Optimal testing methods for early prostate cancer detection

Jan. 23, 2023

Prostate cancer is one of the most common forms of cancer. According to estimates by the American Cancer Society, there will be 268,490 new cases of prostate cancer in 2022 along with 34,500 deaths.1 These are staggering numbers that show just how common the disease is among American men.

While these numbers are concerning, there is a silver lining: the 15-year relative survival rate is 95 percent.2 This is due in large part to an uptick in early detection and new treatment options.

How early detection works in practice

The number one way to detect prostate cancer in its early stages is a prostate-specific antigen (PSA) blood test. It is no coincidence that the prostate cancer death rate began to decline when the PSA test was introduced in the mid-1980s and early 1990s.3

Conversely, when the number of screenings declined during the COVID-19 pandemic, the number of patients diagnosed with high-risk or metastatic disease increased significantly. There has been some debate over this, but recent data seems to show at least a correlation between the decline in the PSA screening rates and an increase in advanced-stage prostate cancer diagnoses.4

Just recently, prostate-specific membrane antigen (PSMA) PET imaging emerged as the most effective and precise method for localizing metastatic prostate cancer. This PET imaging measures PSA levels as well but does so in a highly targeted manner that significantly improves how prostate cancer is detected and treated. Although these scans require machinery not yet available across the country, PSMA PET imaging is the best option to detect areas of suspected metastasis for initial therapy and suspected recurrence.

Holding off on a PSA screening or rectal examination can be a big mistake. Typically, this occurs because a patient isn’t experiencing symptoms like urinary problems, obstruction, and/or bleeding. As a general rule of thumb, patients should start with an annual PSA screening at the age of 50. But if a patient has risk factors, such as a family history of prostate cancer or is of African American heritage, it is best to start regular screenings by age 40 at the latest.

Diagnosis and the importance of a second opinion

A prostate cancer diagnosis is sure to turn a person’s life upside down. With so many questions and concerns, one of the biggest challenges faced is information overload.

In most cases, prostate cancer is diagnosed by a urologist, and in many cases, surgery is offered as the first option. While a diagnosis allows a patient to immediately proceed with treatment, it’s all too common for patients to get ahead of themselves.

For newly diagnosed patients, a second opinion is recommended. While a urologist may suggest the prostate be removed as soon as possible, that is not always the best approach. Data shows patients are more likely to experience serious side effects from a surgical procedure, but a radiation oncologist who specializes in prostate cancer may be able to provide treatment other than surgery depending on the patient’s unique circumstances. In fact, a randomized trial focused on early-stage disease concluded that radiation is equally effective while having significantly fewer serious side effects compared to surgery.5 Furthermore, patients may end up needing radiation to address any cells that were left behind post-surgery anyways.

Thus, external beam radiation can be effective on its own, as a study published in JAMA concluded that in very high-risk patients combining it with brachytherapy provides a 30% better chance of preventing localized cancer from metastasizing.6

Prostate cancer testing

A prostate cancer diagnosis is serious, but doctors should not scare patients into making a rushed decision before additional tests are scheduled. For example, genetic testing on the biopsy specimen will determine how aggressive the disease is and help the patient’s medical team determine the most appropriate treatment program. This contrasts with the more widely employed process of viewing tissue samples from the prostate biopsy under a microscope for cell abnormalities that are a sign of prostate cancer. If cell abnormalities are present, judgment calls are made on how likely the cancer will progress and the best treatment options.

The most exciting advancement happening right now regarding the treatment of prostate cancer is individualized therapy, with genetic testing at the forefront of this process. Genetic (genomic) testing paired with a holistic view of a patient’s lifestyle and health history can reduce the uncertainty of initial treatment decisions. By taking more of the individual’s genetic and lifestyle factors into account, a more aggressive treatment may be deemed necessary, which could result in a higher chance of survival.

Conversely, some patients may believe they have an aggressive form of prostate cancer but learn through genetic testing this isn’t the case. This helps prevent overtreatment and ensures the highest quality of life possible for patients.

In closing

Patients should get an opinion from both a surgeon and a radiation oncologist before making a decision on how to treat newly diagnosed prostate cancer. It is worth noting that once the prostate is removed, treatment options become far more limited.

New tests for genomic evaluation of the cancer cells and high-quality imaging such as T3 MRI and PSMA pet scans are making a real positive impact in treatment outcomes and men’s lives. Prostate cancer treatment is rapidly changing, so staying up to date on the latest research and collaborating with other physicians is the best way to facilitate a positive outcome for your patients. That is something we can all get behind.

REFERENCES

  1. Key statistics for prostate cancer. Cancer.org. Accessed January 3, 2023. https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html.
  2. Prostate cancer prognosis. Hopkinsmedicine.org. Published August 8, 2021. Accessed January 3, 2023. https://www.hopkinsmedicine.org/health/conditions-and-diseases/prostate-cancer/prostate-cancer-prognosis.
  3. Zhou CK, Check DP, Lortet-Tieulent J, et al. Prostate cancer incidence in 43 populations worldwide: An analysis of time trends overall and by age group. Int J Cancer. 2016;138(6):1388-1400. doi:10.1002/ijc.29894.
  4. Norton A. Did the Decline in PSA Testing Lead to More Cases of Advanced Prostate Cancer? U.S. News & World Report. Published October 28, 2022. Accessed January 3, 2023. https://www.usnews.com/news/health-news/articles/2022-10-28/did-the-decline-in-psa-testing-lead-to-more-cases-of-advanced-prostate-cancer.
  5. Donovan JL, Hamdy FC, Lane JA, et al. Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med. 2016;375(15):1425-1437. doi:10.1056/nejmoa1606221.
  6. Kishan AU, Steigler A, Denham JW, et al. Interplay Between Duration of Androgen Deprivation Therapy and External Beam Radiotherapy with or Without a Brachytherapy Boost for Optimal Treatment of High-risk Prostate Cancer: A Patient-Level Data Analysis of 3 Cohorts. JAMA Oncol. 2022;8(3):e216871. doi:10.1001/jamaoncol.2021.6871.

Photo 55901642 © Monkey Business Images | Dreamstime.com
Photo 86264954 © salinrat prasatkaew | Dreamstime.com