PC Testing Archives

Testing is an ever-present part of the journey for prostate cancer, helping identify stage, treatment options, progress, and potential recurrence. Testing can also introduce a whole new vocabulary into your life. Don’t let jargon overwhelm you or undermine your grasp of test options and results.

More resources for Prostate Cancer Testing from Patient Empowerment Network.

How Can You Access Personalized Prostate Cancer Treatment?

How Can You Access Personalized Prostate Cancer Treatment? from Patient Empowerment Network on Vimeo.

How could genetic testing results affect your prostate cancer treatment plan? In this INSIST! Prostate Cancer webinar, Dr. Sumit Subudhi will discuss key prostate cancer tests, the latest targeted therapies and tools to help you advocate for a personalized treatment approach and insist on better care.

Dr. Sumit Subudhi is a Medical Oncologist at The University of Texas MD Anderson Cancer Center.

Download Program Resource Guide

Related Resources

 

 

Three Key Steps to Take Following a Prostate Cancer Diagnosis

 

 


Transcript:

Katherine:                  

Welcome to Insist Prostate Cancer, a program focused on empowering patients to insist on better care. Today we’ll discuss the latest advances in prostate cancer, including the role of genetic testing and how this may affect treatment options.

I’m Katherine Banwell, your host for today’s program. And joining me is Dr. Sumit Subudhi. Welcome, Dr. Subudhi. Would you please introduce yourself?

Dr. Subudhi:        

Hi, I’m Sumit Subudhi. I’m a medical oncologist at MD Anderson Cancer Center, and I specifically focus on prostate cancer.

Katherine:    

Excellent, thank you. Before we start, a reminder that this program is not a substitute for seeking medical advice. Please refer to your own healthcare team. Well, Dr. Subudhi, I’d like you to begin with a brief explanation of the stages of prostate cancer.

Dr. Subudhi:               

Yeah, that’s a great question. So, we use stages, and there’s four – Stage I, II, III, and IV. And we use it to help us determine what treatments the patients need for their prostate cancer. In general, Stage I is localized prostate cancer, and it’s localized only to the prostate. And when we do a digital rectal exam, we cannot feel or palpate the prostate.

And the treatment for Stage I prostate cancer is either active surveillance, where you’re not trying to cure the cancer, you’re just actively watching it, and you’re using a PSA imaging studies, prostate biopsies, and digital rectal exams at regular intervals to follow the patients. But other patients with Stage I prostate cancer can actually get definitive treatment for curative intent with radiation therapy or surgery. Stage 2 prostate cancer is also localized, but on physical exam, we can actually palpate or feel the prostate cancer. And this also can receive definitive treatment for the prostate to cure it, and that, also, you can use radiation therapy and surgery.

Stage III is what I consider locally advance. This is where the prostate cancer is now starting to leave the prostate. And it still can be cured by radiation and surgery, but most likely needs a multidisciplinary approach, where you might need both or maybe even in addition of a systemic therapy. Stage IV is the last stage that I’ll talk about, and it has distant metastases. And here we’re not looking for a curative approach; we’re actually looking for palliation, which means that we’re trying to treat the prostate cancer as a chronic disease.

Katherine:                  

I understand that there are many types of prostate cancer that have been identified. How can patients advocate for a precise diagnosis?

Dr. Subudhi:    

Yes, you’re absolutely right. There are many types. So, we have historically used histological classification. And when I say histological, that means when we look at the cancer under the microscope, we can look at the different structures within the prostate cancer and classify them.

And there are multiple types such as adenocarcinoma, neuroendocrine, small-cell, mucinous, etc. But more recently, with the advances in genetic and molecular testing, we now can look at the genes inside the prostate cancer, and that has also helped us better classify the cancer. Now many of these types of approaches are best done at major cancer centers, where they have experienced pathologists who actually evaluate both histologically and molecularly the cancer.

So, I recommend to my patients, or family and friends, that have been diagnosed with prostate cancer that they don’t necessarily have to go to the major cancer centers. They can have their local doctor send the tissue from the biopsy to the advanced cancer centers to get a second opinion.

Katherine:    

But this would be an initial visit to a doctor. Is that right?

Dr. Subudhi:    

Good question. So, I’m presuming that the patient is actually being seen at a local center where they have a local doctor, and so they don’t have to come, for example, to MD Anderson Cancer Center to see me. They could actually have their tissue sent to our pathologists and get it reviewed, and they can still be at home. And especially in this era of COVID, that’s important.

