… and pray about…then take that information to different experts and be able to query them in a professional, pointed way about some of these hard questions.”

If you are diagnosed with prostate cancer, consider some wise advice from Blum: “Do as little as possible. Consider all the alternatives, which means do your homework. Take a trusted person (a cherished loved one) with you to all your doctor appointments. Let them take notes for you. Learn about collateral damage. Get second and third opinions. Remember that urologists are surgeons.” Perhaps most important, Blum says, “stay calm.”

Hardcover, 293 pages, $24.95, Other Press, Available at Amazon.com and bookstores.

Visit Dr. Scholz at www.prostateoncology.com

Prostate Cancer Research Institute is at www.pcri.org

Doctors still rely on the PSA blood test — article by Scott Keith

Did you know that Prostate Specific Antigen, better known as PSA, is an enzyme produced by the prostate? If you’re a women not familiar with prostate issues, you may be thinking, “so what.” But if you’re a man approaching middle age, you need to get familiar with PSA. Get to know it like the back of your hand. Your PSA level can help determine your chance of developing prostate cancer.

Over the last year or so, you’ve probably read a series of articles about mammograms, pap smears and PSA tests. At what age do you need to be tested? You may be totally confused, based on conflicting opinions from experts. In the absence of any stunning breakthrough in prostate cancer research, the PSA blood test and digital rectal exam remain the best screening methods to catch an early-stage tumor, which is confined to the prostate.

While a prostate biopsy is the only certain way to diagnose prostate cancer, urologists still depend on the two screening tests. Dr. Barry Buffman, a board certified urologist with Boston Medical Group Los Angeles, says the PSA test has been used for many years. Before PSA, a lot of men would present with advanced disease. “If anything, PSA allowed us, as it evolved, to pick up earlier disease, that was more treatable,”says Buffman, Even so, PSA is not always specific to prostate cancer. A bump in the PSA, adds Buffman, can also come from prostate enlargement and prostate inflammation.

Patients may wonder what is a “normal” PSA reading. “It’s not cut and dry,” according to Buffman, in an interview with Men and Health: It’s a Guy Thing. Traditionally, that number has been 4 or lower. But some urologists prefer a reading closer to 3. “Everybody looks at these numbers a little differently, due to their own professional experiences and their own biases.” Buffman says what’s important is PSA velocity, or the change in the amount of PSA over a period of time.

What happens when a man approaches middle age? Buffman says if you’re between 40 and 45, and have no family history of prostate cancer, you may only need a digital rectal exam. For men 45 and over, a PSA test would be practical to establish a baseline count. For African-Americans, and those with a family history of the disease, the first PSA test, says Buffman, should be done at a younger age, closer to 40. And any change in urinary symptoms (including stream, difficulty, bleeding and pain) should prompt a visit to the doctor. While more men are becoming aware of the prostate, a walnut-sized gland between the bladder and rectum, Buffman says, “usually it takes a prompting from the doctor to ask a battery of questions…most men, unless they’re really having a lot of symptoms, don’t bring up the subject.”

Buffman is encouraged that more people are aware of screening. ” I think the public is much more educated today than they’ve previously been, and so they’re much more aware of screening tests and the ability to be proactive and to prevent later, or aggressive disease.”

Visit Dr. Buffman at http://losangeles.bostonmedicalgroup.com

My prostate cancer: Still tracking the stats

“Active Surveillance” continues for yours truly. A week ago, I had another visit with my urologist. We are tracking my prostate cancer, discovered in September, 2008.  After a multitude of up-and-down PSA readings, and a couple of prostate biopsies, a small, organ-confined, low-grade cancer was found. I decided, along with my urologist, to undergo active surveillance. The process is simple. Every four months, I endure a PSA test and digital rectal exam. If there are no abnormalities, I go another four months.

This time, my PSA was 5.57, a slight jump from last September. My prostate felt normal, so we decided to schedule another appointment in May.  On the negative side, my doctor observed that I had gained a few “holiday pounds.”  That’s clearly not acceptable to me.  I need to lose a few more pounds and continue eating a diet rich in vegetables, fruit and whole grains. My blood pressure was a bit high….so I need to bite the bullet and get back to basics!My hope is that by keeping slim, getting upper-body workouts and eating the right foods, I will have a better chance to battle my cancer.

The question you may be asking is should I just have my prostate removed? There’s a very good argument in favor of prostate removal. At least you know the cancerous gland has been yanked out. Prostate removal can result in sexual and urinary side effects, though, and PSA tests would continue to see if there is still cancer.

My doctor wants me to have another prostate biopsy in September. I have a feeling that the next biopsy will give us a good clue whether the cancer continues to be small and low-grade or whether it’s growing and becoming more aggressive.  At that point, I should know if treatment, whether radiation or prostate removal, is in the immediate future.

As I have written elsewhere in my blog, if you are diagnosed with early prostate cancer, you will likely have a comfortable time frame in which to discuss treatment options with your urologist and family.

So the waiting game continues for this blogger. In the meantime, I will continue to work to make this a fun and educational blog for baby boomer men and the women who love them. Please suggest ideas by e-mailing me at scottguythingblog@gmail.com. I want this to be your blog.

My prostate cancer update

Just had my doctor visit. My urologist told me my PSA went up slightly…to 5.0 The prostate felt normal,  so I will extend “active surveillance” for another four months. The doctor was happy I lost 23 pounds since mid-January. Another 15 pounds and I should be good to go. I need to continue to eat my fruits and veggies and stay with my exercise program. Cancer is a tricky foe, so even though I’m pleased with today’s news, my doctor and I have to keep a very close eye on this disease.