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
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 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 an urologist who is comfortable and experienced with a 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 treat 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.
Patient Don Tabler was diagnosed with prostate cancer in 2000, with some charts giving him only six years to live. His husband Russ Bond cared for him throughout his 12-year journey with prostate cancer.
Here, Russ discusses the important role of a caregiver as well as the care his husband received at NorthShore Kellogg Cancer Center, including the cutting edge treatments and clincial trials that helped Don's doctor, Daniel Shevrin, MD, Medical Oncology
and Palliative Medicine, improve and maintain his quality of live and extend his survival far beyond what was intially projected.
When the fourth biopsy in four years revealed some of the cancerous cells were now more aggressive than during the previous four years of active surveillance, I found it very hard to accept that the other shoe had actually dropped. I'd been sailing along
with a Gleason 3 + 3, the least aggressive prostate cancer category. I hoped/believed the numbers would stay that way as I lived through the rest of my 70s and into my 80s and who knows how long from there. After all, my father had lived with prostate cancer
and died from unrelated issues at 86.
As with so many other men, I had the first biopsy after a PSA test suggested a possible problem. In my case the PSA had risen slowly over a decade from 1.4 to 3.7, but being 67 at the time and research changing some of the previous thinking about PSA levels
in older men, the initial urological surgeon and I decided a biopsy was a reasonable option.
My fears after getting the news from the fourth biopsy were:
Navigating My Treatment Options
The urologist who had been following me urged surgery (he performs robotic prostatectomy) and I provisionally scheduled the operation for six weeks hence. I needed time for the biopsy site to heal, digest the diagnosis, and collect and process more
As a dentist turned health reporter, my almost 40 years as a health journalist turned out to be a mixed blessing as I tried to intelligently navigate the daunting amount of often contradictory and confusing information, even for a health professional. I
discovered one of my greatest strengths as a reporter—the ability to thoroughly and unemotionally research virtually any health topic—failed me dismally because this time I was too emotionally involved. I would read the same sentence or paragraph over and
over or talk at great length to trusted sources and come away even more confused. Yes, get the cancer out. No, you can safely keeping watching. Surgery? Robotic or open? Radiation? But what type? Or perhaps one of the less tested treatment options? You can
imagine the toll this emotional roller coaster took on my family: Arline my wife of 41 years and my two sons.
Finding My Advocate: A Six Week Journey
As the six weeks dwindled to two, I still felt uncertain—and frightened—about my decisions and options. While agonizing on the phone one night with my older son he said, “Stop it, Dad! More than most, you are in a position to find one voice you can trust who
can guide you to a decision that you and mom can live with. Find that voice."
I did: Dr.
Charles Brendler, Co-Director of Northshore's John and Carol Walter Center for Urological Health. I was referred to Dr. Brendler by a close personal friend of mine, who is also a physician and serves as a department head at a major Chicago medical center.
He told me Dr. Brendler was the person he would see if he were in my position. Now I understand why.
During the nearly two hours Dr. Brendler spent with Arline and me, he painstakingly reviewed my medical records, gently and carefully examined me, and, for most of the two hours, engaged with us in heartfelt conversation. He reassured both of us, spoke caringly
about our feelings on the personal and intimate issues unleashed by prostate cancer and its treatment, and offered compassionate understanding and objective advice.
Three decisions emerged from our meeting. Two involved additional confirmation of the status of my prostate cancer, one via MRI (Dr. Brendler supported my desire to have the scan) and the other through a second opinion of the interpretation of my four biopsies.
The third and most important was the deciding to accept Dr. Brendler’s recommendation to see a urologic surgeon, who, because of his unparalleled skill in performing open prostatectomies, would be the best fit for me.
When Arline and I exited Dr Brendler's office and walked through the parking lot, we looked at each other and breathed the first sigh of relief in more than a month because we knew we had found peace with my prostate cancer journey. We followed through on
each of the decisions and three weeks after our fateful meeting my prostate was removed by the surgeon Dr. Brendler recommended. The cancer was locally contained and completely removed.
Thanks to active surveillance, I had four years without treatment. And thanks in large part to Dr. Brendler, I remain totally continent and am on the road back to sexual function seven months post-surgery. I’m grateful beyond words that when my son urged
me to find the one voice I could trust, the voice I heard was Charles Brendler's.
Prostate cancer is one of the common cancers found in men (especially in those over 65). Although diagnosis of any type
of cancer can be scary and lead to feelings of uncertainty, in most cases, prostate cancer is slow growing and can be easily managed and treated when identified at its early stages.
Michael McGuire, MD, Urologist at NorthShore, offers the following tips to men about determining their risk and identifying prostate cancer:
While there are mixed reviews about when you should receive the Prostate-Specific Antigen (PSA) test, it is important to talk to your physician about any of your health concerns during your annual visit.
Do you know if your family medical history includes prostate cancer?