13 Sep 2018
Prostate Cancer 101: Not For Men Only
If you are a man – or are related to one – there is a one-in-nine chance that you will have to deal with prostate cancer during your lifetime because it is the second most common cancer for men and the second most common cause of death among American male cancer patients after skin cancers. That makes prostate cancer sound like a really big problem, but only one out of 38 – or 2.6 percent – will actually die from the disease.
There were 26,730 prostate cancer deaths in 2016 and that number is was expected to increase in 2017 or 2018, but it still concerns the medical profession because prostate cancer, in and of itself, is easily detected and very treatable, which makes even these small numbers an indictment of our medical system. Competing prostate cancer organizations have issued different protocols for how to test for prostate cancer and how to treat it, creating considerable confusion among men in general and prostate cancer patients in particular.
First Things First: What’s a Prostate
The prostate is a walnut-sized gland located between the bladder and the penis. The prostate is just in front of the rectum. It wraps around the urethra, which connects the bladder, where urine is stored, to the penis, letting urine flow out of the body. The prostate gland secretes a fluid that nourishes and protects sperm. During ejaculation, the prostate squeezes this fluid into the urethra, and it’s expelled with sperm as semen.
Early Signs of Prostate Cancer
The first and most common indicator of prostate cancer is when men start having difficulty urinating, being unable to empty their bladders fully and having to urinate more frequently. At the far end of the symptom spectrum, we find urinary tract infections, inability to urinate, or blood in the urine, any one of which is enough to send a guy running to the doctor.
Once he gets there, our man is going to learn that these symptoms can be due to an enlarged prostate which seems to occur universally to all men as they get older, but they can also be due to a list of other ailments, including urinary tract infections, inflammation of the prostate, narrowing of the urethra, bladder or kidney stones, or scar tissue from previous bladder surgery.
If the symptoms are due to an enlarged prostate, the prostate enlargement can be due to benign prostatic hyperplasia (BPH), but it can also be due to prostate cancer.
PSA Tests and Digital Rectal Examinations
The first tests you will face in the process of figuring out whether you have prostate cancer is the uncomfortable, embarrassing and absolutely essential digital rectal exam and the more controversial PSA test.
The digital rectal examination is when the doctor gloves up, and sticks his finger up the patient’s ass and palpates the prostate through the rectal wall. If this sounds rather hit or miss, it is, and different doctors will interpret their findings differently. It is important, therefore, to have a continuing relationship with the same urologist because that’s the only way a urologist can detect small changes in your prostate—but a digital exam can only cover the part of the prostate that is accessible through the rectal wall. (Some doctors have longer fingers than others. If your urologist has short fingers, find another urologist and suggest that the short fingered urologist consider a different line of work.)
The second step in the diagnostic process is to begin Prostate-Specific Antigen (PSA) scores. This is a very simple blood test that comes with a strange caveat emptor warning right there on the report from the American Urological Association which states that “Values obtained with different assay methods or kits cannot be used interchangeably. Results cannot be interpreted as absolute evidence of the presence or absence of malignant disease.”
Once upon a time, according to the National Cancer Institute. most doctors considered PSA levels of 4.0 ng/mL and lower as normal. Therefore, if a man had a PSA level above 4.0 ng/mL, doctors would often recommend a prostate biopsy to determine whether prostate cancer was present. More recently, however, it has been found that many men with lower PSA readings have turned out to have prostate cancer, while some men with higher PSA readings have turned out not to have prostate cancer.
To further complicate the matter, it turns out BPH (that’s the benign prostatic hyperplasia or prostate enlargement) can actually cause your PSA scores to go up. Drugs such as Finasteride, which are prescribed to reduce the prostate gland enlargement, can result in artificially lowered PSA scores.
To make matters even worse, you can have BOTH BPH and prostate cancer, but the presence of the benign prostatic hyperplasia could mask the symptoms of the coexisting prostate cancer.
One last fact about PSA testing: According to the National Cancer Institute, only 25 percent of the men who undergo needle biopsies because of high PSA numbers are found to have prostate cancer. This may reflect poorly on the efficacy of the PSA test, or the needle biopsy procedure, or both.
