Prostate cancer often presents unique challenges to patients and physicians alike. It can be indolent and nonaggressive — or life-threatening and everything in between. Unlike most cancers that have a dedicated road map for treatment, prostate cancer revolves around opinions and biases.
1. What is my Gleason score?
The Gleason grade looks to define how close the cancer cells and tissue resemble normal prostate growth. The more normal it looks, the lower the grade and risk; the more different it looks, the higher the grade and risk. The cancer is assigned a grade of 1 to 5, 1 is the lowest risk and 5 the highest. Since the cancer can have multiple tumorous areas that can be different from each other, the two most common patterns found are used to come up with a Gleason score, which is the sum of the two. The aggressiveness of the cancer is defined by this Gleason score:
Gleason 6 (3+3) = low risk.
Gleason 7 (3+4 or 4+3) = intermediate risk, some cancers can act indolent or slow-growing, others aggressive.
Gleason 8-10 = High-risk cancer, aggressive, higher risk of spreading.
2. Is there a nodule expressing my cancer?
A palpable, cancerous nodule is more aggressive than cancer found with no nodule.
3. What is my PSA density?
PSA density is the ratio of the PSA (or prostate-specific antigen, a protein in a man’s blood that is often elevated in men with prostate cancer) to the total volume of the prostate. A PSA density of 0.15 or less is considered reassuring for being able to just observe the cancer.
4. What percentage of the total biopsy samples have cancer?
Most urologists take 12 cores, or biopsy samples. So knowing how many of the 12 are positive for cancer is an important measure for estimating the amount of cancer a patient may have. If fewer than a third of samples turn up positive, that is reassuring.
5. Among the positive biopsy samples, what percent of the tissue was cancerous?
Measuring the total volume of cancer in each positive sample serves as a surrogate for tumor volume. If 50 percent or more of a sample is positive, that would indicate significant cancer.
6. Is there perineural invasion?
When the cancer cells within the prostate begin to grow around the nerves that are in the prostate, this is called “perineural invasion.” Cancers with perineural invasion have a worse prognosis. Any cancer which has confirmed perineural invasion will require treatment as opposed to merely being kept under observation.
7. Should any imaging tests be performed?
Anyone with prostate cancer with high-risk features should have a CT scan of the abdomen and pelvis (to look for spread into the lymph nodes and liver) and a bone scan (to evaluate possible advancement into the bones).
An MRI of the prostate often is used for the initial diagnosis of cancer, since it can show whether the cancer has broken through the outer lining of the prostate, or capsule, and has begun to spread (called extraprostatic spread). Some expert urologists are able to ascertain from the ultrasound performed at the time of biopsy whether the cancer has spread beyond the prostate.
8. What are my options if my cancer is extraprostatic?
Cancers growing beyond the confines of the capsule of the prostate are aggressive and should not be just followed with regular observation. One should prepare for a multipronged approach to treatment. Surgical removal is typically preferred for the younger, healthier patient, followed by possible postoperative radiation (with possible hormonal suppression, as well).
If radiation is chosen, adding androgen (testosterone) suppression is necessary, usually for one year to two years in addition to radiation.
9. Is active surveillance or observation an appropriate treatment for my cancer?
Active surveillance or observation is an integral part of counseling patients newly diagnosed with prostate cancer. Thirty percent of prostate cancers diagnosed in the United States in the past 10 years were followed with regular observation.
The ideal candidates for observation include those with PSA scores of less than 10, Gleason scores of 6, PSA density scores of 0.15 or less, fewer than 15 percent of biopsy cores showing positive for cancer (3 or fewer out of 12), and fewer than 20 percent of one sample being cancerous.
10. What are the side effects of treatment?
It’s important to know all the potential complications of treatment. Not fully understanding them can be a source later of regret and anger (hint: if your doctor underestimates or glosses over the side effects — that should be a red flag).
The prostate is in a delicate neighborhood. It’s near the bladder, rectum, and nerves and blood flow for the penis. Any therapy — both surgical, radiation and others such as cryoablation and HIFU, or high-intensity focused ultrasound — will potentially affect any or all of these areas. After surgery, most men will experience some degree of urinary incontinence and erectile dysfunction, although the degree and duration will vary depending on numerous factors, such as age (younger men in the 50s to early 60s tend to recover relatively quickly), ability to spare nerves during treatment, size of the prostate (most men with larger prostates have more incontinence) and skill of the surgeon. Usually, sexual function is more difficult to recover than urinary function.
Radiation therapy can have similar effects, although sexual decline is more gradual — and rather than incontinence, men tend to experience a slowing of the urinary stream and more urgency. Radiation can also induce damage to the bladder and rectum, resulting in inflammatory bleeding of both organs. It may also induce inflammation and scarring of the urethra. Rarely, radiation can also induce bladder cancer and rectal cancer. These latter effects are usually seen many years after treatment.