Prostate cancer treatment can sometimes cause more problems

With a family history of cancer, Robert Lynch faithfully got a PSA (prostate-specific antigen) test for 30 years to keep tabs on his prostate. His diligence paid off when prostate cancer was detected at an early stage."I had an elevated PSA test two years ago so I had biopsies taken that showed precancerous cells,” said the 73-year-old retired Mifflinburg teacher and administrator. “Later, they did turn into cancer.”Once diagnosed, the trick is knowing which treatment to choose — or whether it’s worth treating at all. Sometimes side effects of treatment, which can include incontinence, impotence or risk of developing a secondary cancer from radiation, may be harder on the patient than the disease itself.Although many men will develop prostate cancer if they live long enough, most men won’t die from it. In 2011, there were some 240,000 new cases of prostate cancer, but only 33,720 men died from it, according to the National Cancer Institute.However, it is the second-leading cause of male cancer deaths and definitely warrants a man’s attention, doctors say.“The question I always ask my patients is, ‘If you were diagnosed with prostate cancer, would you want to go through treatment?’ said Dr. Jay Raman, urologist at Penn State Milton S. Hershey Medical Center. “Some men say, ‘I have eight other medical problems so no, I wouldn’t.’ In that case, we just monitor it with PSAs.”Lynch could have chosen watchful waiting, surgical removal of the prostate gland, or radiation — either high doses of radiation to the prostate gland or implanting radioactive seeds into the prostrate, which work over about an eight-month period. Cryotherapy, which freezes prostate tissue and causes cancer cells to die, is an alternative to surgical removal."With the strong history of general cancer in my family, to me it was a real peace of mind to have it removed,” said Lynch who had a prostatectomy last November. “My health was good so I was a good candidate for surgery. In my mind, I expect to live to be 100!”

Patients and their doctors decide on treatment based on the patient’s age, overall health and grade and volume of the cancer, doctors said. The higher the grade, called the Gleason score, and volume — the number of biopsies out of the dozen taken that test positive for cancer — the more likely the cancer will progress rapidly and metastasize, said Dr. R. Scott Owens of Urology of Central Pa. in Camp Hill.

“The majority of men have a very low-risk disease that’s unlikely to progress and so their decision is easier,” said Dr. Justin Juliano, radiation oncologist at Hershey Medical Center. “It’s the high-risk patients that are hardest to address because there’s not a unified approach on how to treat them and there’s a lot of room for improvement as far as our outcomes.”

Before a man ever gets to a diagnosis, he faces a controversy over whether the PSA test itself is worthwhile.

The American Cancer Society no longer recommends screening with the PSA test. The American Urologic Association, however, recommends a screening PSA test at age 40 combined with a digital rectal exam. If normal, doctors usually repeat the test in another three years.

“There has been this nebulous argument for the past 10 years over the PSA test and it’s frustrating,” Owens said. “Ninety percent of early prostate cancer doesn’t produce symptoms, so the PSA test is the only way to pick up early cancer.”

The PSA doesn’t indicate aggressiveness, but it is a red flag that can save lives, doctors said.

“Having the diagnosis is not synonymous with needing treatment,” Raman said. “I have a lot of men who have had elevated PSAs and have had biopsies, but because it is low grade and low volume, they opt not to be treated. However, there are some men who, regardless of that, want to treat the cancer. While there is a component of overtreatment, there is also a cohort of patients that you could undertreat who may end up dying.”

Most younger men choose surgery, but they face a real risk of incontinence and impotency, Owens said. With robotic surgery, the chances of this are lower, however.

“My parting line with most patients is that they can’t really make a bad choice in terms of outcome because it’s not like one treatment is better than another,” Juliano said. “You look at the side effects and make a personal choice based on that.”

Lynch experienced temporary incontinence that meant he had to wear pads, but said he is 98 percent recovered. He did Kegel exercises daily to strengthen his pelvic floor muscles.

Compromised sexual function can be another side effect. To that, Lynch said, “My wife would tell you I am fully recovered.”

While talking about his personal experience with prostate cancer can be embarrassing, Lynch said he discusses it because he wants to encourage men to get over their embarrassment, especially since it might be endangering their health.