More Aggressive Testing
If it turns out that you have a higher PSA level, and your doctor detects some bumps on your prostate gland through a digital rectal examination, the next step in the testing is a needle biopsy of your prostate. In this process, hollow needles are inserted into your prostate through the rectal wall, and samples are withdrawn for examination.
This sounds worse than a digital rectal examination because it is. It is also hit or miss. Your doctor may use an ultrasound device to help find the suspicious parts of your prostate, but he or she probably won’t tell that by breaking the envelope of the prostate gland, he might be creating an escape route through which cancer cells can infect other parts of the body. The typical needle biopsy only screens one percent of the total mass of the prostate gland. Some patients go through multiple needle biopsies without ever finding the cancer that was present all the time.
The needle biopsy could find nothing at all but your prostate could still be cancerous and the needle biopsy itself can cause complications, as it does for around five percent of the patients who undergo the procedure. According to MDxHealth, a company that offers a noninvasive test for prostate cancer, more than 30 percent of the men who have received a cancer-free finding turn out to have prostate cancer anyway.
Excessive Testing and Excessive Treatment
Excessive testing is defined as testing that reveals the presence of tumors that might never affect the patient’s overall health. Prostate cancer is a very slow growing cancer. The current protocol for PSA testing covers men from 55 to 69 years of age because, after you turn 70, it is more likely that you will die from something other than your prostate cancer, unless the prostate cancer metastasizes, in which case you have other concerns to worry about.
To further complicate the diagnostic landscape, there was a major shift in the PSA testing procedures in 2017, when many labs switched from the Siemens Centar Chemiluminescent Assay test to the Roche Cobas Electrochemiluminescent Immunoassay test. The key difference between these tests is that the Roche test has a 20 percent positive bias when compared to the Siemens test. In other words, the Roche test is either 20 percent more sensitive or 20 percent too sensitive, depending on your point of view.
Men who are undergoing regular PSA testing need to be very careful to make sure that they are getting the results from the same test because, if the lab your doctor is using switches from one test to the other, you may find yourself heading toward an unnecessary biopsy and possible unnecessary prostate cancer surgery.
This doesn’t mean that the PSA test is worthless, but it does mean that we don’t really know what it means from one case to the next.
When Treatment Becomes The Problem
As previously mentioned, with prostate cancer, the treatment is sometimes worse than the disease. That’s why the protocols now in use suggest that doctors stop testing patients after they reach 70 years of age because, at that age, it is more likely that the patient will die from something else, even if they have prostate cancer.
Unfortunately, the treatment for prostate cancer is far from benign itself. The treatments range from broadcast radiation to the implantation of timed release radioactive seeds directly into the prostate, to prostate reduction surgery or outright prostate removal. The side effects from these procedures range from what you might expect from radiation exposure, beginning with Leukemia, through permanent incontinence and impotence, which are pretty high prices for procedures that don’t even assure you of a significant extension of your lifespan.
The United States Preventive Services Task Force has analyzed the data from all reported prostate cancer screening trials, principally from the American-based Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial and the European Randomized Study of Screening for Prostate Cancer study. The Task Force concluded that for 1,000 men in the study, one death from prostate cancer would be prevented, while 120 men would have a false-positive test result that led to a biopsy, some of whom would experience at least moderately bothersome symptoms from the biopsy. One hundred men would be diagnosed with prostate cancer. Of those, 80 would be treated with surgery or radiation, but at least 60 of these men would have a serious complication from treatment, such as erectile dysfunction and/or urinary incontinence.
So, Should You or Shouldn’t You Get Tested
That’s a loaded question if there ever was one. No single article by a single author should ever be the deciding factor in your decision to get tested. Read everything you can and compare the recommendations. Talk to people who have been through it and see what they think.
When I was younger, I didn’t give it a second thought. A PSA test and a digital rectal examination seemed to be a small price to pay for putting fears of prostate cancer to rest. As I got older, I found myself being pushed to have needle biopsies as a a matter of course (meaning, “Of course, you will do the needle biopsy”) but the testimony of friends who had been through the process convinced me that the risks weren’t worth the return, while the reasons for getting tested start to become less convincing.
At 69, I am still being given the PSA tests, and I am still letting my doctor stick his finger up my ass, but I am not willing to have the needle biopsy, which makes the PSA test and the rectal exam pointless for me.