Katherine:      

What is the role of genetic testing in prostate cancer?

Dr. Subudhi:     

That’s a great question, because this is something that wasn’t really available when I was training and understanding prostate cancer. But over the last few years, this has actually hit the mainstream, and it’s very important. And I see it having three roles. The first role is whether or not you can receive a certain type of targeted therapy or systemic therapy known as PARP inhibitors. So, if your genetic test is positive for certain markers – that I think we’ll cover later – then it can help give you more treatment options. The second is that generate testing can give you also risk of other cancers besides prostate cancer. For example, if you have the BRCA mutation, you’re 15% to 20% more likely to get breast cancer in men.

The third is that because the genetic testing is looking for inheritable mutations in your genes, that means you can pass it along to your kids. And this could have a tremendous impact on the screening strategies your children want to use in the future.

Katherine: 

Would you mind going into that a little bit?

Dr. Subudhi:  

Yeah.

Katherine:  

For instance, my ex-husband had early prostate cancer. My 22-year-old son is worried now about also getting prostate cancer. His grandfather had prostate cancer.

Dr. Subudhi:               

Yeah, great question. So, it’s not just about prostate cancer. So, prostate cancer, genetically, is linked to other cancers, as well.

So, in your case, you’re turning by your son. But if you have daughters or any female members in the family, consideration needs to be given to breast and ovarian cancer. And for both men and women, we also have to think about melanoma and pancreatic cancer. So, it’s not just prostate cancer that we’re thinking about when you have these genetic risks. And that’s very important, because each of these different cancers can have different screening modalities.

Katherine:                  

Oh. Well, how is the testing administered then?

Dr. Subudhi:               

The testing is actually a blood test, so very simple.

Katherine:                  

Have there been any major advances in testing?

Dr. Subudhi:               

Yeah, so when we’re talking about the inheritable testing, that’s just a simple blood test. And the reason why it can be done simply through the blood is because every cell in your body has it. So, when they collect the blood, they can just take any cell from there and do genetic analysis. And if that gene is mutated or missing, it will be captured.

Now, there’s another type of testing where they test your tumor tissue itself – so, your cancer tissue – whether you got it by biopsy or surgically removed. And so, that’s a different type of testing. That’s looking for what we call somatic mutations. These are not inherited mutations. These are mutations that are specific for your prostate cancer. Again, in contrast, the inheritable mutations are in every cell in your body – not just your prostate cancer cells, but every cell in your body. And the somatic, it’s just in your prostate tissue itself.

And so, sometimes with prostate cancer, it’s difficult to get the tissue. And what’s happened more recently – and to answer your question – is that the advances have been in what we call liquid biopsies, where they are able to use your blood and get the DNA from the tumors and actually genetically test the cancers that way. And so, that’s where the future is going.

Katherine:      

Oh, that’s amazing. Are there specific tests that patients should ask their doctor for following the diagnosis?

Dr. Subudhi:   

Yeah. So, if inpatients with high risk or metastatic prostate cancer, they should definitely be considering tests to see if they have mutations in what we call the DNA damage repair pathway or homologous recombination DNA pathway. And I know they’re fancy terms. What these genes are, they’re genes that help the body repair their DNA, and DNA is very important. And so, when there’s defects in the DNA repair pathway, then mutations occur. And these mutations can actually help the cancer grow.

Now what’s happening is that what they’re looking for in these genetic tests – whether it’s the inheritable test or the somatic mutation test that’s looking just within the tumor itself – they’re looking to see if there’s any DNA damage machinery that’s defective. And if it is, then you’re more likely to benefit from PARP inhibitors, which are oral drugs that specifically target the DNA repair pathway.

Katherine:    

All right. Dr. Subudhi, what is the link between inherited mutations and prostate cancer?

Dr. Subudhi:               

Yeah, so in approximately 10% to 15% of patients with prostate cancer, they have an inheritable cause for their cancer. And so, this predisposes them to not just having prostate cancer, but potentially to other cancers, but also their family members.

Katherine:                  

Would you give us an overview of common mutations in prostate cancer?

Dr. Subudhi:               

Yeah. So, in regards to the inheritable causes, the BRCA mutations – BRCA2 and BRCA1 – are very common. In fact, BRCA2 is more common than prostate cancer than BRCA1. In addition, there’s CHEK2 and ATM which are common inheritable mutations. And the other ones are the mismatch repair genes. Again, all these play an important role in repairing DNA. So, if you’re mutated in these genes, then your ability to repair DNA has been significantly diminished, and you’re more likely to gain more mutations.

