New testing and treatments reducing stress and deaths
There has been considerable debate about whether or not to screen for prostate cancer since the U.S. Preventive Services Task Force (USPSTF) concluded in 2012 that PSA prostate-specific antigen (PSA)-based screening for prostate cancer offered questionable benefit of reducing the chance of dying of prostate cancer for men. "Many men will experience potential harms of screening with PSA, including false-positive results that require additional workup such as prostate biopsy and would lead to over diagnosis and overtreatment, and treatment complications such as incontinence and impotence," USPSTF said.
Adam Childs, MD
But the recommendations may have been premature, said Adam Childs, MD, a urologist with Ozark Urology in Fayetteville.
"Newer studies have shown that the 2012 USPSTF was not a good recommendation," Childs said. "At this time, screening for prostate cancer should be very individualized. Someone with only a ten-year life expectancy likely does not need screening. Men with family history of prostate cancer and men with a longer life expectancy have potential benefit to screening. I encourage primary care physicians to understand the pros and cons of screening and to try to discuss this with their patients to help them understand the benefits and risks."
Childs said prostate cancer is still the second most common cancer in men, striking an estimated one out of 6-7 men. Early detection of prostate cancer saves lives. And new, better tests are available today.
"We have a lot more options today than a PSA test to help decide whether a biopsy is needed," Childs said. "New screening tests that are much more accurate than a PSA include 4Kscore, a blood test, and SelectMDx, a urine test. Those tests help us identify men at the greatest risk and cut down on unnecessary biopsies and the diagnosis of low-risk, clinically insignificant prostate cancer."
Another improvement is using MRI technology to improve the yield of prostate biopsies. Childs said it gives more information when it is questionable whether a biopsy is needed.
"Prostate MRI helps us avoid unnecessary prostate biopsies and improves the identification of clinically significant prostate cancer," Childs said. "It helps cut down on over diagnosis of prostate cancer. One of the problems with recommendations not to screen came from the issue of over diagnosis and treatment. So, a lot of our aim is to cut down on biopsies and be more effective finding cancers that are aggressive as opposed to those that will never cause an issue."
Prostate cancer is one of the most common malignancies. Most men will not require treatment because they have low grade forms of prostate cancer that just need to be monitored.
"A lot of prostate cancers won't require treatment and can be safely observed," Childs said. "Many will be treated and cured. There is still enough left out there that we need to catch the serious cases to save patient's lives."
Men who are diagnosed with prostate cancer and decide to have treatment have two options: surgery for a radical prostatectomy or radiation-based treatment. Both have potential side effects that impact the quality of life regarding sex life and urinary function.
"I have multiple, long talks with men to help them understand the advantages and disadvantage of treatment options," Childs said. "We try to give them the pros and cons of each option and let them decide for themselves. Some men gravitate toward surgery and some toward radiation. Most surgeons will recommend surgery for younger men, but for older men we often favor radiation over surgery. We are here to educate people and be a reliable source of information. At the end, we want them to be experts in their prostate cancer because no matter what they choose, there are potential ramifications."
There are two choices for surgery, open surgery or robotic assisted laparoscopic.
Whether open or robotic, the entire prostate is removed and a new connection created between the bladder and the urethra.
Many of Childs surgical procedures are done robotically.
"In the past ten to 15 years, robotic assisted laparoscopic prostatectomy has become the gold standard for a lot of reasons," Childs said. "There has been a lot of discussion about which is better. Robotic is more expensive in terms of costs, but has less post-operative complications and shorter hospitalizations and many studies support a better overall outcome with robotics. The largest factor depends on the experience of the surgeon. You can get a less ideal outcome from someone less experienced no matter what technology is used."
Following surgery, it is important for men to undergo physical therapy. Research supports that patients who participate in pre-operative and post-operative therapy have a more significant return to continence compared to patients without therapy.
Ashley Striegler PT, DPT
Ashley Striegler PT, DPT, Washington Regional Medical Center, said physical therapy after prostatectomy is performed to both strengthen the pelvic floor muscles, as well as teach the patient healthy bladder habits.
"We work on retraining the bladder for appropriate void volumes and times as well as urge control techniques," Striegler said. "Our patients are given one-on-one instruction beginning with the basic kegel exercise then we progress them to increasing their strength of squeeze as well as endurance to hold the squeeze. Therapy concludes with the patient performing appropriate body mechanics and proper use of the pelvic floor muscles and abdominals with squatting, lifting, sneezing, and any other activity that may cause urinary leakage."
Striegler said their job is to empower patients to initially reduce urinary loss and eventually perform a maintenance program at home. Continuing with the physical therapy, she said, allows quicker return to continence with men's daily activities, as well as with strenuous activity. It also helps improve sexual performance.