Recently, Keck Medicine of the University of Southern California (USC) published an important study showing that metastatic prostate cancer is on the rise, likely related to the decline in cancer screenings. Incidents of metastatic prostate cancer have risen as much as 43 percent in men 75 and older and 41 percent in men ages 45-74 from 2011-2018, a time where routine prostate cancer screenings have been largely omitted from routine physicals. This study is the first to document a continued rise in metastatic prostate cancer using the most up-to-date population dataset.
Primary care physicians are encouraged to resume testing men for prostate disease during routine exams, if they have discontinued this procedure. Physicians should understand that giving a prostate specific antigen (PSA) test does not indicate a diagnosis of cancer and ultimately what they may consider “drastic” treatment options with radical surgery or radiation. Depending on test results, the physician may want to refer the patient to a urologist who will then track that patient over time and if test scores continue to rise, they may refer the patient for further testing. PSA tests alone are not used to diagnosis prostate cancer, rather they indicate the need to monitor the patient and should be a standard procedure for male patients.
To discuss the findings of the Keck study and to learn more about new options for prostate cancer treatment is Jennifer Linehan, M.D., a practicing urologist in Santa Monica, CA, affiliated with Providence Saint John’s Health Center.
Is what you are seeing in your patients consistent with the results of the study?
Yes, it is consistent, and the study has important ramifications for men because prostate cancer, when caught early, typically through a screening, is treatable and often curable.
Men are living longer lives. I have many 80- and 90-year-old male patients who are healthy enough that they may live another 10 years. Cutting PSA screening off at age 74 or 75 is too early. We will end up seeing more patients in their late eighties and nineties who develop urinary retention, high-grade prostate cancer, prostate bleeding, and bone metastasis because their doctors have stopped following the PSA screening routine. Unfortunately, it can be even harder to treat this age group because these patients don’t have the same health reserve as they did when they were in their seventies.
With proper testing, we can avoid having these older patients suffer from complications of advanced prostate cancer. In fact, when we can diagnose patients earlier, we find lower grade, noninvasive disease which we can treat with minimally invasive treatments with decreased side effects such as focal HIFU (high intensity focused ultrasound).
Because newer technologies like the Focal One, which integrates MRI images with guided ultrasound imaging, we’re able to pinpoint the cancerous tumor and precisely ablate it using high speed ultrasound waves. This approach helps us avoid collateral damage to surrounding tissue and nerves. We can prevent the negative life-changing side effects that often come with surgery and radiation, such as urinary incontinence and erectile dysfunction.
Other focal therapies include cryotherapy or brachytherapy where we use an MRI to target the lesion and then deliver radiofrequency ablation or cryotherapy to the patient while the patient is lying inside an MRI machine.
In some cases, we can monitor the cancer (active surveillance) without any intervention and can prevent patients from suffering with advanced disease with simple blood testing.
What about younger patients? The Keck study showed that cancer in younger men is also on the rise due to lack of testing. What are you seeing in your practice for this group?
Yes, I’m also finding that patients in their forties, fifties and sixties with a family history of prostate cancer are not getting PSA tests. It is the trend of the PSA that matters most to us. I have patients who have always had a low PSA score and some who have had a PSA as high as 22 with no evidence of cancer. We recommend the PSA test for patients so we can establish a baseline early and watch for changes. This allows for early detection which can be life saving for these patients. Over the last few years I have seen patients in their fifties with high grade metastatic cancer that could have easily been detected early had someone followed their PSA.
What do you want primary care physicians to know about prostate cancer screening?
Primary care doctors and family medicine doctors need to understand that giving a PSA test does not condemn the patient to a diagnosis of cancer and ultimately what they may consider “drastic” treatment options with surgery or radiation. The PSA test allows urologists to track the patient over time and if something is suspicious, then we follow it up. It should be a standard procedure for male patients.
What caused the decline in PSA testing, especially for younger men?
The Federal Taskforce felt that urologists were so focused on treatment, not patient care, that there was fear about testing and treating patients unnecessarily. Therefore, the Federal Taskforce discouraged doctors from administering PSA tests.
Before the advent of active surveillance, focal therapy, HIFU and other minimally invasive treatments for prostate cancer, we would operate on a 45-year-old who could potentially end up impotent for the long term as a result. Now, however, with those minimally invasive options and better tools, we can pinpoint the cancerous tumor and destroy it without damaging any collateral nerves and tissue, and our patients can have long and likely, side-effect free lives. We know more now than we did 10 of 15 years ago—and use active surveillance and HIFU more frequently when we can catch the cancer early.
The Federal Taskforce has not caught up to the fact there are new ways to manage prostate cancer and primary care physicians are operating under its outdated guidance. Likewise, patients have been reluctant to have a PSA test. They worry that if they have prostate cancer, they face the risk of a compromised quality of life caused by the traditional options for treatment. They worry that they are going to be impotent or incontinent permanently.
African American men, especially, are at higher risk for aggressive prostate cancer and need to be screened early so we can watch the trend of their PSA and be able to treat them at an earlier stage when they don’t have to worry about the risk of surgery or radiation. Statistics tell us that African American men have a 2-to1 likelihood of prostate cancer over other men.
Any closing advice?
I promote PSA testing every year. I let my patients know that checking their PSA does not directly lead to invasive cancer treatment. Actually, the opposite is true early diagnosis gives patients the option of active surveillance or the possibility of a new generation of minimally invasive therapies like focal HIFU.
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About Dr. Jennifer Linehan
Dr. Jennifer Linehan is a board-certified urologist, and is an associate professor of urology and urologic oncology at Saint John’s Cancer Institute in Santa Monica, CA. She also practices general urology, including both male and female voiding dysfunction and treatment for kidney stones.
Dr. Linehan completed her medical degree at the College of Medicine at the University of Arizona. She subsequently completed a general surgery internship and then urology residency at the University of Arizona where she received the George M. Drach Award for the most compassionate urologic resident. At the time, she also received awards for research in diagnosis and management of kidney cancer.
