Men should have open dialogue about screening, treatment for prostate cancer
By Michaela Gibson Morris | Daily Journal
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Prostate cancer survivor Dick Guyton anticipates he’ll be taking care of business for a long time. The 75-year-old executive director of the Elvis Presley Birthplace will mark the one-year anniversary of completion of his cancer treatment next week.
“It was scary, and it scared me,” Guyton said.
But after being diagnosed in May 2013, Guyton found a way to get past his fear and find the best treatment option for him. After careful research and consultation with physicians, he chose proton therapy, a type of radiation therapy at a Knoxville, Tennessee center.
“This was my first experience with cancer,” Guyton said. “It’s important to gather all the options from multiple sources.”
After skin cancer, prostate cancer is the most common cancer among U.S. men. The American Cancer Society estimates more than 220,000 new cases of prostate cancer will be diagnosed in 2015, and it will kill nearly 28,000 U.S. men. The walnut-size gland that makes a component of semen is located just underneath the bladder. If prostate cancer is found before it spreads to distant parts of the body, the five-year survival rate is nearly 100 percent. It’s extremely rare for men under 40 to develop prostate cancer, but the risk increases substantially as men age. African-American men and men whose fathers or brothers developed prostate cancer are at increased risk.
“It’s more common after the age of 50,” said Tupelo urologist Dr. Hughes Milam. “It’s most common in men in their 60s.”
Universal prostate cancer screening recommendations – which apply to men with no symptoms of prostate problems – continue to be a topic of much debate. The American Urological Association, American Cancer Society and Mayo Clinic continue to recommend screening with prostate specific antigen test, commonly referred to as the PSA, and a physical exam. The urological association guidelines call for men to be screened between ages 55 and 70 if they have more than a 10-year life expectancy. Screening for people at higher risk should be individualized. The U.S. Centers for Disease Control currently recommends screening only for men at high risk for developing prostate cancer. U.S. Preventive Services Task Force discourages the use of PSA screening in the general population, and men and their physicians should go forward with screening only after a comprehensive discussion. The PSA blood test is very good at detecting changes in an antigen associated with prostate problems; however, it can’t distinguish between cancer and other prostate conditions.
“It’s a simple test,” Milam said. “It’s a complicated analysis when it comes with what to do with the results.”
The blood test can’t differentiate between aggressive and slow-moving malignancies; that requires a biopsy. Urologists usually look closely at how the PSA results have changed over time when considering a biopsy. If the biopsy finds cancer, it can be difficult for patients to opt for watchful waiting, even if the results indicate a slow-growing tumor.
“When I tell a patient they have cancer, it’s like telling them they are on fire,” Milam said. “They want a fire extinguisher.”
Even though the PSA has limitations, Milam feels screening is saving lives.
“In the 1980s, we didn’t have prostate cancer screening,” Milam said. “When patients did present, they usually had metastatic disease, and there wasn’t much we could do for them.”
With the advent of the PSA blood test in the 1990s, cancers were found earlier and the survival rates shot up dramatically. However, because prostate cancer often moves very slowly, concerns about overtreatment of cancers that would have remained silent have led some public health organizations to change their recommendations on universal screening.
Once prostate cancer is diagnosed, men and their physicians have a number of tools to consider. Generally, men who are diagnosed at the earliest stages have the most options.
“We try to customize the treatment plan to the patient,” Milam said.
Watchful waiting: Depending on the results of the biopsy, watching to see how the prostate cancer develops may be the recommended course of action. Some prostate cancers grow so slowly they will never cause any symptoms in a man’s lifetime. Usually, men are followed with a PSA and exam every three to four months, Milam said.
- Pros: None of the complications or side effects connected with other treatments.
- Cons: May need a repeat biopsy; long-term worry over cancer.
Surgery to remove prostate gland: Men can opt for an open procedure or a laparoscopic surgery using a surgical robot. It’s very effective at removing localized cancer. There is a shorter hospitalization and less bleeding with the minimally invasive procedure, but otherwise, the outcomes and complication rates are similar, Milam said.
- Pros: Cancer is definitively removed.
- Cons: Irritation of the nerves can cause incontinence and erectile dysfunction that may take from weeks to months to improve.
External beam radiation: This is one of the most common choices for treatment, especially for men in their 70s and 80s. A linear accelerator is used to target the tumor.
- Pros: Cure rates similar to surgical treatment.
- Cons: Radiation usually requires 30 treatments, usually done five days a week. It can irritate the bladder and the rectum, although those side effects are typically not permanent. Erectile dysfunction can develop gradually after the treatment.
Internal therapy: This allows physicians to treat prostate cancer from the inside. Brachytherapy uses radioactive seeds inserted with needles to deliver radiation inside the prostate. Cryotherapy uses a similar technique to brachytherapy but delivers very cold gases to freeze the tissue in the prostate.
- Pros: Less invasive than surgery.
- Cons: These procedures are typically reserved for men with smaller prostates. Requires spinal or general anesthesia. Can cause problems with bladder and rectum. Cryotherapy has a higher rate of erectile dysfunction than surgery.
Guyton settled on proton therapy – a form of radiation therapy – after consulting with his Tupelo urologist and a Birmingham surgeon and doing extensive research.
“I knew I didn’t want surgery,” Guyton said, because of the rates of problems with incontinence and erectile dysfunction.
Proton therapy is delivered in a similar way to external beam radiation, but the protons don’t release their energy until they reach the target, minimizing damage to healthy tissue. Proton therapy was first used to treat cancer 25 years ago, but it is still a relatively new option for prostate cancer. Currently, there are fewer than 20 centers offering proton therapy around the country. The research is still ongoing to see how proton therapy compares to traditional treatments for prostate cancer, Milam said. It remains much more expensive than other treatments and patients must travel to receive it. For Guyton, Medicare and his supplement covered the cost of the procedure. Because his brother lives in Knoxville, he didn’t have the extra living expenses others would face. The procedure was a success for Guyton. He had no side effects and his PSA levels are essentially zero.
“It’s an eerie feeling to know I had cancer and that 12 months later, I don’t have it,” Guyton said.
After his experience, Guyton is an advocate for annual screening and for wider access to proton therapy.
“I would like to see more conversations about proton therapy,” he said.
This article is from the Northeast Mississippi Daily Journal in Tupelo, MS.