Impact Of Age On Treatment
The rising number of men diagnosed with prostate cancer is a result of increasing life expectancy as well as the current practice of screening by prostate-specific antigen blood tests. Besides PSA and Gleason score, age is considered a key prognostic factor in treatment decision making. Although organ-confined disease can be cured by radical prostatectomy and full-dose local radiation therapy, treatment options for advanced- stage disease remain palliative. They include active surveillance, or watchful waiting, early versus delayed hormonal therapy to control disease progression, and continuous or intermittent androgen deprivation. Observational studies of older men with early stage disease have suggested conservative management as a viable option.,
Chodak and associates evaluated 828 men who were managed expectantly in a series of nonrandomized trials. Median follow-up was approximately 6.5 years. Patients with poorly differentiated cancers had a 10-fold increased risk of death from prostate cancer as compared with men showing highly differentiated prostate cancer. A 5-year disease-specific survival of only 34% was found in men with poorly differentiated prostate cancer. In contrast a 5-year disease-specific survival of 87% was described in men with well-or moderately differentiated cancers.
Prostate Cancer Screening Ages 40 To 54
The PSA test is a blood test that measures how much of a particular protein is in your blood. Its been the standardfor prostate cancer screening for 30 years.
Your doctor will consider many factors before suggesting when to startprostate cancer screening. But hell probably start by recommending the PSAtest.
While the general guidelines recommend starting at age 55, you may need PSAscreening between the ages of 40 and 54 if you:
- Have at least one first-degree relative who has had prostate cancer
- Have at least two extended family members who have had prostate cancer
- Are African-American, an ethnicity that has a higher risk of developing more aggressive cancers
Use In Men Who Might Have Prostate Cancer
The PSA blood test is used mainly to screen for prostate cancer in men without symptoms. Its also one of the first tests done in men who have symptoms that might be caused by prostate cancer.
PSA in the blood is measured in units called nanograms per milliliter . The chance of having prostate cancer goes up as the PSA level goes up, but there is no set cutoff point that can tell for sure if a man does or doesnt have prostate cancer. Many doctors use a PSA cutoff point of 4 ng/mL or higher when deciding if a man might need further testing, while others might recommend it starting at a lower level, such as 2.5 or 3.
- Most men without prostate cancer have PSA levels under 4 ng/mL of blood. Still, a level below 4 is not a guarantee that a man doesnt have cancer.
- Men with a PSA level between 4 and 10 have about a 1 in 4 chance of having prostate cancer.
- If the PSA is more than 10, the chance of having prostate cancer is over 50%.
If your PSA level is high, you might need further tests to look for prostate cancer.
To learn more about how the PSA test is used to look for cancer, including factors that can affect PSA levels, special types of PSA tests, and what the next steps might be if you have an abnormal PSA level, see Screening Tests for Prostate Cancer.
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Patients Reports May Aid Prostate Cancer Treatment Choice
But the genetic tests are pricey, around $3,000 or $4,000, and not necessarily covered by insurance. More problematic, they do not give a yes/no answer to whether cancer cells are harmless. Instead, they indicate whether a man has a very low, low, intermediate, or high risk of harboring an aggressive, metastatic cancer.
The problem is, genetic tests dont necessarily shift the risk much, said Mayos Karnes. A man might have a 30 percent risk of an aggressive cancer, before a genetic test, and the test might shift that to 35 percent. What you want is a test that tells you the risk is more like 0 percent or 100 percent.
Even short of perfection, however, genetic tests are offering men reassurance that they can choose active surveillance rather than treatment. Duane Foulkes, 70, recently sold the manufacturing business he founded near Madison, Wis., when, in late 2015, his PSA test came back over 5. It rose to above 9 three months later, and he had a biopsy at Mayo. His Gleason score of 6 concerned me at first, Foulkes said.
But a genetic test indicated that he had at most a slow-growing, non-aggressive type of cancer, Foulkes said, giving him confidence to choose active surveillance.
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When To Get A Prostate Cancer Screening
A prostate screening can help your doctor find prostate cancer early, but youll need to decide if the benefits of the exam outweigh the risks. Have a discussion with your doctor about prostate cancer screenings.
The U.S. Preventive Services Task Force now recommends that men ages 55 to 69 decide for themselves whether to undergo a prostate-specific antigen screening test, after talking it over with their doctor.
They recommend against screening for men at or above the age of 70.
The American Cancer Society strongly recommends that no one be screened without discussion of the uncertainties, risks, and potential benefits of prostate cancer screening.
They give these specific recommendations for the date at which these discussions with a healthcare provider should take place:
- Age 50 for men who are at average risk of prostate cancer and are expected to live at least 10 more years.
- Age 45 for men at high risk of developing prostate cancer. This includes African Americans and men who have a first-degree relative diagnosed with prostate cancer at an early age .
- Age 40 for men at even higher risk .
You should also speak with your doctor about a prostate exam if youre experiencing symptoms of a prostate problem, such as frequent or painful urination or blood in your urine.
