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Prostate cancer, the second leading cause of cancer death in American men, does not lend itself to "one size fits all" diagnosis and treatment, according to a local urologist. The disease's lack of early symptoms, combined with an imperfect marker to detect the disease, can contribute to delayed diagnosis. The decision about whether to treat the cancer is no less clear-cut when factoring in the health and age of the patient, family history, longevity and the growth rate of the disease.

"There have been questions raised within the medical community about whether we are over-screening," said Gregg E. Zimmerman, M.D., of Morris Urology, a division of Garden State Urology, and physician program coordinator of robotic surgery at Saint Clare's Hospital. He is one of the few fellowship-trained urologic oncologists in northern Jersey with expertise in robotic surgery.

"There is no harm in screening," said Zimmerman. "The better question is: When should we be treating the disease?" The answers are controversial in the medical community and often confusing for patients. Doctor and patient must look at all factors for each individual case to help the patient arrive at the decision that is right for him.

The Difficulty in Diagnosis: An Asymptomatic Disease and an Imperfect Marker

The prostate gland is found in the male reproductive system. About the size of a walnut, it is located below the bladder and in front of the rectum. It surrounds the urethra, the tube that connects the bladder and penis. The prostate has two functions: It controls the rate at which urine flows out of the bladder, and it secretes a whitish fluid that is fed into the urethra during ejaculation. The fluid gives the ejaculate its whitish appearance and also helps the movement of sperm.

It is estimated that one in six men will develop prostate cancer in their lifetime. The National Cancer Institute notes that there are 192,280 new cases of prostate cancer in the United States annually, with 27,360 men dying from the disease.

One difficulty in diagnosis is that prostate cancer is largely asymptomatic during the early stages. It is not unusual for a patient to be diagnosed with prostate cancer during this time and still "feel fine." In advanced cases, there may be symptoms such as difficulty urinating, urine retention, bone pain, weakness and weight loss. There may also be blood in the urine or semen, discomfort in the pelvic area and swelling in the legs.

The primary screening method involves a blood test called a prostate specific antigen, which measures the level of a protein produced by the prostate, and a digital rectal exam to evaluate for abnormalities. The PSA level is used as a tumor marker because the level typically rises in men when prostate cancer is present. A DRE may reveal a nodule on the prostate. If the PSA level is elevated and/or the DRE is abnormal, a prostate biopsy may be recommended.

A "normal" PSA reading historically has been considered to be between 0 and 4 ng/mL. However, as Zimmerman notes, men with PSA levels in this range can still have prostate cancer.

"Although PSA levels below 4 ng/mL are considered a normal range by the medical community, there is no real ‘normal' range," explained Zimmerman. "The PSA marker is the best we have, but it's not perfect. The PSA velocity, or how that number changes over time, is a more accurate indicator. For example, a patient with a PSA of 6 consistently over a number of years may not be cause for concern. However, if a patient has a PSA that jumped from 0.5 to 1 and then 2, it could indicate a problem, even though the numbers are in ‘normal' range."

While PSA is very sensitive and thus useful in detecting prostate cancer, it also can rise for other reasons. Common causes of PSA elevations include inflammation, such as in prostatitis; urinary tract infections; or an enlarged prostate called benign prostatic hyperplasia, which is common in men over 50. Even seemingly innocuous events such as a bumpy car ride or an ejaculation can cause the level to rise.

The Decision to Treat and the Options Available

Fortunately, prostate cancer is typically a slow-growing disease. There are often many treatment options for patients with prostate cancer. Options include continued monitoring or active surveillance, surgical removal of the prostate, radiation, and cryoablation - a freezing technique. The decision to treat often depends on grade (how aggressive the cancer is), stage (where the cancer is), patient age and life expectancy, presence of other medical problems and a patient's personal preference.

Prostate Cancer Surgery Options

One common way to treat prostate cancer is with surgical removal of the entire prostate. The open radical prostatectomy has been the surgery of choice for many years. In recent years, the minimally invasive robot-assisted laparoscopic radical prostatectomy was introduced and has since become the gold standard treatment for prostate cancer.

"There has been a shift in the paradigm for treatment of prostate cancer, from the open radical prostatectomy to minimally invasive robotic prostatectomy," said Zimmerman.

• Open Radical Prostatectomy. This traditional form of surgery requires a large, open midline incision. It is a major surgical procedure with a hospital stay of three to five days. Patients wear a catheter following surgery for two or three weeks and typically return to work in approximately six weeks.
• da Vinci Robot-Assisted Laparoscopic Radical Prostatectomy. This procedure allows better control, extreme precision, and a greater range of movement than is possible for a surgeon operating with his or her own hands inside the body. This is a technically more advanced procedure that requires additional training and skill. Benefits for the patient include a shorter hospital stay (typically overnight), smaller incisions, less blood loss, less pain and a quicker return to normal activity. Patients wear a catheter for about a week following surgery and may return to work within two weeks.

After surgical removal of the prostate, PSA levels should become undetectable, as long as the cancer was organ-confined (had not spread outside the prostate).

Questions to Ask Your Doctor

Annual screening for prostate cancer is typically recommended for some men beginning at age 50. High-risk patients, including African-American men and those with a family history of the disease, should begin screening at age 40. Men concerned about prostate cancer should ask the following questions of their primary caregiver or urologist:

• Is PSA a reliable marker for the detection of prostate cancer?
• What are my options if prostate cancer is suspected?
• What are the personal factors that should be considered for treatment?
• Does prostate cancer need to be treated in all cases? In my case?
• What are all the treatment options and the respective risks and benefits?
• Can urinary continence and control and sexual function be affected by treatment?

Patient Example: 57-Year-Old Oak Ridge Man

At age 57, Joseph Riggs was a healthy, active resident of Oak Ridge, N.J. He made it a point to get annual checkups, eat right and exercise regularly. It was during an annual physical that he discovered his PSA reading had jumped from 0.6 to 1.6 in just the past year. Although it was well within "normal" range, the elevation gave Zimmerman reason to pause, and he educated Riggs about his options. These included follow-up with PSA testing and rectal examinations at shorter intervals of three or six months, or the more aggressive approach: a prostate biopsy.

Riggs chose to be aggressive. The biopsy came back positive, indicating cancer. Risks and benefits were all discussed, and Riggs elected to undergo a robot-assisted laparoscopic radical prostatectomy performed by Zimmerman. He went in on a Thursday morning and walked out of the hospital on Friday. He wore a catheter for a week. The day after it was removed, he was able to resume his regular exercise program.

"I probably could have gone back to work except for the catheter," said Riggs. "There was very little pain and almost no aftereffects."

Riggs continues to have normal urinary and sexual function. A year later, he remains cancer-free.

— ANDY LAGOMARSINO, NEWJERSEYNEWSROOM.COM