The U.S. Preventive Services Task Force, an independent advisory panel, recently recommended that healthy men not be given PSA blood tests to detect prostate cancer. But that won't mean the end of diagnosis and treatment of the disease, the most common cancer and the second most common cause of cancer death in American men.
Dr. E. James Wright, associate professor and director of the Division of Reconstructive and Neurological Urology and chief of urology at Johns Hopkins Bayview Medical Center, answers questions about diagnosis and the latest treatments, including measures to mitigate side effects such as incontinence and impotence.
Why did the U.S. Preventive Services Task Force recommend that healthy men not be routinely screened for prostate cancer?
The task force has recommended this based on its evaluation of evidence of both the benefits and harms of screening. It should be noted, however, that the panel that made the assessment had no experts in the field and no urologists were invited to participate. We believe that early diagnosis is crucial, as it has dramatically reduced death and suffering in men with prostate cancer.
If these recommendations are adopted, who will still need to be screened?
The answer to this question continues to evolve. Several current guidelines suggest that men with a 10-year life expectancy should have an informed discussion of the benefits and risks of prostate-specific antigen, or PSA, screening. If men do decide to be screened earlier, age 40 is the time to assess individual risk. If the risk is high — i.e., if there's family history or the person is of African-American race — annual screening is recommended. If the risk is average, the next screening is recommended at age 45, and then, if it has remained average, annual screening should begin at age 50. PSA testing should certainly continue to be used for monitoring patients with prostate cancer after treatment, when it's necessary to monitor disease progression.
Do all men who are diagnosed need treatment?
No. The challenge, however, is determining with certainty which men can safely forgo therapy. Because prostate cancer can be a fatal disease and there is no reliable cure when the cancer has spread outside of the prostate, we favor intervention rather than observation in most cases. Because men with certain forms of prostate cancer can do well without treatment, a new therapy strategy called "active surveillance" is emerging. This involves vigilant follow-up and periodic testing to watch for any changes in the prostate cancer that might signal increased risk for harm. If this occurs, patients have an opportunity to pursue further treatment without compromising a potential cure. The criteria for this treatment are very specific and the best process for monitoring the disease continues to be evaluated.
What are the medical and surgical treatments?
Treatment is based on the stage of the disease. When diagnosed early, before the cancer spreads beyond the prostate, the options include active surveillance, surgical removal of the entire prostate and radiation therapy. Currently, surgical removal of the prostate is done either by using an open procedure or a robotic-assisted laparoscopic procedure.
Medical therapy is typically used for more advanced cases of prostate cancer. Drugs that can turn off the production of testosterone (antiandrogens) can be used to slow the progression of disease, lessen symptoms and keep the cancer somewhat dormant. There are also a number of other chemotherapy agents under investigation.
Why does treatment often mean side effects, including erectile dysfunction and incontinence?
The side effects of treatment for prostate cancer are related to the position of the prostate, which lies deep in the pelvis between two sphincter muscles that control urinary continence. In addition, the nerves necessary for normal erectile function run along either side of the prostate. These structures lie directly in the field of radiation therapy and surgical removal. In essence, all therapies for prostate cancer carry a risk of compromise to urinary control and erectile function.
Are there methods to avoid or minimize those side effects?
It's important to remember that the most critical goal of therapy for prostate cancer is to remove or treat all of the malignant cells. Only prostate cancer confined to the prostate can be reliably cured. The side effects of erectile dysfunction and loss of urinary control can be corrected. Restoration of normal function is possible. To minimize the risk of incontinence and erectile dysfunction, surgical techniques have been developed at Johns Hopkins to identify the erectile nerves and carefully preserve them. The likelihood of success is related to preexisting function and a patient's age, with younger age being an advantage. The majority of patients treated at Johns Hopkins recover continence and their baseline erectile function.
Note: To hear more information on care options and side effects from prostate cancer treatment from Dr. Wright, there will be a free 90-minute "Men's Health Seminar" at 6:30 p.m. Oct. 26 at the Sheraton Towson North, 903 Dulaney Valley Road in Towson. Call 877-546-1009 or go to http://www.hopkinsmedicine.org/healthseminars
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Dr. E. James Wright, is director of neurourology and chief of urology at Johns Hopkins Bayview Medical Center. (Kim Hairston, Baltimore Sun)