By Deborah J. Botti Published: 2:00 AM – 11/23/11
Recent findings have called into question the value of regular PSA screening for men. PSA — prostate specific antigen-based screening — is a simple blood test that can lead to the early detection of prostate cancer.
Arlene Ryan of Kingston can’t help but recall her father-in-law’s experience. “My husband’s father’s prostate cancer was diagnosed because of a broken bone,” she says, pointing to the fact that metastasizing prostate cancer has a penchant for bones. “He died at 63. Of course, we’re against what this study indicates.”
Frank E. Schuerholz of Middletown, a retired educator and one of the organizers of the Middletown Chapter of the Us too support group back in 1995 — a group he continues to facilitate — says that somewhat controversial report by the United States Preventive Services Task Force was the topic of discussion at the meeting early this month.
Prostate Cancer 101 has been imparting information to the newly diagnosed for almost 17 years. It meets the first Tuesday of the month at 4:30 p.m. at the Hurley Reformed Church.
Arlene Ryan, a nurse and board member, has been involved since her husband’s diagnosis 10 years ago. “We give them the tools. We tell them to bring their wives or girlfriends. We are not doctors and we do not give medical advice, but the one thing are group does is take away the fear factor,” she says. “Most likely, you will not die of this disease – but it’s not a one-size-fits-all, and you only have one shot at the treatment that’s best for you. We empower you.”
And then, Ryan says, they encourage men to come back and share their stories. “We had a guy last month attend – who was a month from surgery and felt good,” she says.
For more information, call her at 338-9229.
“The bottom line is that patients today are encouraged to be informed and to make decisions based on feedback and education,” says Schuerholz.
And that simple PSA blood test is part of that information necessary to make an informed decision, the experts say.
“Before the PSA, a large percentage of men presented with metastatic disease at the initial time of diagnosis. We don’t see that anymore,” says Dr. Gerard Galarneau, a urologist with Middletown Urologic Associates and chief of staff at Orange Regional Medical Center. “It’s not a perfect test, but you shouldn’t have to take four steps backward. It provides important information.”
And Galarneau believes that hundreds of his practice’s patients are alive today because of that test.
The test measures prostate-specific antigens or a type of protein in the blood.
“The PSA was never meant to be a screening test. Rather, it was meant to follow men after surgery. If the prostate is removed, the PSA should be zero,” says Galarneau.
However, a correlation was discovered between PSA levels that rose above four and an increased risk of prostate cancer.
“All the guys (in Us TOO) were pleased they found out about their prostate cancer with the PSA test, followed by a biopsy,” says Schuerholz.
Because in most cases, the cancer was detected in its very early stages, offering the most treatment options.
“Right now, the PSA is the only real measurement a man has to determine if he has prostate cancer,” says Ryan. “By the time symptoms appear, treatment might not work.”
The PSA test for Arlene’s husband Bill Ryan when he was 60 was borderline normal. Given his father’s outcome, Bill took action.
“The Internet offers a lot of information, but it’s also confusing and conflicting — especially 10 years ago,” says Arlene, who is also a nurse. “What helped us was the group.”
The support group she’s referring to is Prostate Cancer 101, of which she’s an active board member. she attends the meetings in Hurley while her husband continues to work full time.
Toward the goal of providing education and useful tools with which men can address their cancer, her group keeps an ongoing list, with permission, of contact information and each man’s physician and treatment selected.
“I called the men on that list of about the same age as my husband who had surgery,” she says. “We then went for a second opinion, and the doctor said the surgeon we selected was excellent, ‘But we could do seeds.’
“I then called all the people on the list with seeds, and was reassured there was no recurrence.”
So why is this group flagging PSA tests?
The USPSTF board concluded:
“Prostate-specific antigen-based screening results in small or no reduction in prostate cancer-specific mortality and is associated with harms related to subsequent evaluation and treatments, some of which may be unnecessary.”
“I will concede, there probably is some overtesting and overtreatment out there,” says Galarneau. “Older men are more likely to develop prostate cancer and less likely to die from it. So an 80-year-old probably does not need treatment — but a 50-year-old probably does.”
