John E. Sylvester, MD, a radiation oncologist with GenesisCare, reviews the importance of treating prostate cancer at the earliest stage possible.
According to estimates by the American Cancer Society, there will be 268,490 new cases of prostate cancer in 2022, along with 34,500 deaths due to prostate cancer.1 These are staggering numbers that show how common the disease is among American men.
While these numbers are concerning, there’s a silver lining: the 15-year relative survival rate is 95%.2 This is due in large part to an uptick in early detection and new treatment options.
How Does Early Detection Work?
Every year, patients who could be diagnosed with prostate cancer aren’t. The reason for this is that they don’t visit their doctor for an evaluation and to express any issues they’re having.
Since receiving FDA approval in 1994, a prostate-specific antigen (PSA) blood test has been the number one way to detect prostate cancer.3 When detected early, physicians and patients have more treatment options. Conversely, when screening numbers wane, such as witnessed during the COVID-19 pandemic, the number of patients diagnosed with high-risk or metastatic disease increases significantly.
Holding off on a PSA test and digital rectal exam can cause a much worse prognosis down the line when prostate cancer is eventually found. Typically, delay in testing and examination occurs because these potential patients aren’t experiencing symptoms such as urinary problems, obstruction, and/or bleeding. Even so, if they wait until symptoms present, the disease is likely to be much more advanced.
As a general rule of thumb, individuals should start with an annual PSA screening at the age of 50. But if there are risk factors, such as a family history or African American heritage, regular screenings should be performed by age 40 at the latest.
Genetic Testing as an Add-On to Regular Screenings
Genetic testing is often suggested for individuals with risk factors. If it’s found that a patient has a genetic mutation linked to prostate cancer, they can step up their approach to screening to improve the likelihood of catching any disease in its early stage. An example is starting regular screenings before the age of 40.
Men with metastatic prostate cancer should also consider the benefits of genetic screening. Inherited genetic mutations can be present in men with metastatic disease, and this knowledge will impact the type of treatment the patient receives.
The Importance of a Second Opinion
A prostate cancer diagnosis can be extremely distressing for patients. With so many questions and concerns, one of the biggest challenges they face is information overload. Their friends and family will tell the patient what type of treatment to receive, even though they’re unfamiliar with the specifics of the disease and symptoms. Additionally, they will see advertisements online and locally that can be misleading.
In most cases, prostate cancer is diagnosed by a urologist. While a diagnosis allows the patient to immediately proceed with treatment, it’s common for patients to get ahead of themselves.
For a newly diagnosed patient, a second opinion is a must. The urologist may suggest that the prostate be removed as soon as possible, but that’s not always the best approach. Seeking an opinion from a radiation oncologist who specializes in prostate cancer is important.
The problem is that many patients listen explicitly to the doctor that makes their initial diagnosis. In many cases, surgery is offered as the first option and because of the patient-physician relationship and trust, the patient obliges. Down the road, the patient is likely to experience the adverse events of a surgical procedure. Furthermore, patients end up needing radiation to address any cells that were left behind.
Surgery Isn’t Always the First or Only Option
A prostate cancer diagnosis is serious, but patients shouldn’t be scared into making a rushed decision. Ideally, a radiation oncologist will be having conversations and scheduling tests first. For example, genetic testing on the biopsy specimen will help the medical team determine how aggressive the disease is and determine an even better treatment program. This is in contrast to the more widely employed process of simply viewing the specimen under a microscope, which frequently results in a judgment call by just the one physician.
This should be done before opting for surgery. Once the prostate is removed, treatment options become more limited. The latest research shows radiation typically works as well as surgery, as a randomized trial focused on early-stage disease concluded that radiotherapy is roughly equal to surgery in effectiveness.4
Thus, external beam radiation can be effective on its own. In addition,a retrospective study concluded that combining radiotherapy with brachytherapy provides a better chance of preventing local cancer from metastasizing.5
The Future is Now
The most exciting advancement happening right now with the treatment of prostate cancer is individualized therapy. As previously noted, genetic testing is at the forefront of this process.
A patient’s prostate cancer may look favorable under a microscope, but genetic testing paired with a more holistic view of a patient’s lifestyle and history may tell a different story. By taking more of the individual’s genetic and lifestyle factors into account, more aggressive treatment may be deemed necessary, which could result in a higher chance of survival with fewer adverse events.
Conversely, some patients believe they have an aggressive form of prostate cancer, but their oncologist may learn through genetic testing that this isn’t the case. This helps prevent overtreatment, such as the use of radiation along with androgen deprivation therapy.
The bottom line is for patients to get an opinion from more than just the person who diagnosed them. A radiation oncologist will look at the big picture—as opposed to focusing solely on surgery—to make an educated decision on the best path forward. The treatment of prostate cancer is rapidly changing, so an open mind will go a long way in managing this disease.
1. Key statistics for prostate cancer. American Cancer Society. Accessed December 8, 2022.https://bit.ly/3qPZt6z
2. Prostate cancer prognosis. John Hopkins Medicine. Accessed December 8, 2022.https://bit.ly/3BuK2pn
3. Prostate-specific antigen (PSA) test. National Cancer Institute. Accessed December 8, 2022. https://bit.ly/3BianI8
4. Hamdy FC, Donovan JL, Lane JA, et al. 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med. 2016;375(15):1415-1424. doi:10.1056/NEJMoa1606220
5. Amar K, Ryan C, Jay C, et al. Radical prostatectomy, external beam radiotherapy, or external beam radiotherapy with brachytherapy boost and disease progression and mortality in patients with gleason score 9-10 prostate cancer. JAMA. 2018;319(9):896-905. doi:10.1001/jama.2018.0587