By Chien Peter Chen, M.D.
September is National Prostate Cancer Awareness Month, a time to learn the latest about this significant men’s health issue.
The American Cancer Society estimates that in 2016 there will be more than 180,000 new cases of prostate cancer in the United States, along with more than 26,000 deaths from the disease.
While the first reaction to learning of a prostate cancer diagnosis may be to seek immediate treatment, this is not always necessary. “Prostate cancer is a complex disease and each patient’s situation should be evaluated thoroughly to arrive at the most appropriate, individualized care plan,” said Chien Pong (Peter) Chen, M.D., a radiation oncologist at the Scripps Radiation Therapy Center on the Torrey Pines Mesa.
Some cases of prostate cancer are highly aggressive and pose significant risk of death, while other cases are nonaggressive and carry relatively low risk. The key is to identify which patients have more aggressive cancer and would therefore benefit from more aggressive treatments.
Patients with a slow-moving form of prostate cancer can consider a strategy called “active surveillance.” With this approach, patients can be tracked through a series of prostate-specific antigen (PSA) tests and biopsies. As a result, they don’t have to rush into treatments, such as surgery, radiation or hormone therapy.
Active surveillance allows patients to avoid the potentially life-altering consequences of aggressive treatment. But if the cancer changes course, clinicians have a growing number of treatment modalities available, including some exciting developments in radiotherapy.
Advances in Radiation Therapy
Many prostate cancer patients who choose to undergo treatment receive radiation therapy as part of their care. The most prevalent form of radiation therapy, external beam radiation, has seen considerable advances in recent years.
For many years, the traditional course of radiation treatment for prostate cancer patients has been eight weeks of daily treatment, Monday through Friday, for a total of 40 treatments. But data from clinical trials have shown the effectiveness of a technique called “hypofractionation” – delivering higher doses of radiation in a smaller number of treatments, which is reasonable for low- and intermediate-risk prostate cancer.
With hypofractionation, physicians can safely deliver the same effective radiation dose to the patient in four to five weeks, which is approximately half the time of the traditional approach. The use of hypofractionation for prostate cancer is now part of the National Comprehensive Cancer Network guidelines, and the option is available to patients at Scripps in appropriate cases.
Stereotactic body radiation therapy (SBRT) is another relatively new approach to delivering radiation to low- and intermediate-risk prostate cancer patients. With SBRT, a very high dose of radiation is delivered in one to five total treatments. Clinical trials data have been steadily maturing in support of SBRT for some prostate cancer patients.
For both hypofractionation and SBRT, the main benefit to the patient is convenience, while still achieving comparable treatment outcomes as the longer conventional treatment regimens. With hypofractionated radiotherapy, patients are able to complete their treatment in far fewer treatments, which allows them to get on with their recovery process more quickly.
Some men are confused about whether they need to be screened for prostate cancer, and understandably so. In recent years, the United States Preventive Services Task Force recommended to end routine PSA screening for all men. Access to PSA tests should not be completely eliminated, but rather modified to catch the most worrisome prostate cancers at an early stage.
Men younger than 55 who are at higher risk, which includes African-Americans and men who have first-degree relatives diagnosed with prostate cancer at an early age, can consider discussing the pros and cons of PSA screening with their doctor.
The greatest benefit of screening appears to be in men 55 to 69 years and thus, men in this age range with no family history can consider discussing PSA screening with their doctor. Men 70 or older who are in excellent health and have more than 10 to 15 years of life expectancy can also consider PSA screening.
Men should keep in mind that the PSA test is both clinically valuable and flawed. There are men who have high PSA numbers and no cancer, and others who, despite normal PSA results, still have the disease. But it’s the best initial screening test available.
Because the PSA test has these shortcomings, the medical community has developed a more nuanced approach to its results, individualizing care for each patient. PSA numbers must be put into context with ethnicity, family history and other risk factors. In addition, one test may not tell the complete story. A series of PSAs can show if the numbers are changing over time.
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