Prostate Cancer Breakthroughs
by Jay Cohen, MD
A major advancement in the diagnosis and treatment of prostate cancer is underway, but many doctors and most men diagnosed with prostate cancer have not heard about it. Instead, today men are quickly dispatched for aggressive treatment such as prostate surgery or radiation that often cause permanent damage to bladder control and/or sexual functioning. The numbers are startling: 85% of men diagnosed with prostate cancer get surgery or radiation, yet only 15% actually need it.
I was diagnosed with prostate cancer in December 2011. Steered immediately toward radical treatment, the doctors said, "Your PSA is very high and your biopsy is positive, so your only choices are surgery or radiation." I chose surgery and was scheduled for the next month. Fortuitously, I heard about new tests that enabled me to avoid these aggressive treatments.
It wasn't my doctor or the surgeon or radiologist who told me of the new tests, but other men with prostate cancer who keep abreast of the quietly emerging revolution underway. I looked into it, liked what I heard, underwent the new tests (why not?) and was able to avoid surgery or radiation. I decided to chronicle my experience in order to tell men about the new tests, new treatments, and better options. The result is my new book, Prostate Cancer Breakthroughs.
No matter if you are a man or woman, the information in the book may be vital to you someday. If you think about all of the men in your life, family and friends, neighbors and acquaintances, men you work or worship with, one in six of these men will someday be stricken with prostate cancer. Two hundred thousand cases are diagnosed each year in the U.S. Prostate cancer kills 30,000 annually. To put it in perspective, prostate cancer is as serious a problem for men as breast cancer is for women.
I knew virtually nothing about prostate cancer when I was diagnosed in December 2011. I am an integrative doctor with a background in general medicine, acupuncture research, pharmacology, psychiatry, and natural medicine. My first consumer books were on how to prevent the epidemic of medication side effects, and my last five are on natural remedies for high blood pressure, elevated cholesterol, and migraine headaches. None of this work prepared me for dealing with prostate cancer as a patient.
New Tests Can Provide a More Accurate Diagnosis
MRIs are essential to the diagnostic evaluation of many medical problems. No evaluation of the brain, sinuses, spine, shoulders, knees, and most other areas of the body are complete without an MRI. Yet until now, MRIs have not been helpful for the evaluation of prostate cancer. The prostate is situated so deep in the pelvis, MRI pictures were unclear and prostate cancer could not be accurately identified. Now, there is a new generation, parametric MRI with high accuracy for identifying where the prostate cancer is and where it isn't. A handful of major medical centers now offer it. Dr. Peter Scardino, chairman of urology at Sloan-Kettering Cancer Hospital, says of this new MRI: "It has proven to be the best means we have today for seeing a cancer in the prostate."
Another test, the color doppler ultrasound, can also identify cancer in the prostate gland. A couple dozen doctors in the U.S. perform this test, which can be done in the doctor's office. Prostate Cancer Breakthroughs contains a list of medical centers that offer the advanced MRI and of practitioners of the color doppler ultrasound.
Blind Biopsy vs. Targeted Biopsy
Urologists perform 1.2 million prostate biopsies each year, 600,000 too many according to prostate cancer specialist Dr. Mark Scholz. In addition, the standard biopsy today is blind, meaning that urologists take samplings from both lobes of the prostate with nothing to guide them. In contrast, if a color doppler ultrasound test shows areas suggestive of cancer, the biopsy can be done at the same time, and the needles can be aimed at the suspicious areas. The new MRIs are now being adapted for this same use.
This is important because blind biopsies have been shown to miss existing prostate cancers about 20% of the time. Often, the urologist will want to repeat the blind biopsy, sometimes multiple times. Biopsies are surgical procedures, and although usually safe, they are uncomfortable and can cause blood loss or infections, sometimes requiring hospitalization.
