Prostate Cancer—Hidden but treatable
A recent episode of the TV show House opened with the confrontational doctor threatening a talkative patient with an unnecessary prostate exam. The patient quieted down. Good for Dr. House, bad for the prostate cancer advocates who have been trying to break the stigma surrounding routine screenings.
Prostate cancer screenings have become something of a controversy in recent years, mostly due to the nature of prostate cancer itself. After skin cancer, prostate cancer is the most common cancer in American men. Depending on the research, it’s either the second or third leading cause of cancer deaths. It would seem that such a common disease should be tested for regularly and treated aggressively, but prostate cancer is somewhat of a sleeper cancer. It lurks, with little to no symptoms, for years. Many clinicians argue that the treatment for the cancer is worse than the cancer itself. They believe that men may be better off not treating, and sometimes not even knowing about, the cancer at all.
But for Don Garlin of Hummelstown, early detection through a simple blood test gave him nine years to research his options and make well-informed decisions about treatment. Although he had no symptoms and no known family history of prostate cancer, Garlin was given a prostate-specific antigen (PSA) test as part of his retirement physicals from active duty with the military.
“I was already 52 at that time and never had it checked,” Garlin says. “When they told me I had an elevated PSA, I didn’t even know what they were talking about.” Garlin’s PSA levels were detected through a routine blood test that monitors the amount of a protein released by the prostate. Considered one of the first warning signs of prostate cancer, elevated PSA levels can also indicate a prostate infection, a benign growth, or a reaction to certain medications, such as finasteride (Proscar). Garlin was sent to Walter Reed Army Medical Center in Washington, D.C., for a follow-up exam and biopsy of the prostate.
The biopsy results, however, were negative. This is a common issue when searching for the cause of elevated PSA, as there other causes of an elevated PSA besides prostate cancer, or cancer may be present without the entire gland being affected by it. It’s the proverbial needle-in-a-haystack situation as a small focus of cancer may be present.
Once cancer is detected one option is active surveillance. “The good news is that this is usually a slow growing disease,” says Carl T. Reese, M.D., assistant professor of surgery, Division of Urology, Penn State Hershey Medical Center. “A patient has time to decide on what treatment is right for him and can wait to have treatments.”
Screening before symptoms start
Avoiding late-stage symptoms is the reasoning behind regular prostate cancer testing. Penn State Hershey Cancer Institute follows the American Urological Association’s (AUA) guidelines regarding prostate cancer screening, which suggests that men age 40 and older have a baseline PSA test and digital rectal exam (DRE) with annual checks after age 50. African American men, who are in a higher risk group, and men with a family history of prostate cancer should begin annual testing at age 40.
But men often shy away from prostate screening. Since few people object to a simple blood test, it’s obvious that the DRE is the part of the preventative screening that give men pause. But here’s the good news—it’s done quickly and, although it’s uncomfortable, it shouldn’t really hurt. When done annually, it’s only a few minutes of discomfort and possible embarrassment compared to living with a cancer that could be spreading.
But the AUA and the American Cancer Society both caution men and their doctors to consider the benefits and drawbacks to early detection and treatment. Many men may develop prostate cancer as they age. This many times is a small focus of low grade disease. Due to the slow growth of the cancer, the disease may never progress to the point where treatment is needed. In these cases, the treatment options can be more harmful than the cancer itself and can cause lasting effects on the body.
Patients may be best served by viewing the first few years of PSA checks as a simple baseline. Watching the numbers steadily rise over a few years will give doctors a better idea of when treatment is needed. These are years when most men will live symptom-free and when there is little risk of the cancer spreading.
“Initially in men who have an elevated PSA, we follow up with another test in a few months,” says Reese. “If needed, we’ll start talking about a biopsy and if that’s positive, we can start treatment.” For many patients, like Garlin, watching those rising PSA levels gives them time to explore their options and make decisions about treatment well before that treatment is even needed.
While exploring those options, Garlin’s daughter, then a recovery room nurse at Penn State Milton S. Hershey Medical Center, recommended Reese. It turned out to be a familiar name as the two men served in the army together while stationed at Fort Indiantown Gap. Garlin was relieved to have his daughter’s recommendation and a familiar face to help him.
“I never really thought of getting a second opinion,” Garlin recalls. “I felt very confident with Hershey and Dr. Reese.”
When treatment is needed
Some cancers are fast moving, with little time available for making treatment decisions. Others have a known and predictable course. Prostate cancer, by cancer-standards, is a kinder disease in that it’s both slow growing and relatively predictable. In 2006, Garlin’s PSAs began increasing and he started to notice symptoms of prostate cancer. “Some of the symptoms include bone pain, weight loss, and voiding problems from an obstructed urethra,” Reese says. “It’s rare to have a patient present with some of the later stage symptoms of back pain and bone pain in the era of wide-spread prostate cancer screening.”
Active surveillance is one option with delayed treatment in some men diagnosed with prostate cancer. In men who have a PSA that is continuing to rise after a negative biopsy , a patient has several options to consider. For Garlin, it meant another biopsy, his fourth, but this time doctors took thirty tissue samples from the prostate. “Another doctor told me after the third biopsy that ‘benign just means we didn’t find it,'” Garlin recalls. “There’s no way to know for sure if the cancer is there or not unless they find it in the biopsy.”
The results of this biopsy were more clear-cut—a small concentration of cancer was found on Garlin’s prostate. Garlin and his wife Beverly sat down with Reese to discuss their options of radiation treatment, surgery, or continuing to monitor the cancer closely. “Dr. Reese said to think about these options, but we had already come to the conclusion to have it removed. In my mind, I’d been prepared after nine years to expect that one of these days; it’s going to show, so we knew what we wanted to do.”
Garlin was diagnosed with prostate cancer on April 19, 2008, and had a prostatectomy on May 29. He went home the next day. “We have really refined the surgical techniques in recent years,” Reese says. “Fifteen years ago, patients stayed in the hospital for 3-4 days and up to a week before that. There is much less blood loss now so patients go home earlier.” Garlin’s surgery included removal of some surrounding lymph nodes to ensure that the cancer hadn’t spread beyond the prostate. “The margins were all negative, which means he had clear healthy tissue around the prostate, so we know there wasn’t any cancer left behind,” Reese says.
“If untreated, prostate cancer can spread to the lymph nodes and the bones,” Reese says. “Not all will do that but the problem is that we don’t know which ones will.”
Garlin has been cancer free since the surgery and has his PSA levels checked every six months. He has had no lasting effects from the surgery, is symptom-free, and has become an advocate for prostate cancer screenings. “I tell other men ‘Don’t forget to get your PSA checked. If it’s elevated, you need to get it biopsied.'”
“It’s a decision that we never regretted and we were glad to take care of,” Garlin says.
By Holly Swanson