Genitourinary Cancer – 6
(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Thank you Chiragbhai for some very interesting and eye opening points about prostate cancer: 1. It is related to mainly lifestyle changes, obesity, high fat diet especially animal fat. Also a sizeable number have family history, and sometimes an identifiable gene defect such as BRCA. 2. PSA TEST SHOULD NOT BE DONE FOR MASS SCREENING, without discussion with individual. This is because it has very high incidence of false positives, leading to several unnecessary biopsies, related complications in some, and anxiety. 3. PSA SCREENING also identifies many early stage tumors in elderly who actually do not need treatment. However post screening most patients will get treatment, resulting in unnecessary treatments and related complications. 4. USA GUIDELINES and others have advised reduction in PSA screening. This led to reduced incidence of prostate cancer in USA. Now can you tell us more about prostate cancer diagnosis.
Answer: Diagnosis of prostate cancer requires clinical examination, a sonography, PSA and confirmation by a biopsy. Technique of prostate biopsy is different compared to most cancer biopsies. In other biopsies, directly obtaining one or two biopsies or FNAC from an obvious cancerous area is sufficient. In prostate cancer, multiple biopsies are required from several areas of prostate, even if they are looking normal. A composite grade is derived from analysis of multiple areas. This grade, known as Gleason score, is an integral part of treatment planning. Hence just presence of cancer is not sufficient. For example, treatment of low and high Gleason score patients is different even if rest of the stage, PSA are same.
For most patients with low PSA, additional evaluation like bone scan, CT scan etc are not required. For patients with locally advance disease or suspicion of outside spread, a bone scan, CT scan, or PET-CT scan may be required. A new test, now available in Ahmedabad, PSMA PET scan is even more sensitive. MRI of specific bone sites can be sometimes used to differentiate suspicious bone metastases. PSA level alone is not enough to decide stage. However, below PSA level of 20, metastatic disease is very uncommon.
Que: Any special tests, new molecular markers, prognostic test etc are recommended as in so many other cancers nowadays?
Ans: Good question. As of now, no such additional tests are done. Prognosis depends on stage, Gleason score, PSA level. However patients with a family history of cancers or cancer at young age, should be considered for a genetic counseling. Formally trained counselors are now available in Gujarat. They can guide appropriate testing based on possible genetic syndrome or mutation.
For patients with very early stage prostate cancer, mainly those detected by routine screening, a number of genetic tests are being actively studied or already studied. Some of these may be approved soon. Purpose of these tests is to guide patients about treatment decision i.e. decision between whether to treat or just monitor. Later strategy is often referred to as “active surveillance” in medical literature. It involves annual tests to determine if there is any progression of disease enough to require treatment. This is important as majority of very early stage tumors with low Gleason score and low PSA do not progress enough to warrant treatment even after 10-20 years. Thus for many people diagnosed at age 60-70 years, treatment may never be required, especially if they have other major comorbidities.
Que: Another interesting fact about prostate cancer. This cancer seems so different. On one hand, you screen people with an easily available blood test to make early diagnosis so as to treat them. Then you say that most of these don’t need any treatment, so we need to figure out more tests to decide which patients need treatment.
Ans: Agree. It is unfortunately confusing but this is the fact. Premature acceptance of a screening test on a wide scale has led to this confusion. And we need to learn from this in India before we start ordering this test similarly. For a man with such diagnosis of very early cancer, choices are very confusing too. “Active surveillance” is mentally difficult for most people to live with, even in USA with so much higher education level. It leads to a lot of anxiety, involves a biopsy every year which also is not an easy thing to go through. Hence most people will choose some form of treatment to end this anxiety and move on. But treatment options, either surgery or radiotherapy, both have potential serious side effects, both in short term and/or long term. And both involve significant cost too.
March 14th 2018.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org