Screening For Prostate Cancer With The Psa Blood Test
The Prostate Specific Antigen blood test is used to diagnose prostate cancer. Prostate cancer is the most commonly diagnosed cancer in men and the second leading cause of cancer death in the United States. Every year, approximately 200,000 men are told for the first time that they harbor this disease. Approximately 30,000 men die of prostate cancer every year.
Treating Stage 0 Bladder Cancer
Stage 0 bladder cancer includes non-invasive papillary carcinoma and flat non-invasive carcinoma . In either case, the cancer is only in the inner lining layer of the bladder. It has not invaded the bladder wall.
This early stage of bladder cancer is most often treated with transurethral resection with fulguration followed by intravesical therapy within 24 hours.
Table 1 Why A Low Psa Does Not Mean You Are Cancer
The Prostate Cancer Prevention Trial included a provision that men randomized to receive placebo undergo a prostate biopsy at the end of the study, even if they had normal PSA levels and digital rectal exams. To their surprise, investigators found that many of these men had prostate cancer in some cases, high-grade prostate cancer.
PSA level 13 *Note: A PSA level over 4.0 ng/ml traditionally triggers a biopsy. Adapted with permission from I.M. Thompson, et al. Prevalence of Prostate Cancer Among Men with a Prostate-Specific Antigen Level 4.0 ng per Milliliter. New England Journal of Medicine, May 27, 2004, Table 2.
This study inadvertently provided evidence not only that prostate cancer occurs more often than once believed, but also that PSA levels may not be a reliable indicator of which cancers are most aggressive. Both findings add weight to the growing consensus that many prostate tumors currently being detected may not need to have been diagnosed or treated in the first place.
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Future Predictors Of Prostate Cancer
Researchers are seeking more accurate ways of diagnosing, monitoring, and treating prostate cancer. Many of the studies focus on genes and genetic abnormalities of a cancer. Scientists have found that the product of a certain gene appears more often in advanced prostate cancers than in early stage prostate cancers. Now the goal is to determine if the presence of this gene product means that a cancer is more aggressive. Knowing this information can help doctors decide which patients may benefit from immediate treatment, and of what type. This and other genetic research will pave the way for earlier, more accurate predictors of cancer growth.
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Low Grade And High Grade Bladder Cancer
Bladder cancer starts in the lining of the bladder in about 90 percent of people diagnosed with this cancer. Bladder cancer is called low grade or high grade.
- Low-grade bladder cancer means the cancer has not invaded the muscles around the bladder . People rarely die from this type of bladder cancer, it often recurs after treatment.
- High-grade bladder cancer also often recurs and has a higher chance of spreading to other parts of the body. Almost all deaths from bladder cancer result this type so it is treated more aggressively.
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Treating Stage Ii Bladder Cancer
These cancers have invaded the muscle layer of the bladder wall , but no farther. Transurethral resection is typically the first treatment for these cancers, but it’s done to help determine the extent of the cancer rather than to try to cure it.
When the cancer has invaded the muscle, radical cystectomy is the standard treatment. Lymph nodes near the bladder are often removed as well. If cancer is in only one part of the bladder, a partial cystectomy may be done instead. But this is possible in only a small number of patients.
Radical cystectomy may be the only treatment for people who are not well enough to get chemo. But most doctors prefer to give chemo before surgery because it’s been shown to help patients live longer than surgery alone. When chemo is given first, surgery is delayed. This is not a problem if the chemo shrinks the bladder cancer, but it might be harmful if the tumor continues to grow during chemo.
If cancer is found in nearby lymph nodes, radiation may be needed after surgery. Another option is chemo, but only if it wasn’t given before surgery.
For people who have had surgery, but the features of the tumor show it is at high risk of coming back, the immunotherapy drug, nivolumab, might be offered. When given after surgery, nivolumab is given for up to one year.
For patients who cant have surgery because of other serious health problems, TURBT, radiation, chemotherapy, or some combination of these may be options.
What Are Prostate Cancer Treatment Side Effects
Some prostate cancer treatments can affect the bladder, erectile nerves and sphincter muscle, which controls urination. Potential problems include:
- Incontinence: Some men experience urinary incontinence. You may leak urine when you cough or laugh, or you may feel an urgent need to use the bathroom even when your bladder isnt full. This problem can improve over the first six to 12 months without treatment.
- Erectile dysfunction : Surgery, radiation and other treatments can damage the erectile nerves and affect your ability to get or maintain an erection. Some men regain erectile function within a year or two . In the meantime, medications like sildenafil or tadalafil can help by increasing blood flow to the penis.