After this discussion, if you decide to get a prostate cancer screening, the ACS and the American Urologic Association recommend getting a prostate-specific antigen blood test.
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What To Expect During The Exam
You can get a prostate exam easily and quickly at your doctors office. Generally, for cancer screenings, your doctor will take a simple blood test.
Your doctor might also choose to perform a DRE. Before performing this exam, your doctor will ask you to change into a gown, removing your clothing from the waist down.
During a DRE, your doctor will ask you to bend over at the waist or lie on the exam table in a fetal position, with your knees to your chest. They will then insert a gloved, lubricated finger into your rectum.
Your doctor will feel for anything abnormal, such as bumps or hard or soft areas that might indicate a problem. Your doctor may also be able to feel if your prostate is enlarged.
A digital rectal exam can be uncomfortable, especially if you have hemorrhoids, but isnt overly painful. It will last only a couple of minutes.
A DRE is one of your doctors tools that can help them detect several prostate and rectal problems, including:
- BPH
- prostate cancer
- abnormal masses in your rectum and anus
Your doctor will be able to tell immediately if there are any areas of concern that may warrant further testing.
The results of a DRE exam are either normal or abnormal, but doctors typically rely on several different tests to help them make a prostate cancer diagnosis.
If your doctor feels something abnormal during the DRE, they will probably recommend getting a PSA blood test, if you havent done so already.
- transrectal ultrasound
Prostate Biopsy Avoidable In Some Elderly Men With High Psa
Prostate biopsies can be avoided in men older than 75 years who have PSA levels above 20 ng/mL because it is highly probable prostate cancer will be detected and conservative treatment recommended, Scottish researchers concluded.
Michael Nomikos, MD, and colleagues at the Western General Hospital in Edinburgh, U.K., studied 293 men over 75 years of age who underwent prostate biopsies. These men had a mean age of 82.6 years and a mean PSA level of 30.37.
The overall PCa incidence was 73.7%. PCa was detected in 91% of men older than 75 with a PSA level above 20, the researchers reported in Urologia Internationalis . Additionally, 92.7% of these men received hormonal deprivation therapy. The sensitivity and specificity of an abnormal digital rectal examination for detecting PCa in men with a PSA value below 20 was 69.2% and 60.3%, respectively, the study found.
In addition, among men older than 75 but younger than 80 who had PSA values between 20 and 40 and normal DRE, prostate biopsy revealed that 23% had benign disease.
The authors noted that prostate biopsies are still useful in fit men older than 75 but younger than 80 with a PSA level below 20 who can still be potential candidates for treatment with curative intent.
Men older than 75 years with a PSA level above 20 and an abnormal DRE can safely avoid biopsies as these will not influence treatment, the authors wrote. Diagnosis can be made with a reasonable accuracy by using a combination of PSA and DRE.
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After Prostatectomy: What To Expect
At the hospital : You should expect to be in the hospital for one night. At Johns Hopkins, all rooms on the urology floor are private. Here, nurses help patients get moving shortly after surgery to prevent blood clots and other postoperative risks.
First few days at home : After youre sent home, you might find that regular ibuprofen or acetaminophen will be sufficient pain management for the first few days. If over-the-counter medications arent enough, your doctor can help you with alternatives.
One week after surgery : After your surgery site heals, your catheter will be removed. This is usually seven to 10 days after surgery. This can easily be done at your doctors office. Some people decide to take out their catheter at home. If thats the case, ask your doctor for instructions first.
This is also about the time your surgeon will call you with the final pathology results. He or she will discuss what you should know and whether further treatment is necessary.
One month after surgery : Doctors recommend no strenuous activity or heavy lifting for at least one month after surgery. Most people take off work for three to four weeks. If you work from home, you could return to work sooner.
- Urinary incontinence
- Erectile dysfunction
Recovery from surgery takes time. These side effects are often temporary. However, if they are affecting your quality of life, ask your doctor about options that can help.
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Getting The Results Of The Biopsy
Your biopsy samples will be sent to a lab, where they will be looked at with a microscope to see if they contain cancer cells. Getting the results usually takes at least 1 to 3 days, but it can sometimes take longer. The results might be reported as:
- Positive for cancer: Cancer cells were seen in the biopsy samples.
- Negative for cancer: No cancer cells were seen in the biopsy samples.
- Suspicious: Something abnormal was seen, but it might not be cancer.
If the biopsy is negative
If the prostate biopsy results are negative , and the chance that you have prostate cancer isnt very high based on your PSA level and other tests, you might not need any more tests, other than repeat PSA tests sometime later.
But even if many samples are taken, biopsies can still sometimes miss a cancer if none of the biopsy needles pass through it. This is known as a false-negative result. If your doctor still strongly suspects you have prostate cancer , your doctor might suggest:
- Getting other lab tests to help get a better idea of whether or not you might have prostate cancer. Examples of such tests include the Prostate Health Index , 4Kscore test, PCA3 tests , and ConfirmMDx. These tests are discussed in Whats New in Prostate Cancer Research?
