Signals from the prostate: Is it smoke? Or fire?
Staging, and grading, and risk stratifying, oh my.
By Howard Wolinsky
Some sage or another said: When the student is ready, the teacher will appear.
A loyal reader of TheActiveSurveillor, com sent me a note about what are the steps to staging grading ad stratifying risk for prostate cancer.
The next day the teacher appeared: Stephen Freedland, MD, a urologist at Cedar Sinai Medical Center in Los Angeles, appeared in a video at Urology Today. The video at https://www.urologytimes.com/view/staging-grading-and-risk-stratification-of-prostate-cancer is worthwhile, especially for those with rising PSAs in the twilight zone and for the newly diagnosed.
“Diagnosing prostate cancer is tricky. There are a lot of tests we use, and, typically, patients are referred for an elevated PSA from their primary care doc. Sometimes we’re doing the actual screening. But usually, they come in the door with an elevated PSA. So, it’s our job – I always explain to patients, it’s kind of a smoke signal. It’s our job to figure out if there is a fire there or not.”
The doctor takes a history. Does the patient have a urinary tract infection? Is there a family history of prostate cancer? Are there comorbidities such as heart disease, kidney disease, or diabetes?
Next comes a digital rectal exam. The urologist is looking for nodules, a sign of a more advanced prostate cancer.
“One of the first steps I have to do is repeat that PSA and make sure it’s real. You’d be surprised how often the PSA is elevated, and when we repeat, it comes back down as normal,” Freedland said.
Patients with 4-10 ng/mL and those even higher these days move on to multiparametric MRI..
The average age of diagnosis is 66.
The process between doctor and patient is supposed to involve “ shared decision-making.”
“Based upon the MRI and the PSA level, we make a decision collectively whether to proceed to biopsy or not. If there is uncertainty in that decision, at least in my practice, I think that’s where additional biomarkers, whether it be urine or blood, can come into play,” Freeland said. “To a certain degree when in doubt, biopsy. If we’re really not sure, we can keep doing test after test, but eventually, we have to put some needles in there and find out for peace of mind. It all depends on the patient’s mindset, their aims, their comorbidities, their life expectancy - a lot of factors are in play there.”
Next? Determine how aggressive the cancer is through staging and grading.
“The grading is relatively straightforward. That’s what the pathologist looks at – at the microscope and tells us, first off, is there cancer? Yes? No? And second, if there is cancer, how aggressive does it look in the microscope? And the third is how much cancer?” Freeland said.
For more, check out the video. Freedland also does a presentation on treatment options for high-risk localized prostate cancer.
The Prostate Forum of Orange County is holding a webinar “Making Peace with Anxiety” (Perspectives from a cancer survivor) at 7:00-8:30 p.m. Pacific July 28.
Sarah Fenlon-Falk, LCSW, of Sarah Falk Coaching and Consulting, a therapist and cancer patient, will be speaking about how to identify stressors and soothers and rethinking anxiety so it won’t stop us.
Click on: https://us02web.zoom.us/j/85477749453
Join the ASPI program on diet: “Eat to Beat Prostate Cancer,” at 12p.m. Eastern July 30 featuring Dr. William Li, a famed TED talker on diet and cancer.
Free Registration: www.aspatients.org or go direct to: https://bit.ly/3t5lFLx
Free prostate-healthy recipes for all registrants.
More info: info@aspatients.org; or DrDavidKingKeller@gmail.com
Stacy Loeb, MD, of NYU Langone, and Justin Gregg, MD, of MD Anderson, recently presented a webinar on diet and other lifestyle factors to the AnCan group. To view, go to: https://ancan.org/webinar-optimizing-sleep-exercise-and-nutrition-in-prostate-cancer/
If you haven’t already, sign up for free genetic testing for prostate cancer: prostatecancerpromise.org from a study at Johns Hopkins and Memorial Sloan Kettering Cancer Centers.
Thanks, Bert. Appreciate your weighing in. I underwent "shared decision-making," where my urologist only recommended surgery and wouldn't support AS.
Howard
Ok, so shared decision-making sounds reasonable but patients can easily be steered towards unnecessary evaluation and treatment by the physician.
> The PSA is horrible biomarker that is not cancer-specific and comes with a 78% false positive rate.
> MRI, other types of imaging and pathology, are subject to significant errors of interpretation.
> The grade 3 in the G6 is a bogus cancer.
> Biopsies weren't defined - if random, this "test" is risky and grossly unscientific - sampling blindly and randomly 0.1% of the prostate.
> MRIs should be undertaken only by real experts in the field and if hi Pirads areas are detected, further evaluated by MRI-guided biopsy.
All healthcare recommendations should be supported by irrefutable and reproducible scientific data.