- Infertility: Treatments can affect your ability to produce or ejaculate sperm, resulting in male infertility. If you think you might want children in the future, you can preserve sperm in a sperm bank before you start treatments. After treatments, you may undergo sperm extraction. This procedure involves removing sperm directly from testicular tissue and implanting it into a womans uterus.
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Surgery For Prostate Cancer
There are many types of surgery for prostate cancer. Some are done to try to cure the cancer others are done to control the cancer or make symptoms better. Talk to the doctor about the kind of surgery planned and what you can expect.
Side effects of surgery
Any type of surgery can have risks and side effects. Be sure to ask the doctor what you can expect. If you have problems, let your doctors know so they can help you.
Prognosis And Survival For Prostate Cancer
If you have prostate cancer, you may have questions about your prognosis. A prognosis is the doctor’s best estimate of how cancer will affect someone and how it will respond to treatment. Prognosis and survival depend on many factors. Only a doctor familiar with your medical history, the type and stage and other features of the cancer, the treatments chosen and the response to treatment can put all of this information together with survival statistics to arrive at a prognosis.
A prognostic factor is an aspect of the cancer or a characteristic of the person that the doctor will consider when making a prognosis. A predictive factor influences how a cancer will respond to a certain treatment. Prognostic and predictive factors are often discussed together. They both play a part in deciding on a treatment plan and a prognosis.
The following are prognostic and predictive factors for prostate cancer.
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Treating Stage I Bladder Cancer
Stage I bladder cancers have grown into the connective tissue layer of the bladder wall , but have not reached the muscle layer.
Transurethral resection with fulguration is usually the first treatment for these cancers. But it’s done to help determine the extent of the cancer rather than to try to cure it. If no other treatment is given, many people will later get a new bladder cancer, which often will be more advanced. This is more likely to happen if the first cancer is high-grade .
Even if the cancer is found to be low grade , a second TURBT is often recommended several weeks later. If the doctor then feels that all of the cancer has been removed, intravesical BCG or intravesical chemo is usually given. If all of the cancer wasn’t removed, options are intravesical BCG or cystectomy .
If the cancer is high grade, if many tumors are present, or if the tumor is very large when it’s first found, radical cystectomy may be recommended.
For people who arent healthy enough for a cystectomy, radiation therapy might be an option, but the chances for cure are not as good.
What Questions Should I Ask My Healthcare Provider
If you have prostate cancer, you may want to ask your healthcare provider:
- Why did I get prostate cancer?
- What is my Gleason score? What is my Grade Group? What do these numbers mean for me?
- Has the cancer spread outside of the prostate gland?
- What is the best treatment for the stage of prostate cancer I have?
- If I choose active surveillance, what can I expect? What signs of cancer should I look out for?
- What are the treatment risks and side effects?
- Is my family at risk for developing prostate cancer? If so, should we get genetic tests?
- Am I at risk for other types of cancer?
- What type of follow-up care do I need after treatment?
- Should I look out for signs of complications?
A note from Cleveland Clinic
Prostate cancer is a common cancer that affects males. Most prostate cancers grow slowly and remain in the prostate gland. For a small number, the disease can be aggressive and spread quickly to other parts of the body. Men with slow-growing prostate cancers may choose active surveillance. With this approach, you can postpone, and sometimes completely forego, treatments. Your healthcare provider can discuss the best treatment option for you based on your Gleason score and Group Grade.
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Figure 1 Location Of The Prostate Gland
The prostate gland, about the size of a walnut, produces fluid that forms part of the semen that is ejaculated during sexual activity. The prostate is located adjacent to the rectum and just below the bladder, and wraps around the upper part of the urethra, which carries urine from the bladder out of the body.
This location creates challenges in both diagnosis and treatment. During a digital rectal exam, for example, a doctor is able to feel only the back portion of the prostate. If cancer has developed in the apex, base, or deep inside the prostate, it may not be palpable.
Surgeons and radiation oncologists also face challenges in eradicating a tumor without causing lasting damage to surrounding organs and structures. When removing a tumor from the breast or colon, a surgeon is able to remove enough surrounding tissue to ensure clean margins, meaning that all the cancer has been removed. But when treating prostate cancer, a comparable amount of tissue cannot be removed surgically or targeted. It takes a skilled surgeon and radiation oncologist to eradicate diseased tissue without harming portions of the rectum, bladder, and penis, thereby minimizing the likelihood of complications.
Its also important to understand the limits of current medical knowledge about prostate cancer.
How Serious Is My Cancer
If you have prostate cancer, the doctor will want to find out how far it has spread. This is called the stage of the cancer. You may have heard other people say that their cancer was stage 1 or stage 2. Your doctor will want to find out the stage of your cancer to help decide what types of treatment might be best for you.