Katherine:                  

How do these mutations affect disease progression?

Dr. Subudhi:               

Yeah. So, what they can do is they can lead to mutations that make the cancer grow more. And there’s two ways to do it. You can have a mutation in what we call an oncogene, a gene that when it’s active, it’s going to just promote the cancer.

And then we have other genes called tumor suppressor genes. Their normal function is to prevent the cancer from growing. But if the tumor suppressor gene gets mutated so it’s no longer functional, then the cancer can then take off, because it’s no longer suppressed. So, those are how these genes can actually affect the prostate cancer.

Katherine:                  

What about treatment options, what’s available?

Dr. Subudhi:    

Yeah. So, if you have either an inheritable mutation in these genes or a somatic mutation, then there’s a chance that the PARP inhibitors could actually work for you. And the PARP inhibitors, they actually target cancers where there’s a defect in the DNA repair pathway.

Now, there’s one thing that I want to point out that a lot of people sort of are missing, and it’s not a subtle point. Not all inheritable mutations are made the same – or even somatic mutations. Meaning, what we’re learning is the PARP inhibitors seem to be more active with the “Braca,” or BRCA, mutations and the ATM mutations. Whereas, they’re less active with other types of DNA repair mutations. So, the point is not all mutations are made the same.

Katherine:                  

Let’s turn to targeted therapies. How exactly do they work?

Dr. Subudhi:      

Yeah. So, this is a form of personalized medicine. So, what you’re doing is you’re looking at the patient’s cancer, either their inheritable cause of genetic causes or the somatic. And then you’re saying, oh, wait, they have a genetic defect in a DNA machine. So, let’s use the PARP inhibitor, which also targets the DNA machinery.

And these are the cancer cells that are most likely to be susceptible to PARP inhibition. And actually, the cancer cells will die from it. Whereas if a patient has a normal DNA machinery, the PARP inhibitors will actually not have any effect on the cancer.

Katherine:                  

Oh, I see. Just as a follow-up, how are these targeted therapies administered?

Dr. Subudhi:               

They’re given, actually, orally twice a day. The two drugs are rucaparib and Olaparib that have been FDA approved for this indication.

Katherine:                  

How do these newer treatments differ from traditional chemotherapy?

Dr. Subudhi: 

That’s a great question. So, with chemotherapies, at least in prostate cancer, they’re given intravenously every three weeks. And the goal of the chemotherapies, they are actually designed to kill any actively dividing cell in the body.

And the problem is it’s not just cancer cells that are actively dividing in our body. For example, with the chemotherapy such as docetaxel or cabazitaxel, that’s used in prostate cancer – their brand names are Taxotere and Jevtana – these chemotherapies will also affect hair loss. Why? Because hair grows really fast. And in fact, I need a haircut every three to four weeks, which my wife has been helping me with.

So, the chemotherapies are targeting all actively dividing cells, and that’s why you also get nausea vomiting, because the cells of our GI tract are also affected by that. So, chemotherapies are not personalized. They’re there to kill actively dividing cells. Luckily prostate cancer divides a lot more quickly than any other cell in our body, and that’s why they’re susceptible to chemotherapy.

Katherine:   

And as far as the targeted therapies, Dr. Subudhi, are there side effects with those?

Dr. Subudhi:     

Yeah, there are. One of the most predominant side effect is actually anemia. And so, that’s when the red blood cells in our body are lower than usual. And so, that’s one of the major side effects for PARP inhibitors. But in addition, you can have nausea, vomiting, and diarrhea as other side effects with the PARP inhibitors.

Katherine:  

What are you excited about in prostate cancer research right now?

Dr. Subudhi:  

So, to me, it’s the combination of treatments. So, not just treating with one PARP inhibitor or just one hormonal therapy, it’s combining these approaches, and especially with immunotherapies, so that we can potentially cure what’s considered incurable cancer. To me, that’s the most exciting.

Katherine:   

What would you say to patients who are nervous about participating in a clinical trial?

Dr. Subudhi:    

Yeah. This is a common question that I deal with in clinic, because we tend to have a lot of trials at MD Anderson. And the first thing, for me, is to understand why they’re nervous, because there’s different reasons why people are nervous.

