It has been said that if a man lives long enough, he will get prostate cancer. Yet nowhere in medicine is there more controversy and differing opinions, than in the diagnosis and treatment of prostate cancer. For example, a year or two ago, the United States Preventative Services Task Force (USPSTF), a federal committee that makes recommendations on screening for diseases, recommended that physicians stop doing Prostate-specific antigen (PSA) screening because, they reasoned, PSA screening was causing too many false positives and unnecessary surgeries. Many physicians, urologists, and professional societies disagree with this recommendation. As an aside, in someone with prostate cancer the PSA level is an integral part of assessing whether he is low-risk or high-risk.
A vital part of staging prostate cancer is the Gleason scale. It was invented by Dr. Donald Gleason in the 1960s. The Gleason score is determined by a pathologist who examines the tissue obtained from a prostate biopsy. Two areas of the tissue are examined under the microscope. Each area is given a score of 1 to 5, where 1 is normal-appearing prostate tissue and 5 is highly abnormal tissue. The first area examined is the area where the tumor is, and the second area is where the tumor is less prominent. Both scores are then combined to make a total score of 2 to 10. Then the patient is placed into a low-risk, medium-risk, or high-risk category (risk meaning risk of tumor growth and spread). Low-risk is a Gleason score of 6 or lower, PSA of less than 20, and early tumor stage (the tumor is well-confined within the prostate as seen on MRI or ultrasound). Medium-risk is a Gleason score of 7, PSA below 20, and medium tumor stage. High-risk is Gleason of 8 to 10, PSA over 20, and advanced tumor stage. Age and overall health are also used in defining risk.
Now comes the controversy. A recently published review article found that men with prostate cancer, who were followed for 10 years, had the same (very low) risk of death from prostate cancer, whether they were only monitored, had surgery (prostatectomy), had radiation, or received hormone therapy. The study did find, however, that those who were only monitored had a higher rate of tumor growth and spread. So there is the dilemma. Many urologists will recommend monitoring only for those in a low-risk category. Most of the differences of opinion among experts is how to treat the moderate-risk patients. A significant factor is the side effects of treatment. Prostatectomy can lead to urinary and sexual problems, hormone treatment can lead to sexual problems, and radiation can lead to both sexual and urinary problems, plus bowel issues. So deciding on treatment is an individualized process that includes age, overall health, and, most importantly, being sure that the patient is well-informed and able to participate in the treatment decision process.
I am a primary care physician who still believes in PSA screening. However it is not for all men. Men over 70 to 75 should not get tested for PSA as the results can be misleading, plus should they develop prostate cancer, it is very unlikely to lead to their demise. Younger men, say between 45 and 50, should be tested because a low PSA level in those men imparts a lower risk of developing prostate cancer in the future.
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