The stage is based on the growth or spread of the cancer through the prostate, and if it has spread to other parts of your body. It also includes your blood PSA level and the grade of the cancer. The prostate cancer cells are given a grade, based on how they look under a microscope. Those that look very different from normal cells are given a higher grade and are likely to grow faster. The grade of your cancer might be given as a Gleason score or a Grade Group . Ask your doctor to explain the grade of your cancer. The grade also can helpdecide which treatments might be best for you.
Your cancer can be stage 1, 2, 3, or 4. The lower the number, the less the cancer has spread. A higher number, like stage 4, means a more serious cancer that has spread outside the prostate.
If your cancer hasn’t spread to other parts of the body, it might also be given a risk group. The risk group is based on the extent of the cancer in the prostate, your PSA level, and the results of the prostate biopsy. The risk group can help tell if other tests should be done, and what the best treatment options might be.
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How Is Tumor Grade Determined
If a tumor is suspected to be malignant, a doctor removes all or part of it during a procedure called a biopsy. A pathologist then examines the biopsied tissue to determine whether the tumor is benign or malignant. The pathologist also determines the tumor’s grade and identifies other characteristics of the tumor.
What Are The Benefits Of Psa Screening Risks
Will an early diagnosis of prostate cancer benefit every single man who undergoes the test? The answer is no. Some forms of prostate cancer are low-grade, posing little to no threat of spreading and becoming life threatening. Low-risk prostate cancer can be safely monitored without any treatment if it remains confined to the prostate. So in theory, there is no need to diagnose these particular individuals because it will only cause unnecessary anxiety and fear about a disease that is called cancer but will probably never be a risk to their lives. Patients who are diagnosed with low-risk prostate cancer may have an additional misfortune should they fall into the hands of overly aggressive doctors who administer unnecessarily aggressive treatments, as some treatments for prostate cancer can lead to life-long side effects such as impotence and urinary incontinence.
It is advantageous to know if one harbors early-stage prostate cancer, even if one discovers that it is a form of low-grade prostate cancer that can be safely watched. Armed with this information, one is then in a position to choose between simply monitoring the situation versus adopting a more aggressive approach if higher grade disease is discovered.
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Hallmark Four: Unlimited Replicative Potential
Mammalian cells seem to have an inherent autonomous function, independent of cell-to-cell signalling, that limits their replicative ability. Cancers disrupt this intrinsic pathway.
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What Remains Unanswered
The ProtecT trial has one important weakness: The participants have only been observed for ten years so far. But it would only be possible to draw any reliable conclusions about the pros and cons of the three treatment approaches after 15 or 20 years.
Surgery is the only treatment for which there is currently conclusive long-term data gathered over a period of 23 years. This data comes from a Scandinavian study that compared the surgical removal of the prostate with the watchful waiting approach. But only about one third of the men in this study had low-risk prostate cancer. So its not possible to draw any reliable conclusions about the long-term pros and cons of the current standard treatment options for low-risk prostate cancer.
The ProtecT trial also has another limitation: The check-ups that men had in the “active surveillance” group were different from the current standard approach in Germany. In the ProtecT trial, the men had a PSA test every 3 months in the first year, and then every 6 to 12 months after that. If the PSA levels were too high or if the men developed symptoms such as problems urinating, they had further tests. In Germany, men who have abnormal PSA test results are also advised to have regular biopsies . This is meant to increase the likelihood of finding out soon enough if the cancer progresses, but it can also be more distressing.
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What Is Tumor Grade
Tumor grade is the description of a tumor based on how abnormal the tumor cells and the tumor tissue look under a microscope. It is an indicator of how quickly a tumor is likely to grow and spread. If the cells of the tumor and the organization of the tumor’s tissue are close to those of normal cells and tissue, the tumor is called “well-differentiated.” These tumors tend to grow and spread at a slower rate than tumors that are “undifferentiated” or “poorly differentiated,” which have abnormal-looking cells and may lack normal tissue structures. Based on these and other differences in microscopic appearance, doctors assign a numerical “grade” to most cancers. The factors used to determine tumor grade can vary between different types of cancer.
Tumor grade is not the same as the stage of a cancer. Cancer stage refers to the size and/or extent of the original tumor and whether or not cancer cells have spread in the body. Cancer stage is based on factors such as the location of the primary tumor, tumor size, regional lymph node involvement , and the number of tumors present.
When Should You Get Immediate Treatment For Prostate Cancer
If your cancer is advanced or higher-risk, you will probably need treatment right away. Signs of higher-risk cancer include:
- PSA value that is high or rapidly rising.
- Test results show that the tumor is outside the prostate gland. Or the tumor is growing rapidly and is likely to spread outside the gland.
- Gleason score is high-risk.
Ask your team if your cancer shows any of these signs. If so, active surveillance may not be a good choice.
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