Some people have heard of placebo trials, where the experimental drug that they’re hoping to get is only given to a portion of the patients and not all. And so, patients are worried what if they get on the placebo arm. And so, what I tell patients in that case is that please note that you’re going to be monitored very closely – more than usual, and so I’ll be seeing you in clinic more often. And if there’s any signs of progression, I will take you off the study. But I also always have a back-up plan. So, I tell them this is the next drug I’m going to give you if you progress, so don’t worry, I’ve got a plan for you. So, that’s one thing.

The other thing that people get concerned about are experimental drugs – just the fact that they are experimental. And I have to remind them that all these standard therapies that we have for prostate cancer were all experimental at one point. And it was the courage of the other patients that went through clinical trials that helped bring it as standard of care. And then sometimes some people have issues with travel, and those are more logistical issues. And especially now with the COVID era, we have to think about that. And so, we’re also trying to find and use networks to see if there’s other trials that are more amenable for patients so they don’t have to travel far.

Katherine:     

How can patients find out about clinical trials that may be right for them?

Dr. Subudhi:               

Yeah. So, one way is using clinicaltrials.gov. And that’s a website that allows you to search for specific trials either by drug name or by disease type – so, for example, prostate cancer. So, that’s one resource. And the others are cancer societies like the American Cancer Society or ASCO or Prostate Cancer Foundation. They also have links to clinical trials that are exciting.  

Katherine:                  

Do you recommend having patients see a specialist?

Dr. Subudhi:               

Absolutely. I think that if you have a metastatic disease, you need to have a medical oncologist on board that can still work with your urologist, who’s more surgically trained.

Katherine:                  

Right. Well, we’ve talked about COVID a couple of times, and I’d be remiss if we didn’t touch upon it now. What should prostate cancer patients be considering at this time, especially those with advanced disease?

Dr. Subudhi:               

Yeah, so what I don’t want are people to say, oh, I can wait a little bit longer to contact my physician, whether it’s primary care or a prostate cancer doctor, because of COVID. I think it’s very important that the medical team is up to date on a patient’s symptoms and what’s going on medically, whether it’s related to prostate cancer or not. And so, that’s one of the messages we’ve been trying to pass on to our patients.

And with every single patient, we try our best to see if we can provide medical care as well as expertise without having physically see them through telehealth, whether it’s through video or whether it’s just through a simple phone call. So, we’re trying to look at that with each individual patient. Now, sometimes when there’s treatment decisions that have to be made – especially like do we start chemotherapy? – it’s harder to do that over the phone. But sometimes what I’ll do for my patients that are in areas where COVID is really worrisome, I’ll work with the local medical oncologist and talk to them and basically see if we can develop a plan together so that the patient can be served best.

Katherine:                  

Is there a time when telemedicine is more appropriate than others?

Dr. Subudhi:               

I think that has to be a case-by-case basis. And that’s how we do it in clinic.

Every week, a week before hand, I go through my entire clinic list – I go through each patient’s case – and I say, okay, this is a patient that would be better served with telemedicine, this is a case that I really need to see the patient to get a better sense of what to do next.

Katherine:                  

If a patient has to go into clinic, what safety measures are in place for them?

Dr. Subudhi:               

Yeah, so I can only speak for our hospital and how we’re doing it. But there’s actually like a thermal scan where when you walk in the building, they actually measure your temperature without you even knowing it. But they delete it, so it’s not something that’s kept. And this is still kept private, so you don’t have to worry about public disclosure of your temperature. And so, they’re monitoring both the staff and the patients – their temperatures. The staff themselves have to go through screening questions that they have to answer every time, and they’re actually handed a mask that’s required to be used at all times.

As far as patients go, they are also getting their temperature measured. But in addition, they are asking questions about their exposures, whether it’s family members that are asymptomatic, or not symptomatic. And in addition, the new patients will get a COVID test done prior to seeing the medical team. And for the follow-up patients, they’re not required to get a COVID test unless there’s concerns of symptoms.

Katherine:                  

Unless they’ve been exposed to somebody?

Dr. Subudhi:               

Correct, that’s right. Thanks for pointing that out. In addition, all patients are asked to wear their masks at all times, especially if they’re going to be within 6 feet of a healthcare provider or a patient or anyone else. And so, these are the measures that we’re taking to keep our patients safe.

Katherine:                  

Oh, good. Dr. Subudhi, what advice do you have for patients who may be hesitant to speak up an advocate for themselves when it comes to their own care and treatment?

