The Quiet Revolution in Prostate Cancer Treatment

How better testing can prevent harmful overreactions
By Jay S. Cohen, MD

From ignorance to awareness

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, and psychiatry. Though I had written consumer-oriented medical books on how to prevent the ongoing epidemic of medication side effects and on natural remedies for elevated cholesterol, high blood pressure, and migraine headaches, none of this work prepared me for dealing with prostate cancer as a patient.

What I found was a medical model of diagnosis and treatment that is outdated, error-prone, and unnecessarily harmful (often permanently), to a majority of men diagnosed with prostate cancer. As I went through PSA testing, biopsy, and was scheduled for prostate surgery, I learned many things about dealing with prostate cancer to avoid being harmed unnecessarily by the mainstream medical approach.

This is not to say that the mainstream approach does not help some men—it clearly does. Yet experts also agree that the current approach causes a great deal of harm that could be avoided with the right information.

Early diagnosis requires regular PSA testing

When caught early, prostate cancer is almost always treatable. Our most proven tool for catching prostate cancer early is the PSA blood test. PSA stands for “prostate-specific antigen,” a protein released by normal prostate cells. Prostate cancer cells release higher than normal amounts of PSA, so 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. Despite this some HMOs, veterans hospitals, and Medicare are no longer covering PSA testing.

In May 2012, the US Preventive Services Test Force (USPSTF) issued a directive to discontinue PSA testing in men. Their goal was to prevent the widespread misinterpretation of PSA findings by doctors that is leading to harmful overtreatment. The problem is that PSA is a nonspecific test. An elevated PSA level does not always mean cancer—it may also indicate infection or enlargement of the prostate. Sometimes when doctors see an elevated PSA result they assume it is due to cancer and rush men to prostate biopsy. Mark Scholz, MD, a prostate cancer specialist, states that a full 50 percent of the 1.2 million prostate biopsies performed each year in the US are unnecessary.

A prostate biopsy is a minor surgical procedure done in the doctor’s office. Although usually safe, biopsies can cause blood loss or infection. A friend of mine, a doctor, ended up in the hospital with a life-threatening blood infection after his biopsy. Prostate biopsies should be recommended only when truly necessary, but this is often not the case today.

Breakthroughs in diagnostic testing

Current biopsies are done “blind.” The doctor uses a needle to puncture the prostate in 12 different places, hoping to find evidence of the cancer if it is there. But prostate biopsies sometimes find nothing. Because biopsies have been shown to miss cancer 20 percent of the time, doctors will often want to perform repeated biopsies just to be sure a cancer wasn’t missed. Further harm can ensue.

All of this can be avoided with advances in MRI technology that have become available just recently. MRIs were one of the most important diagnostic developments of the late 20th century. No current evaluation of the brain, sinuses, spine, shoulders, knees, and most other areas of the body is complete without an MRI. Unfortunately, the prostate’s location deep in the pelvis prevented a clear picture of prostate cancer via MRI—until now. The big innovation is the contrast 3.0 Tesla parametric MRI. (The “Tesla” in the name refers to a power rating. A 3.0 Tesla MRI is considerably more powerful than the typical MRI.)

The new contrast MRI is being used in a few medical centers, sometimes even before a biopsy. If an MRI shows areas of possible cancer, the biopsy can then be directed to these areas—this is called a “targeted biopsy.” If the MRI shows no areas of concern, the biopsy can be postponed, and the man can be followed with successive PSA tests and a repeat MRI in six or 12 months. Another test, the color Doppler ultrasound, can be used in a similar way. A couple dozen doctors in the US perform the color Doppler ultrasound.

These new technologies herald the way things will be done in a decade. The problem is that only a few doctors know about the new MRIs or have implemented them in their evaluations of men with elevated PSA tests or other signs of possible prostate cancer. Instead, doctors all too often perform unnecessary biopsies, find prostate cancer, and rush the men to prostate surgery or radiation therapy. In the appropriate cases, these extreme treatments can be lifesaving—but not all of the cases that receive extreme measures warrant them. These extra biopsies often identify non-aggressive cancers. And, despite the non-aggressive nature of these cancers, many men are told they need extreme treatments like prostatectomy and radiation that can cause many serious side effects like long-term impairment of bladder control and/or sexual functioning.

The magnitude of the problem is revealed by this startling statistic: of the 200,000 men diagnosed with cancer each year, 85 percent receive prostate surgery or radiation, yet only 15 percent actually need these harsh therapies. This is why USPSTF recommended halting PSA testing: to avoid rampant overtreatment. The problem is that without PSA testing, early detection of prostate cancer will be thwarted, and we will be back where we were in 1985 when most prostate cancers were detected too late to be curable.

These new tests allow PSA testing to be used properly. They enable precise diagnosis in men with prostate cancer so overtreatment can be minimized. So, men over 50, get an annual PSA test.

The quiet revolution

Unfortunately most doctors haven’t heard about this revolution in prostate cancer care. Nor have most men. In much the same way as the new MRIs improved diagnosis, new treatments are now available that are less damaging than surgery or radiation and less injurious to bladder and sexual functioning.

These revolutionary new treatments include high-intensity focused ultrasound, cryosurgery, laser surgery, and others that are soon to emerge. I describe all of these and more in Prostate Cancer Breakthroughs, a book I wrote as I went through both the old-fashioned approach and then, fortunately, the newer diagnostic and treatment approach. I never did require surgery and am now doing fine with a closely watched method called active surveillance. I check my PSA level every three months and obtain a color Doppler ultrasound and parametric MRI every six. I describe all of these and more, step by step, so you will know the tests and treatments to ask about.

Because most prostate cancers are non-aggressive or slow growing, there is usually time to gather information and obtain a more thorough approach than most men receive. Though a diagnosis of cancer understandably terrifies many men and their families, resist the urge to rush into surgery and “get the damn thing out.” Remember, prostatectomy and radiation are not always curative. They fail to halt the cancer about 25 percent of the time.

I wrote this book to help ensure that all of the 200,000 men diagnosed with prostate cancer each year can get the tests that are most helpful and the treatments that are most appropriate, even if their own doctors don’t know about these advances or fail to inform the men they are treating for prostate cancer.

 

Jay S. Cohen, MD, is the author of Prostate Cancer Breakthroughs and is a nationally respected expert on prescription medications, avoiding side effects, and natural remedies. Dr. Cohen is an adjunct associate professor of family and preventive medicine and of psychiatry at the University of California, San Diego. He is online at medicationsense.com.