Screening and Diagnosis of Prostate Cancer
Prostate cancer screening
A PSA (prostate specific antigen) is a blood test that assesses risk of prostate cancer. It is a common component of routine health maintenance for many men along with a digital rectal exam (DRE) to assess for firmness or irregularity of the prostate. A high PSA does not necessarily reflect prostate cancer, but higher levels are associated with higher risk. An elevated PSA will often provoke additional investigations to clarify whether a prostate biopsy is needed. Similarly, a bump or irregularity on the prostate as detected by DRE may warrant additional testing. If a primary care physician suspects prostate cancer, he or she may refer a patient to the Prostate Cancer Risk Clinic to discuss options.
PSA screening controversy
There has been considerable discussion regarding the usefulness of PSA testing for early detection of prostate cancer. As prostate cancer is very common in men as they age, and most prostate cancers are slow growing, there is a concern for "overdiagnosis", or detection of cancers that were never destined to cause harm. This concern, however, requires balance against the important interest of detecting more aggressive or dangerous types of prostate cancer. Ultimately there are pros and cons of PSA testing for early detection of prostate cancer, and a nuanced discussion between patient and provider is needed to ensure his individualized risk factors are considered and his preferences are met. Not all men should have PSA testing, and some men should be more scrutinized for their risk (e.g. men of African American descent, those with a father or brother diagnosed with prostate cancer < 65 years old). See the American Urological Association guidelines for early detection of prostate cancer.
In the Prostate Cancer Risk Clinic, we individualize the discussion to a man's particular risk factors. We review laboratory data, physical exam findings, medical history, family history, demographic information, and available imaging findings to determine options and yield of additional testing. Not all elevated PSA values require additional testing or a prostate biopsy! The PSA may be elevated for diverse reasons including prostate enlargement, inflammation, infection, recent procedures, recent ejaculation, among others. Our approach is to use "shared decision-making" to determine the role of additional testing and possibly biopsy.
For patients desiring a prostate biopsy based on concern for prostate cancer, we provide detailed counseling regarding risks and benefits, and can generally offer a biopsy on the day of initial consultation. This is not true for some men who may be on blood thinners or who have signs of urinary tract infection. Prostate biopsy is a procedure performed under local anesthesia with a 'prostate block' that numbs that area of the body. The procedure lasts about 10-15 minutes, and involves 12 or more biopsies of the prostate using a trans-rectal ultrasound probe. Risks including bleeding, infection and discomfort; patients are able to go home shortly after their procedure with counseling on short term activity restriction. Patients receive phone calls within a week regarding the result of biopsy and whether follow-up consultation is needed.
Patients who are seen in this clinic include those with risk factors for prostate cancer desiring detailed counseling, those who may have had a prior normal biopsy with ongoing concerns, and those with a prior diagnosis of "low risk" prostate cancer who are being followed with an observational strategy, such as "active surveillance."
Additional testing that may be offered to patients include novel blood tests or urine tests (e.g. PCA3), genetic tests, or advanced imaging techniques (e.g. multi-parametric MRI) that may clarify whether a dangerous cancer is present and guide subsequent biopsy approaches.
Patients or providers interested in scheduling an appointment for discussion of prostate cancer risk and the option of prostate biopsy may call (603) 650-5091 for more information.
If a prostate cancer is detected through biopsy, follow-up consultation will be scheduled to discuss the best treatment approach. We offer multi-disciplinary counseling by urological surgery and radiation oncology to review all treatment approaches including observation (either active surveillance or watchful waiting), radical prostatectomy including robotic-assisted laparoscopic techniques, and radiation therapy (both brachytherapy and external beam radiotherapy). Our team includes high volume providers in surgical and radiation therapy, and we treat a high volume of patients with this condition at DHMC. We have state of the art technology that enables optimal care for patients regardless of their selected treatment.