A System That Is Slow to Change
A targeted biopsy is a far better alternative, but it will probably not be provided by most urologists for another five to ten years. Why so long? Medicine is a conservative profession. Doctors are reluctant to embrace new technologies until they are well proven. Early studies of the parametric prostate MRI have been encouraging, but the associations of urologists and cancer specialists are awaiting further confirmation studies. Until then, the standard medical approach will continue, and many men like me -- more than 70,000 each year -- will be sent for surgery or radiation they do not need.
Overtreatment: an Ongoing Problem in Prostate Cancer Care
My parametric MRI showed a modest, single nodule of cancer in the left lobe of my prostate. It is in a safe area, not near any vital structures, nor the edge of the gland. There is no indication of spread of the cancer.
Because no test is 100 percent, I confirmed the findings by having a color doppler ultrasound that found exactly the same thing. I am now engaged in active surveillance, obtaining PSA levels every three months, a color doppler ultrasound every six, and a parametric MRI once a year, under my doctor's guidance. Eighteen months after my diagnosis, my findings remain the same, and I am doing fine.
New Treatments, Safer Options
With the additional knowledge about each man's prostate cancer provided by the new tests, additional treatment options are now possible. If a man has a localized cancer, he might be eligible for a local treatment such as high intensity focused ultrasound, cryosurgery (freezing technique), laser treatment, and others that are now emerging. Using MRI guidance, these treatments can be performed with enhanced accuracy. This in turn reduces the risk of injury to nearby nerves, injuries that commonly occur with surgery or radiation. Because of greater accuracy with these new methods, normal bladder control and sexual functioning can usually be spared.
The PSA Test: Vital for Early Diagnosis
When caught early, prostate cancer is almost always treatable today. Our most proven tool for catching prostate cancer early has for 23 years been the PSA blood test. PSA stands for prostate specific antigen, a protein released by normal prostate cells. Because prostate cancer cells release even greater amounts of PSA, an elevated PSA level can signal prostate cancer. Studies have repeatedly proven that since the implementation of PSA testing around 1990, deaths from prostate cancer have dropped dramatically. Yet, some HMOs, Veterans Hospitals and Medicare are no longer covering PSA testing.
This is because in May 2012, the U.S. Preventive Services Test Force (USPSTF) issued a directive to discontinue PSA testing in men. Why? To prevent the widespread misinterpretation of PSA findings by doctors and the harmful overtreatment of men. The problem is that PSA is a nonspecific test. An elevated PSA does not always mean cancer. It may indicate infection or enlargement of the prostate or other causes, as described in the book. Sometimes, when doctors see an elevated PSA result, they assume it means cancer and rush men to prostate biopsy. If the biopsy shows cancer, even a non-aggressive cancer, doctors may rush men to surgery or radiation.
Without any tests to differentiate a local cancer from an extensive one, doctors frequently opt for aggressive treatment in order to avoid under-treating a serious cancer and placing a man's life in jeopardy. This approach made sense in the past and remains the mainstay today. When I asked my highly experienced urologist about obtaining the new parametric MRI, he said the test wasn't proven enough. But I reviewed the studies, obtained the test and found it was extremely helpful. Knowing I had prostate cancer, I didn't have time to wait for some panel of experts to approve the test five or ten years from now.
The revolution in prostate cancer care that has benefited me so much remains unknown today to most men when they are diagnosed with prostate cancer. I wrote Prostate Cancer Breakthroughs to provide men with information they will likely not receive from their doctors and to offer them a different, medically sound path with new tests, new treatments and, very often, better results.
Dr. Jay Cohen is a nationally esteemed medical practitioner and researcher, a university professor, author of eight health books and more than a hundred medical articles, and an expert on medication safety and nutrition.
His newest book, Prostate Cancer Breakthroughs: New Tests, New Treatments, Better Options (2013), is the only book that takes readers step-by-step through the evaluation process, informing men how to obtain the new, breakthrough tests and treatments that can help tens of thousands of men avoid unneeded surgery or radiation.