Berkshire Senior Online

By Jesse I. Spector, M.D.

Q : There is much controversy whether people should have a PSA test or not. What is a PSA test and when do you believe it is a good idea to have the test?

A: The issue is not so much as to whether the blood test is a good test, since it has a very good track record in detecting early prostate cancer, but the issue is whether the early diagnosis of prostate cancer is associated with an improved outcome of a person's survival. Usually if one diagnoses a cancer at an earlier stage, and it is treated adequately the hope is that the survival of the person should be improved. This is where the controversy with the PSA comes in.

There is some consensus that PSA screening should be limited to patients under age 65, or to those with life expectancies exceeding ten years or more. This decision to limit PSA screening in older men is based in part on the relatively long natural history of untreated prostate cancer. The thinking is, prostate cancer is so common in elders and very often does not cause any symptoms, that to impose a specific treatment that may cause illness is not desirable in elders. Other experts believe, regardless of age, patients should be offered a choice about prostate cancer screening with an explanation emphasizing the associated risks and benefits.

Older patients have been shown to be more likely to focus on quality, rather than quantity of life, and may be less willing to trade possible increased longevity for potential treatment side effects.

Q : What are the latest treatments and tests for prostate cancer?

A: Beside the PSA, there is a rectal examination to actually feel the surface of the prostate gland to see if it is irregular. However, one can have prostate cancer without an elevation of the PSA and with a normal texture to the prostate gland. An ultrasound of the prostate is a simple way of visualizing the prostate gland and giving additional information. Additionally, there are more sophisticated tests including the MRI scan (magnetic resonance imaging).

Treatments run the gamut from observation in elders to radiation therapy - both the more traditional external radiation or radioactive particles inserted directly into the prostate gland. The third approach to treatment is surgery when the prostate gland is removed.

Many elders with prostate cancer prove to have a very low grade of prostate cancer that often does not cause death nor actually result in any symptoms, so one can make an argument for observation without any treatment. This can be difficult to accept for an otherwise healthy individual who may feel that watching without treating a cancer is unacceptable. If a patient, together with the physician, determine that treatment is best, then whether radiation therapy or surgery should be used becomes a controversial decision. The nature of the argument often depends on whether a patient is being seen by a radiation oncologist or by a surgical urologist. A natural tendency for an individual may be more with treatment they routinely give.

Nevertheless, with good patient education, most urologists who would perform surgery and most radiation therapists who would be doing the radiation therapy, will give the patient full disclosure and statistics regarding both sides of the treatment options. Today patients are often requesting consultations from both types of physicians.

There are complications that can occur with either type of treatment and the complications from radiation therapy do not necessarily overlap with the types of complications that can occur with surgery. The main issues revolve around difficulty controlling one's urine, loss of sexual potency, bleeding complications after radiation therapy, as well as some lesser complications. Interestingly, radical prostatectomy is probably better tolerated in older patients than has been previously appreciated.

Q: What is the role of the various physician specialists in the management of prostate cancer?

A: Four types of physicians are generally involved at one time or another. The primary care physician, whether a family practitioner or an internist, is very often the front line of diagnosis, since they see patients more regularly and perform rectal examinations to evaluate the physical texture of the prostate gland, and also are the physicians who are most likely to perform a screening PSA. If there is a suspicion of prostate cancer based on evaluation by the primary care physician, then the urologist is usually next. This physician most often will make the definitive diagnosis with a prostate biopsy which can be performed on an outpatient basis with minimum discomfort and with a high degree of accuracy.

If a diagnosis of prostate cancer is established, then the physicians involved would include the urologist, and/or a radiation oncologist, and/or a medical oncologist. Very often the decision about whether the patient should be seen by one, two, or three specialists depends on the amount of information that is given by the physician most closely related to the diagnosis and the comfort level of the patient with the information given. There is a natural tendency, particularly in younger patients to wish to be seen by specialists in each of the areas of cancer evaluation in order to obtain several opinions before a final decision on a treatment program. Therefore, it is uncommon for a urologist to render an opinion, and to ask that the patient be seen by a radiation oncologist and/or by a medical oncologist. The medical oncologist will have the potential for some therapeutic input on medications in the form of hormone treatments, which is frequently given prior to radiation therapy before a surgery. Often the medical oncologist can help the patient with the decision to consider radiation therapy or surgery, or an observation approach.

The management of prostate cancer has been tremendously complicated and will very likely remain so for the foreseeable future. The best course for the patient is to become as informed as possible by obtaining as reasonably many opinions from the specialties as mentioned above as that patient requires for peace of mind. In the long run, an informed patient very often is the most satisfied patient.