Prostate cancer often presents unique challenges to patients and physicians alike. It can be indolent and non-aggressive — or life-threatening and everything in between. Unlike most cancers that have a dedicated roadmap for treatment for prostate cancer revolves around opinions and biases.
To help patients navigate the landmine of prostate cancer, I’ve compiled a list of 10 basic questions to ask when diagnosed with prostate cancer. Here they are:
1. “What is my Gleason score?”
The Gleason grade looks to define how close the cancer cells and tissue resemble their native forms – the more it resembles normal prostate growth, 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 which can be different from each other, the two most common patterns are graded on this scale to give a Gleason score (the sum of the two most common patterns). 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, 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. This is usually on digital rectal exam.
3. “What is my PSA density?”
PSA density is the ratio of the PSA/to the total volume of the prostate. For instance, if a patient has a PSA of 4 and a prostate volume of 40 cm3, the PSA density would be 0.10. PSA density <0.15 is considered reassuring for potentially observing the cancer.
4. “What percentage of the total biopsy has cancer?”
Most urologists take 12 cores as standard. So knowing how many of the 12 are positive is an important surrogate the amount of cancer a patient may have. Having less than 1/3 of the cores taken positive is reassuring.
5. “Of each biopsy positive biopsy specimen, what percent of the tissue is cancer?”
Each core biopsy that is taken usually is 12 to 15 mm in total length.
Measuring the total volume of cancer in each positive core also serves as a surrogate for tumor volume. For instance, if there is a 6 mm of cancer noted in a core that is 12 mm long, 50 percent of the core is positive for cancer. In general, cores that are 50 percent or more positive 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 observation.
7. “Should there be any imaging tests performed?”
Any cancer with high-risk features should have a CT scan of the abdomen and pelvis (spread into the lymph nodes and liver) and a bone scan (to evaluate possible advancement into the bones).
MRI of the prostate is being utilized for all grades and risks of cancer. For the initial diagnosis of cancer, this may be useful to ascertain extraprostatic spread (meaning the cancer has broken through the capsule, which is the outer lining, of the prostate). A minority of skilled and expert urologists (and I would put myself in this category) can ascertain spread of the cancer beyond the prostate from the ultrasound performed at the time of biopsy
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 observed. In fact, one should prepare for a multimodality approach to treatment. If surgical removal is chosen (typically preferred for the younger, healthier patient), one should prepare for possible postoperative radiation (with possible hormonal suppression as well).
If radiation is chosen, adding androgen (testosterone) suppression is necessary, usually for 1 to 2 years in addition to radiation.
9. “Should I observe my cancer?”
Active surveillance or observation is an integral part of counseling patients newly diagnosed with prostate cancer. Fully 30 percent of cancers diagnosed in the U.S. are observed over the last ten years. Many of the above criteria are utilized to determine which patients are best suited.
Gleason score 6
PSA density <0.15
<15 percent of cores positive for cancer (less than 3 out of 12 cores)
<20 percent of any one core positive
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 of subsequent regret and anger (hint: if your doctor underestimates or glosses over the side effects — that should be a red flag).
The prostate is located in a very delicate neighborhood. It’s near the bladder, rectum and near nerves and blood flow for the penis. Any therapy, both surgical, radiation and others such as cryoablation and HIFU, 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 on numerous factors such as age (younger men 50s to early 60s recover relatively quickly), ability to spare nerves, 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.
Likewise, radiation can affect these as well, although sexual decline is more gradual and rather than incontinence, men experience slowing of the 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.
Naeem Rahman is a urologist and can be reached at his self-titled site, Naeem Rahman, M.D.
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