Prostate cancer is the second leading cause of cancer death in men. If detected and treated early, prostate cancer survival rates are high and associated with good functional outcomes. Brian Helfand, MD, PhD, Urologist at Northshore, answers questions about prostate cancer risk, PSA values, early signs and symptoms, recommended screening, as well as current treatment options for prostate cancer and recovery after treatment.  

What is a normal PSA?
I always tell my patients that you should compare your PSA to what is "normal" for your age group. Most men age 50 and younger have a PSA below 0.7ng/ml. For simplicity, you could use a cutoff of 1.0ng/ml. It’s important to point out that having a PSA value that is above your age group does not mean that you have prostate cancer. It does, however, mean that you are statistically at a slightly increased risk for being diagnosed with the disease. For that reason, you should continue to be screened with PSA on an annual basis at least. 

There are other factors that should go into the interpretation of PSA before deciding to perform a prostate biopsy and these include: PSA values that have been rising over time, family history of prostate cancer, African-American heritage and history of benign prostatic hyperplasia (BPH). Remember, PSA is not a perfect test but it has saved many lives and it’s still the best test for prostate cancer screening.

Guidelines for median PSA levels by age:

• Age 40 to 49: 0.7 ng/mL median PSA
• Age 50 to 59: 0.9 ng/mL median PSA
• Age 60 to 69: 1.3 ng/mL median PSA
• Age 70 to 79: 1.7 ng/mL median PSA

If there is a family history of the disease, does that increase your risk? When should someone with a family history of the disease begin screening?
Prostate cancer is one of the most inheritable of all cancers. As such, risk factors that are most associated with prostate cancer are first-degree family history (father, brother, uncle, etc.) and race (i.e. African-Americans). Based on statistics, a man with a first-degree connection to the disease is almost two times more likely to be diagnosed with prostate cancer than a man without a family history. Although there is some debate regarding the routine use of PSA screening, I’m a firm believer that if there is a family history, one should start undergoing annual PSA screening by the age of 40.

After treatment, how often should a patient return to their physician for further tests and screenings?
After surgery, patients should have an initial post-operative PSA in about four to six weeks and then every three to four months (based upon their urologist's preference). After two years of having an undetectable PSA, I suggest my patients get PSAs every six months.

Are there preventative measures that could potentially reduce one’s risk for developing the disease? 
It’s possible that a heart-healthy diet low in fats and simple sugars may help reduce one’s risk of developing prostate cancer. There is emerging evidence that obesity is a driving factor for a benign growth of the prostate (referred to as BPH or benign prostatic hyperplasia) and that it could also contribute to one’s risk for prostate cancer. Extra weight may also make it harder to detect the disease until it is advanced. Obesity also is thought to contribute to prostate cancer recurrence. That’s why it’s important for men to realize that a heart-healthy diet can help keep their prostates healthy too!

How likely is a patient’s sexual function to be affected after treatment? What surgical options result in the best possible outcome as far as recovering sex life?
I tell my patients that your post-operative sexual function is significantly related to your age and pre-operative function. In general, treatment for prostate cancer (radiation or surgery) has never improved a man's erectile function. However, if a man is young, not diabetic or obese and had good erectile function prior to surgery, he has a very good chance of having normal erections post-op.

I believe that good, nerve-sparing surgery significantly helps with the recovery of erectile function. This can be done by a urologic surgeon who is trained in the technique and frequently performs the operation. In addition, I believe that all men should start (at minimum) a rehabilitation program before and immediately after surgery that helps to recover nerve function. This could involve taking drugs like Cialis before and after surgery.

If you do suffer from sexual dysfunction after prostate cancer treatment, what can you do to aid/improve recovery?
Unfortunately, there is no universal solution for every man but there are many different options that are available for treatment of sexual dysfunction after surgery. Prostate cancer patients should have an assessment of psychological function and desire for sexual activity following surgery. Many men get nervous about intimacy following surgery and an evaluation by a trained professional can help relieve a lot of this anxiety.  

If there are erectile issues after treatment, many men respond to simple medical therapies like Viagra and Cialis. This is often a starting point. If you fail to respond to these therapies, other interventions such as a vacuum erection device or injection therapies can be used to obtain an erection. As always, regular exercise and a heart-healthy diet help increases your chances of a successful recovery.

What are the differences between robotic laparoscopic surgery and conventional open prostatectomy in terms of recovery?
I think the answer is surgeon experience. There are many urologists who can perform open surgery with excellent outcomes (great cancer control, erectile function and continence). And there are many urologists who can perform robotic surgery with similar outcomes. It’s most important to be treated by a urologist who is comfortable and experienced with radical prostatectomy. Having said that, robotic surgery has recently become the most commonly used surgical intervention for prostate cancer. When compared to open surgery, robotic surgery offers significantly less blood loss and a shorter hospital stay. Although not proven, it’s likely that the robotic surgery offers increased visualization of the area by the surgeon which provides an opportunity to spare more nerves and create a nice connection between the bladder and urethra. These are both associated with increased erectile function and increased continence.

What does active surveillance involve? Why would someone choose to do that instead of actively treating their cancer?
We have come to a "new era" of understanding prostate cancer and realized that many men have prostate tumors that may not harm them during their lifetime (benign-type prostate cancer). This is because many prostate tumors grow very slowly and other medical problems may ultimately harm a man before the prostate cancer spreads

Unfortunately, there is currently no diagnostic test that can tell whether one has a lethal prostate cancer or more benign-type tumor; therefore, we have developed a program of surveillance in which we avoid treating patients with prostate cancer until there is evidence that it has an aggressive component. This involves actively and regularly monitoring men through the use of PSA tests and prostate biopsies. While this does increase the number of times that a man is evaluated by an urologist, it avoids overtreatment, like unnecessary surgery or radiation that could cause erectile problems and/or incontinence. Currently, NorthShore University HealthSystem has the largest program in the Midwest.