Tag: PSA

Prostate Cancer: An Introduction

Prostate cancer is one of the most common cancers among men; the American Cancer Society estimates that approximately one in eight men will be diagnosed with it at some point in their lives.

Prostate cancer is the second leading cause of cancer death in men, after lung cancer. However, most men diagnosed with prostate cancer do not die from the disease.

The five-year survival rate for localized and regional prostate cancer is nearly 100%, thanks to advances in early detection and treatment. Even for men with more advanced disease, treatments such as hormone therapy, radiation, and newer systemic therapies have improved survival outcomes; still, in some cases, prostate cancer can be aggressive and life-threatening.

That said, prostate cancer remains a significant public health concern. The American Cancer Society estimates that approximately 34,000 men in the U.S. died from prostate cancer in 2024. The risk of death increases with more aggressive cancer types, higher Gleason scores, and cancer that has spread to distant organs such as the bones.

In this article we will explore key aspects of prostate cancer, including diagnostic tools such as PSA and the Gleason score, the various treatment options available, and the debate surrounding prostate cancer screening, particularly for men over 70.

Prostate-Specific Antigen (PSA) Test: A Controversial Screening Tool

One of the primary tools used to screen for prostate cancer is the prostate-specific antigen (PSA) blood test. PSA is a protein produced by both normal and cancerous prostate cells, and elevated levels of PSA in the blood can indicate the presence of prostate cancer. However, an elevated PSA level does not always mean cancer is present, as benign conditions like prostatitis (inflammation of the prostate) or benign prostatic hyperplasia (BPH, an enlarged prostate) can also cause high PSA levels.

The PSA test has been at the center of much debate over the past few decades. On the one hand, it has undoubtedly led to earlier detection of prostate cancer, sometimes before any symptoms appear. On the other hand, the PSA test is not a perfect screening tool. It can lead to overdiagnosis and overtreatment of cancers that may never have become clinically significant. Many prostate cancers grow so slowly that they would not have caused harm during a man’s natural lifespan, yet once detected, patients may undergo unnecessary treatments with side effects such as urinary incontinence and erectile dysfunction.

Because of these limitations, the decision to undergo PSA screening should be made after a thorough discussion between the patient and his healthcare provider, considering individual risk factors such as age, family history, and race. Additionally, prostate cancer tends to develop at a younger age in African American men and it is generally recommended that consideration be given to initiate screening beginning around age 45, or even earlier if there’s a strong family history.  Additionally, African American men are more likely to be diagnosed with aggressive forms of prostate cancer, leading to poorer outcomes.

In a prior post on medical guidelines, I discussed my personal experience with PSA screening and my diagnosis with prostate cancer.

The Gleason Score: A Key Factor in Diagnosis

Once a prostate cancer diagnosis is confirmed, typically via biopsy, one of the most important prognostic tools is the Gleason score. The Gleason score is a grading system that assesses the aggressiveness of prostate cancer cells under a microscope. Pathologists examine the prostate tissue samples and assign two numbers based on the appearance of the cancer cells. The appearance of cancer cells is evaluated, and each area of abnormal cells is assigned a number on a scale from 1 to 5, with 5 being the most abnormal. (In clinical practice today, grades 1 and 2 are almost never used.) The first number is the most common area, and the second number is the next most common. These two numbers are then added together to give a composite Gleason score between 6 and 10. There is one caveat; not all scores are equal. For example, while 4 + 3 and 3 + 4 both produce a score of 7, the former is more significant because its most common area is of a higher grade.

• A Gleason score of 6 typically indicates low-grade cancer that is less likely to spread and may grow slowly.
• Scores of 7 suggest an intermediate risk, with some potential for more aggressive growth.
• Scores of 8 to 10 represent high-grade cancer that is more likely to grow quickly and spread to other parts of the body.

