Prostate cancer often presents unique challenges to patients and physicians alike. It can be indolent and non-aggressive, or life-threatening, and everything in between. With the multiple treatments (surgery, radiation, hormonal ablation, HIFU, cryoablation) that are available, patients, family members, physicians and even the non-expert urologist are often confused and frustrated. Unlike most cancers that have a dedicated road map for treatment (think kidney cancer where the mainstay is surgery or rectal cancer where chemo/radiation and surgery is standard), treatment for prostate cancer revolves around opinions and biases. To complicate further, the treatments impact some of the most basic and sensitive aspects of a man’s life – urination and sexual function.
To help patients navigate the land-mine of prostate cancer, I’ve compiled a list of 10 basic questions to ask when diagnosed with prostate cancer. Here they are
1. WHAT IS MY GLEASON SCORE?
Pathologist have used the Gleason grade and sum since the 1960s to help understand the potential aggressiveness of prostate cancer. Cancer by definition is disorderly growth of cells and tissue. The Gleason grade looks to define how close the cancer cells and tissue resemble their native forms – the more it resembles normal prostate growth, the lower the grade and risk; the more different it looks, the higher the grade and risk. The cancer is assigned a grade of 1-5, 1- lowest risk and 5 the highest. Since the cancer can have multiple tumorous areas which can be different from each other, the two most common patterns are graded on this scale to give a Gleason score (sum of the two most common patterns). Aggressiveness of the cancer is defined by this Gleason score:
Gleason 6 (3+3) = low risk
Gleason 7 (3+4 or 4+3) = intermediate risk, some cancers can act indolent, others aggressive
Gleason 8-10 = High risk cancer, aggressive, higher risk of spreading
2. IS THERE A NODULE EXPRESSING MY CANCER?
A palpable, cancerous nodule is more aggressive than cancer found with no nodule. This is usually determined on digital rectal exam making this a vital part of the screening and evaluation process. I have had many cases in my career where the PSA values were less than 4, but patient’s had a palpable nodule with more aggressive than expected cancer.
3. WHAT IS MY PSA DENSITY?
PSA density is the ratio of the PSA/to the total volume of the prostate. For instance if a patient has a PSA of 4 and a prostate volume of 40 cm3, the PSA density would be 0.10. There is a direct correlation between PSA density and aggressiveness of cancer. A small prostate with a high PSA is more worrisome for aggressive cancer, and a very large prostate with an average PSA (or higher than average PSA) is less worrisome. PSA density <0.15 is considered reassuring for potentially observing the cancer
4. HOW MANY BIOPSY CORES HAVE CANCER?
It’s important to know the total percentage of biopsy core
s’s that were positive for cancer. Most urologist take 12 cores as standard, and so knowing how many of the 12 are positive is an important surrogate the amount of cancer a patient may have. Having less than 1/3 of the cores taken positive is reassuring.
5. WHAT IS THE TOTAL AMOUNT OF CANCER IN EACH CORE?
Each core biopsy that is taken usually is 12-15 mm in total length. Measuring the total volume of cancer in each positive core also serves as a surrogate for tumor volume. For instance if there is a 6 mm of cancer noted in a core that is 12 mm long, 50% of the core is positive for cancer. In general cores that are 50% or more positive would indicate significant cancer
6. IS THERE PERINEURAL INVASION?
When the cancer cells within the prostate begin to grow around the nerves that are in the prostate, this is called “perineural invasion”. Stage for stage, cancer’s with perineural invasion have worse prognosis as it is more likely that the cancer can spread outside of the prostate with this feature. Any cancer which has confirmed perineural invasion will require treatment as opposed to observation.
7. SHOULD THERE BE ANY IMAGING DONE?
Any cancer with high risk features should have systemic imaging such as CT Scan of the abdomen and pelvis (spread into the lymph nodes and liver) and a Bone Scan (to evaluate possible advancement into the bones) performed. Any Gleason score above 8 or PSA above 20 is considered high risk and these tests would be warranted. Conversely, PSA testing below 10 and Gleason score’s less than 6 would not require systemic imaging.
MRI of the prostate is being utilized for all grades and risks of cancer. For the initial diagnosis of cancer, this maybe useful to ascertain extraprostatic spread (meaning the cancer has broken through the capsule, which is the outer lining, of the prostate). A minority of skilled and expert urologists (and I would myself in this category) can ascertain spread of the cancer beyond the prostate from the ultrasound performed at the time of biopsy
8.WHAT ARE MY OPTIONS IF CANCER HAS SPREAD OUTSIDE OF THE PROSTATE CAPSULE?
Cancers growing beyond the confines of the capsule of the prostate are aggressive, considered locally advanced, and should not be observed. In fact one should prepare for a multimodality approach to treatment. If surgical removal is chosen (typically preferred for the younger, healthier patient), one should prepare for possible postoperative radiation (with possible hormonal suppression as well).
If radiation is chosen, adding androgen (testosterone) suppression is necessary, usually for 1-2 years in addition to radiation.
9. SHOULD I OBSERVE MY CANCER?
Active surveillance or observation is an integral part of counseling patients newly diagnosed with prostate cancer. Fully 30% of cancers diagnosed in the U.S. are observe over the last 10 years. Many of the above criteria are utilized to determine which patients are best suited.
Gleason score 6
PSA density <0.15
<15% of cores positive for cancer (less than 3 out of 12 cores)
<20% of any one core positive
10. WHAT ARE THE SIDE EFFECTS OF TREATMENT?
It’s important to know all the potential complications of treatment. Not fully understanding them can be a source of subsequent regret and anger (hint: if your doctor underestimates or glosses over the side effects, that should be a red flag).
The prostate is located in a very delicate neighborhood. It’s near the bladder, rectum and near nerves and blood flow for the penis. Any therapy, both surgical, radiation and others such as cryoablation and HIFU, will potentially affect any or all of these areas. Post surgery, most men will experience some degree of urinary incontinence and erectile dysfunction, although the degree and duration will vary on numerous factors such as age (younger men 50’s to early 60’s recover relatively quickly), ability to spare nerves, size of the prostate (most men with larger prostates have more incontinence) and skill of the surgeon. Usually sexual function is more difficult to recover than urinary function.
Likewise radiation can affect these as well, although sexual decline is more gradual and rather than incontinence, men experience slowing of the stream and more urgency. Radiation can also induce damage to the bladder and rectum, resulting in inflammatory bleeding of both organs. It may also induce inflammation and scarring of the urethra. Rarely radiation can also induce bladder cancer and rectal cancer. These latter affects are usually seen many years after treatment