“Are we needlessly spending a lot of money?” is the question Schuerholz says the study really asks. Schuerholz’s cancer was detected in November 1992, at the age of 58, following a PSA test. “Studies indicate that most men will develop prostate cancer if they live long enough.”
That’s where sound medical judgment and patient-physician communication become critical. Individual circumstances vary — as do the cancers. Many prostate cancers are slow-growing — but some are aggressive.
There is a theory, says Galarneau, that younger men who get prostate cancer will also typically be at risk for a more aggressive cancer.
“But older guys can get an aggressive prostate cancer, too,” he says.
So it’s not really the PSA test in and of itself that’s coming under the microscope — but the more expensive biopsies and subsequent treatments that follow.
If a 60-year-old man on oxygen with several chronic conditions has a rising PSA score, is treatment warranted?
Conversely, just because a man is 75, should he automatically not have a PSA test? what if he’s in picture-perfect health with an activity level and mental outlook decades below his chronological age — but there’s an aggressive cancer taking hold?
Or what about a typical 75-year-old with a slower-growing cancer? should he immediately undergo the rigors of treatment?
“We can debate individually who should and should not have a PSA test,” says Galarneau. “But a blanket statement is just wrong. … An informed patient needs to make an informed decision — along with his doctor, spouse and family.”
Cancer is not the only cause of an elevated PSA score.
“It can be an infection or a benign growth,” says Schuerholz.
So what’s next? Generally, a DRE, or digital rectal exam would be recommended, during which the physician would be able to feel an enlarged prostate.
Then the question becomes when, and if, to biopsy. your physician’s advice, in conjunction with the wealth of information available to discuss, will provide the answer.
“Some say it’s not so bad,” says Ryan of the rectal probe used to shoot the little needles — under local anesthesia, of course.
Not only is the intent of the biopsy to confirm or deny cancer, but it can offer a window into the type of cancer itself. The Gleason grade or score assigns a number value to the cancer cells. Typically, the lower the number, the better the prognosis, but that isn’t always the case.
“Prostate cancer is a very complex disease,” says Ryan.
“It’s important to know your scores, to document and chart your PSA levels and to understand what they mean,” says Schuerholz.
As a result of the pathology determined by the biopsy, a protocol that can now be chosen for an early-stage cancer that probably won’t affect the duration of a patient’s life is “watchful waiting,” says Galarneau, also called “active surveillance.”
“Active surveillance wasn’t even an option 10 years ago,” says Ryan. “For those men who fall within certain guidelines, the PSA test can be repeated every three to six months, watch the trend and continue not to treat until a change is noted.”
Schuerholz says there’s a 75-year-old member of his group who elected just that five years ago.
“His PSA levels are monitored regularly, he’s in good health and has no symptoms,” he says.
There are others who would not be able to psychologically deal with knowing they have cancer and are not actively trying to get rid of it.
“My husband never would have been able to choose active surveillance because of his dad,” says Ryan, who points to a couple of men from her group who did chose active surveillance — and began treatment a couple of years after diagnosis when the PSA levels began to rise.
“They had two years without side effects,” she says. “Treatment is not a free lunch.”
Galarneau says the gold standard of treatment is surgery; and there are often choices in that category, too — open or robotic, the latter of which is less invasive.
Cryosurgery is another technique, wherein the diseased tissue is frozen. Radiation is also available — either from an outside source or the seeds, as well as hormone therapy — or a combination of approaches, particularly if the cancer is aggressive.
“Radiation and surgery generally have very close outcomes now,” says Galarneau.
Still, there are side effects — incontinence and erectile dysfunction of most concern among men — and the older the patient, the more likely to experience side effects, says Galarneau. some may have already experienced some difficulties — worsened by the surgery.
“Untreated prostate cancer will cause impotence,” says Galarneau. “With treatment, at least you’re getting rid of the cancer. and we try to spare the nerves (required for sexual performance).”
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