Dr. Subudhi:               

Yeah, I’d say that it’s interesting because we all do this ourselves. And when it comes to our car – let’s say a car breaks down, or if we’re trying to buy furniture – we’ll get three, four different opinions. But for ourselves, for our own body, we don’t do that. And when you watch – we were talking earlier about Major League Baseball – and these players, when they get injured, they get the three best specialists in the world to evaluate them. And they’re seeing the best of the best.

And so, we owe it to ourselves and the patients owe it to themselves to actually get second opinions. I encourage it. I encourage my patients to get second opinions, even if I’m the first doctor they see, because I want them to feel comfortable with their decision.

And it’s important to understand that just because you’re seeing a doctor doesn’t mean that it’s a one-size-fits-all. You will get different opinions from different doctors, and you have to go with the one that makes you feel most comfortable.

Katherine:    

We have a question from the audience, Dr. Subudhi. Amy is saying she’s the daughter of a prostate cancer patient. And she’s curious to know how she goes about getting genetic testing, and if her children should be tested, as well.

Dr. Subudhi:               

Yeah. So, one of the things is that family history is very important in determining who should get genetically tested. So, if you’re a prostate cancer patient and you have metastatic disease, you should get genetically tested. And the reason for that is because we have a new set of drugs, the PARP inhibitors. But if you’re a family member that’s wanting to know whether you have a loved one has inheritable cancer that you may end up inheriting, that requires more understanding of the family history.

For example, did the grandfather have prostate cancer? Did the uncle have prostate cancer? And as I mentioned earlier, it’s not just prostate cancer. Is there a family member with breast cancer or ovarian cancer? These things play out in the decision-making of who should be genetically tested.

Katherine:                  

Absolutely. As a researcher in the field doctor, Dr. Subudhi, what would you like to leave patients with? Are you hopeful?

Dr. Subudhi:               

Yeah, I’m very hopeful. It’s a really interesting time, because with the technological advances and scientific advances – Traditionally, prostate cancer has always been treated just with hormonal therapies from the 1930s all the way to early 2000. Then in 2004, chemotherapy became the next thing. And then after chemotherapy, we’ve now got a dendritic cell vaccine; we’ve also got a radiopharmaceutical agent. And so, what the point is now we have a lot more different FDA-approved agents. And now, experimentally, the PARP inhibitors have now become a standard of care for those patients with mutations in the BRCA1, BRCA2, or ATM.

And then, in addition, we have many other types of technologies, such as BiTE and CAR T cells, that are coming out that are showing in early studies to be exciting. And so, I feel like that these therapies in combination may actually lead us to cure the cancer.

Katherine:                  

ASCO happened in June. Was there any news that patients should know about?

Dr. Subudhi:   

Yeah, so the PARP inhibitors got a lot of press during ASCO, as they should, because this is a new class of drugs that is the first personalized version of medicine that we have in prostate cancer. Now, personalized medicine has been around for a long time in cancers such as breast and lung cancer. But for first time, we actually have it in prostate cancer.

Katherine:

Dr. Subudhi, I want to thank you so much for joining us today.

Dr. Subudhi:

Thank you for your time. I really appreciate it.

Katherine:

And thank you to all of our partners. To learn more about prostate cancer and to access tools to help you become a more proactive patient, visit powerfulpatients.org. I’m Katherine Banwell.

Prostate Imaging

This resource was originally published by the Prostate Cancer Research Institute here.

TRANSCRIPT:

“So your PSA number came back high. What now?”

Let’s say, like many men,  you’ve been getting your PSA checked every year as part of your routine checkup. In the past it has always hovered around 2 or maybe as high as 3.0, and suddenly it’s up to 5! Or maybe this is your first PSA test. Everyone knows that 4.0 is the magic number, anything above that means something is not right with your prostate. Right? Actually, it’s a lot more complicated than that, but for this video we’ll take that as a given. OK, so the number is high, what do you do? Well, if you’re like many men your first instinct might be something like this…

“Aaaah,  I’ve got prostate cancer! Cut the *****ing thing out”!

Unfortunately, there are a bunch of people in the medical community that will support and even encourage that instinct. It’s the wrong instinct.

Wait.

Slow down.

Take a deep breath.

Now just to be clear, this video is not advocating any sort of wonder-cure and we’re not downplaying how serious prostate cancer can be. Everything we’ll talk about here is backed up by good science, the latest technology, and highly trained medical professionals.