The Gleason score plays a crucial role in determining treatment options. For instance, low-grade cancers may be candidates for active surveillance, where the patient is closely monitored without immediate treatment. In contrast, high-grade cancers may require more aggressive intervention, such as surgery or radiation therapy.  It is also important to recognize that a biopsy may miss an area of high-grade tumor giving an artificially low Gleason score, although with modern use of MRI this is less likely.

Treatment Options

Prostate cancer treatment decisions depend on several factors, including the Gleason score, PSA level, the stage of the cancer (whether it has spread beyond the prostate), the patient’s overall health, and personal preferences.

1. Active Surveillance

Active surveillance is often recommended for men with low-risk prostate cancer, especially those who are older or have other significant health problems. Instead of immediate treatment, the patient is closely monitored with periodic PSA tests, digital rectal exams (DRE), and biopsies to detect any signs of progression. The goal is to avoid over-treatment while keeping a close eye on the cancer in case it becomes more aggressive.

2. Surgery (Radical Prostatectomy)

For men with localized prostate cancer, especially those with higher Gleason scores or younger patients, surgery may be recommended. A radical prostatectomy involves removing the entire prostate gland and some surrounding tissues. While surgery offers the potential for a cure, it comes with risks of side effects such as incontinence and erectile dysfunction, depending on factors such as nerve preservation during the procedure.  The newer robotic surgical techniques have fewer side effects than the older open technique.

3. Radiation Therapy

Radiation therapy is another option for treating localized or locally advanced prostate cancer. External beam radiation or brachytherapy (internal radiation) can target the cancerous cells while sparing healthy tissue. Radiation therapy is often used as an alternative to surgery or in combination with other treatments. The side effects are similar to those of surgery, including urinary and sexual dysfunction, though the timing and severity of these side effects may differ.

4. Hormone Therapy (Androgen Deprivation Therapy, or ADT)

Prostate cancer growth is often fueled by androgens, the male hormones such as testosterone. Hormone therapy aims to lower androgen levels or block their effects on prostate cancer cells, which can slow the growth of the cancer. Hormone therapy is typically used in cases where the cancer has spread beyond the prostate or recurred after previous treatment. It may also be used in combination with radiation for high-risk cancers.

5. Chemotherapy and Other Systemic Treatments

For men with advanced prostate cancer that has spread to other parts of the body (metastatic cancer), chemotherapy may be an option. Other newer treatments, such as immunotherapy and targeted therapies, are being developed to improve outcomes for patients with advanced disease.

The Age 70 Screening Debate

One of the most debated topics in prostate cancer screening is when to stop PSA testing. Many organizations, including the U.S. Preventive Services Task Force (USPSTF), recommend that routine PSA screening should generally stop at age 70. The rationale behind this recommendation is that prostate cancer often grows very slowly, and older men are more likely to die from other causes before prostate cancer becomes life-threatening. Moreover, the risks of treatment often outweigh the benefits for older men with low-risk cancers.

However, this recommendation is not without controversy. Some experts argue that healthy older men, particularly those with a life expectancy of 10 years or more, should continue to be screened because they may still benefit from early detection and treatment. Discontinuing screening might result in missing aggressive cancers that could benefit from early intervention. Some studies suggest that older men who continue screening are less likely to be diagnosed with high-risk disease.

As with other aspects of prostate cancer care, the decision should be individualized based on the patient’s health, preferences, and overall risk profile.

Conclusion

Prostate cancer is a complex disease with a wide range of outcomes, from slow-growing tumors that may never cause harm to aggressive cancers that can be fatal. Screening and diagnostic tools such as the PSA test and Gleason score are valuable, but they must be used carefully to avoid over-diagnosis and over-treatment. Treatment options range from active surveillance to surgery and radiation, and the choice depends on the individual patient’s cancer characteristics and overall health. Finally, the decision to stop PSA screening at age 70 should be made on a case-by-case basis, with the goal of balancing the benefits of early detection against the potential harms of treatment.

Prostate cancer is a serious diagnosis, but with appropriate screening and treatment, many men can live long and healthy lives.