- Getting a repeat prostate biopsy. This might include getting additional samples of parts of the prostate not biopsied the first time, or using imaging tests such as MRI to look more closely for abnormal areas to target.
Prostate cancer grade
Gleason score
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Additional Tests That May Aid Prostate Cancer Diagnosis
There are few other diagnostic tools or tests, which can be performed before you have a prostate biopsy, that may help your physician gather more information about your specific case. These procedures may help determine the likelihood of the presence of cancer and its aggressiveness and increase the accuracy of a biopsy when performed. Those tests include:
4Kscore blood test is a molecular test that helps predict the likelihood and risk of a patient having aggressive prostate cancer. If youre a patient whose PSA values are borderline for a prostate biopsy or you have a condition that could be aggravated by a biopsy, your physician may use this test before to help determine whether you should get a biopsy or a repeat biopsy.
Urine sample testlooks for biomarkers that may indicate the presence of prostate cancer cells in a patients body. This test may also be helpful when trying to determine whether a patient should be rebiopsied or not.
Multiparametric MRI
The use of multiparametric MRI imaging of the prostate gland before a biopsy has been a game changer in prostate cancer diagnosis, increasing the accuracy of biopsies over standard biopsies. The mpMRI doesnt replace the standard biopsy, but by improving its accuracy, it may help decrease the number of biopsies needed.
The mpMRI has a higher resolution than a standard prostate ultrasound. This increases the ability to see suspicious lesions in the prostate, providing additional targets for the biopsy to sample.
Screening For Prostate Cancer In Men With A Family History
Burden
The introduction of PSA-based screening for prostate cancer has substantially altered the epidemiologic data for prostate cancer, greatly increasing the number of men with a diagnosis of prostate cancer and thus also the number of men with a father, brother, or son with a history of prostate cancer.
Available Evidence
It is generally accepted that men with a family history of prostate cancer are more likely to develop prostate cancer. A study of twins in Scandinavia estimated that genetic factors may account for up to 42% of prostate cancer risk.18 An analysis from the Finnish site of the ERSPC trial concluded that men with at least 1 first-degree relative with prostate cancer were 30% more likely to be diagnosed with prostate cancer than men without a family history.19 Men with 3 first-degree relatives with prostate cancer or 2 close relatives on the same side of the family with prostate cancer diagnosed before age 55 years may have an inheritable form of prostate cancer associated with genetic changes passed down from one generation to the next. This type of prostate cancer is thought to account for less than 10% of all prostate cancer cases.20
The USPSTF searched for evidence about the potential benefits and harms of PSA-based screening for prostate cancer in men with a family history of prostate cancer.
Potential Benefits
Potential Harms
Advising Men With a Family History of Prostate Cancer
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What Are Some Common Uses Of The Procedure
A prostate biopsy is currently the only way to definitively diagnose prostate cancer. It also helps differentiate cancer from benign prostatic hyperplasia or nodular enlargement of the prostate, a very common condition in middle-aged and older men that requires a different treatment approach than that of cancer.
A prostate biopsy may be ordered if the physician detects a nodule or other abnormality on the prostate during a digital rectal examination , a common prostate cancer screening test.
A biopsy also may be ordered when a blood test reveals elevated levels of prostate-specific antigen. While there are several reasons for an elevated PSA level, higher PSA levels are sometimes associated with cancer. PSA trends over time may trigger your physician to order a biopsy.
MRI-guided prostate biopsy may be used in patients who have a rising PSA level yet a negative ultrasound-guided biopsy. It also may be used in situations where a diagnostic prostate MRI performed due to rising PSA demonstrates a very small abnormality that may not be easily targeted by ultrasound. MRI is also useful in patients who have previously undergone a biopsy and want to improve the sensitivity of the procedure and the precision of the biopsy.
A biopsy not only detects cancer it also provides information on the aggressiveness of the cancer and helps to guide treatment decisions.
Patient Population Under Consideration
This recommendation applies to adult men in the general US population without symptoms or a previous diagnosis of prostate cancer. It also applies to men at increased risk of death from prostate cancer because of race/ethnicity or family history of prostate cancer. The sections below provide more information on how this recommendation applies to African American men and men with a family history of prostate cancer.
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Dealing With Bph Since 2003
Based on the experience of 2003, I will never again have a prostate biopsy. Since having my left cancerous kidney removed in April of 2015, the condition of my prostate has been monitored by more PSA tests and semi-annual prostate sonograms. My new urologist has me on the drug Avodart containing dutasteride to help shrink the prostate and another, Harnal containing tamsulosin hydrochloride, which makes it easier for me to urinate during the night.
This content is accurate and true to the best of the authorâs knowledge and does not substitute for diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed health professional. Drugs, supplements, and natural remedies may have dangerous side effects. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.
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