Dr. Dan Sperling
There’s an ugly rumor that men avoid seeing a doctor until they have undeniable symptoms, or a loved one nags them. As a doctor who specializes in prostate cancer, however, nearly 100% of my patients are prevention-minded and well informed before I see them. Perhaps they are exceptions. When I give presentations in the community, I get questions like “If I get prostate cancer, will I die?” or “Why didn’t my doctor tell me that?”
From such comments, it seems that a lot of guys are simply not as informed as my patients. That’s why I want to bust some myths and offer news about the latest innovations in the world of prostate cancer.
Myth-busting
To start with facts, 1 out of 8 men will be diagnosed with prostate cancer in his lifetime. Prostate cancer is the most common non-skin cancer in men. In the U.S. there will be roughly 313,780 newly diagnosed cases of prostate cancer, and 35,770 men will die specifically from this disease. In fact, prostate cancer is on the rise around the world. Globally, it’s projected that there will be over 35 million new cases by 2050. This is a 76.6% increase over the 20 million cases in 2022. Experts point to factors like population growth, aging, and exposure to risk factors like tobacco, alcohol and obesity to account for it.
On the other hand, here are some common beliefs that are now cobwebby myths medicine’s attic:
- Prostate cancer is an old man’s disease – True, autopsies show that at least 80% of men in their 70s who died of other causes also had prostate cancer. However, it is estimated that 1 out of 38 younger men (ages 40-59) will be diagnosed with PCa, and 1 in 15 by age 69.
- Prostate cancer is slow growing – Not all prostate cancer cells behave the same. Younger men being found to have this disease tend to have more aggressive cell lines that progress faster. It’s important to detect prostate cancer early, especially if there’s a family history of cancer.
- Prostate cancer is a multifocal disease – Doctors were long taught this, but more recently there’s evidence that perhaps a third of patients have what is called unifocal disease, or an index tumor that needs to be treated while other stray cancer cells are likely inactive.
- Prostate cancer should be treated by surgically removing or radiating the whole gland – today there are alternatives to surgery or radiation, but patients must be thoroughly and accurately diagnosed to be sure they are good candidates.
The latest news every prostate cancer patient should know
Three areas of innovation have now revolutionized the world of prostate cancer, and every man—especially those at risk or newly diagnosed—should know about it.
The first area is thorough and accurate diagnosis of each individual’s disease. We’ve come a long way from previous standard practice of immediate needle biopsy following an abnormal PSA blood test result. While it’s true that a high or rising PSA may signal prostate cancer, it’s also true that it may not. Until fairly recently there was no way to know except by extracting prostate tissue using biopsy needles. Here are two innovations that clarify the meaning of an unusual PSA result:
- A special kind of imaging called multiparametric MRI (mpMRI). This is a high-tech way to get a 3-dimensional portrait of the prostate. MRI (magnetic resonance imaging) is harmless because it uses no radiation, yet it reveals pictorial evidence of normal prostate tissue vs. unhealthy tissue like infection or cancer. If it doesn’t show a suspicious tumor, a biopsy is not needed. The patient can be monitored by a repeat PSA test at an interval recommended by his doctor.
- Biomarker tests. There are now tests using blood or urine specimens that can be analyzed for important cancer clues such as stray cancer cells or genomic variants.
Thus, an abnormal PSA result can be followed by these tests to see if a biopsy is needed.
The second area is the type of biopsy. The conventional type, guided by ultrasound, requires a high number of needles because ultrasound can’t “see” the difference between healthy and unhealthy prostate tissue. This type of biopsy can miss cancer. On the other hand, if the mpMRI scan has picked up a suspicious tumor, the biopsy can then be done under MRI guidance so the doctor can target a minimum number of needles precisely into that area. This is the least invasive yet most accurate way to sample cells, which are then analyzed to see if they are truly cancer, and how aggressive they are.
The third area is matching the treatment to the disease. Now that we know detailed information about the location, size, and aggression level of the tumor, there is a menu of choices depending on how dangerous (or not) the tumor is. Options range from Active Surveillance to focal treatment or to whole gland (radical) surgery or radiation. And of course, a whole gland treatment is an option at any risk level depending on physician recommendation and patient preference, but this choice generally has more potential urinary, sexual or bowel side effects.
However, now that we know about unifocal prostate cancer, many patients with low- to favorable intermediate-risk prostate cancer find the idea of a minimal or noninvasive targeted focal treatment attractive because it destroys the cancer within the body while preserving healthy gland tissue and function (very low side effect risks). Methods like Focal Laser Ablation or TULSA are done as outpatient procedures under real-time MRI guidance, which also is used to monitor treatment effectiveness. Since the diagnostic innovations described above give detailed information, it is possible to qualify which patients are good candidates for this approach, and to tailor the treatment to their disease.
In summary, when prostate cancer is detected early thanks to PSA blood tests followed by mpMRI, the majority of newly diagnosed patients are found to have prostate cancer that is still contained in the gland, when there is a high probability that the best treatment match will have a successful outcome with minimal side effects. This is truly good news for the 1 out of 8 men who encounter prostate cancer in their lifetime.
