Prostate Cancer Does Not Always Require Surgery

Actice Surveillance is a method of monitoring men with low risk prostate cancer without the need for aggressive treatment like surgery or radiation therapy.  Until recently, a man with an elevated PSA ended up with a biopsy and radical prostatectomy if cancer was found.  That is despite the fact that most prostate cancer is slow growing and most men will die from something other than their prostate cancer.  The erroneous belief was that catching it early and removing the prostate was a god thing to do.   Here are the numbers:  Out of 1 million biopsies each year, 240,000 are diagnosed with prostate cancer, half of those diagnosed have low risk disease.  The problem is 90% have either radical prostatectomy or radiation when only a small number (3%) will progress and spread.  And a large number are left impotent, incontinent or both as a result of the treatment.

Now there are a few new diagnostic tests that help separate which men have aggressive disease that requires surgery from the majority that can manage it more like a chronic disease via Active Surveillance.  These include:

  • PCA-3 gene test –  guides the decision whether to perform a biopsy by measuring a prostate cancer specific marker in urine.  It is not affected by prostate size or inflammation like PSA.  If a man’s result is below the test cutoff, there is a very low likelihood thsat a biopsy will be positive.  And if it is positive it is overwhelmingly likely to be a low risk cancer.
  • Advanced Prostate MRI – is actually a series of MRI techniques:  high resolution imaging, dynamic contrast enhancement, and diffusion weighted imaging (and sometimes MR Spectroscopy).  It produces very clear and accurate images of the prostate and surrounding tissues to distinguish between normal and malignant areas noninvasively.  If cancer is detected, a small number of guided biopsies can be done rather than a dozen or so “blind” biopsies as is the current practice.
  • Oncotype Dx Assay – Once a biopsy is performed, if cancer is detected this test is done on the cancer specimen to measure genetic markers that reveal the biology and behavior of the tumor.  It helps guide treatment by assessing how aggressive the tumor is and how likely it is to spread.

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