Let’s stop and talk for a second about the prostate. No offense to our creator, or to evolution or whatever you believe about human origins, but you couldn’t find a worse place to situate an organ, especially one that can be prone to problems. It’s…”down there”. And it’s in the middle of everything “down there”. Your urethra, that tube that carries urine out from the bladder, runs right through it… as do a couple of nerve bundles that control your ability to get and maintain an erection. And its located right in there close to the rectum. So, right in the middle of three really important systems.

OK. Back to your story. You’ve got the high PSA number. What’s likely to happen now?

Your general practitioner is probably going to want to refer you to a urologist. The urologist is almost certainly going to want to perform a needle biopsy and usually right away. It’s cancer! There’s urgency! Right?  Ummm. Not really. But we’ll get to that in a future video. For now, just know that for the overwhelming majority of men prostate cancer is very slow growing. You have time.

Here’s your first step in taking control. That’s what this is all about. Taking control of your own healthcare.

Unless your PSA number is crazy high (above 20 for example) or your GP has felt that something is wrong during the Digital Rectal Exam or DRE (that’s the finger up your butt exam that we all adore), you need to tell him or her that you want another PSA test. You see, that test measures a substance in the blood that the prostate gives off when it’s aggravated, and it can be aggravated by quite a few things other than cancer. Sexual activity, inflammation, certain types of heavy lifting, even riding a bike. So you’ll want to wait a few weeks, take it easy for the last few days, refrain from sex for 48 hours (you can do it), and retake the test. If your number has gone back down to near its normal level, you’re done for now. Just make sure to keep getting those yearly PSA tests and DREs.

If it remains high, then its time to move to the next step. Biopsy, right?

Nope. Not if you can help it.

The random needle biopsy, as it’s called, involves sticking a rather large needle into the area just in front of the rectum 12 times to remove samples, called cores, from different areas of the prostate.

It sounds horrible but, to be honest, it’s not terribly painful and it’s usually over in 10 or 15 minutes. A visit to the dental hygienist is probably just as uncomfortable. But it is invasive. Three percent of the men undergoing needle biopsies get infections, some of which are very serious. More importantly though, is the fact that the random needle biopsy is not very accurate. It can miss serious cancer or it can pick up low level, non-aggressive cancers that really don’t require treatment. (We’ll talk about the types of prostate cancer in a future video.)

The doctors who use the random needle biopsies don’t do it because they are mean or ignorant…maybe just a little slow to change. Until the last couple of years the needle biopsy was the best diagnostic tool that we had. Recent advances in MRI imaging have changed everything. The latest generation of MRI machines called 3 Tesla, or 3T machines, scan at a much higher resolution than the earlier machines. They enable radiologists to see all but the tiniest tumors. The tumors that they can’t see almost certainly don’t matter.

What improvements in imaging mean is that biopsies, when they are needed, can be targeted, right to the suspicious area in the prostate. No more random poking.

So, to summarize. If your PSA number comes back high:

Schedule a second PSA test.
Start doing some research. A good place to start is PCRI.org.
If the number is still high after that test, find an MRI center that does “Multi-parametric” testing using a 3T scanner. The MRI report will provide two types of important information:

The MRI measures the size of the prostate. The scan report will enable you to determine if your PSA elevation is proportionate to your prostate size. We’ll talk about this more in a future video. As regards cancer,  there are three possible outcomes:

No high-grade cancer. Further monitoring without biopsy is OK.
A high-grade lesion is detected.  Targeted biopsy is needed.
An ambiguous area is detected.  Another MRI in 6 months may be appropriate.

Scanning the prostate in men with PSA elevation is a brand new approach that is more reliable than the old-fashioned method of using 12 random needle sticks. However, this claim is only accurate when using the very latest state-of-the-art MRI technology at approved centers. This technology is so new that finding doctors willing to abandon the old random needle biopsy approach is still a major challenge.  Even so, there is a big payoff, being able to bypass those needles, those infections, and the inaccuracy is worth it.

Screening for Prostate Cancer

This resource was originally published by the Prostate Cancer Foundation here.

Screening for Prostate Cancer

Cancer is a frightening possibility, but today’s medical technology has put some powerful screening tools in our hands, and we know: early detection saves lives. The earlier you find out about cancer, the greater the likelihood that it can be successfully treated. Prostate cancer, in particular, is almost 99% treatable if detected early.

So when do you start screening for prostate cancer? Most guidelines recommend that men practice joint decision-making with their physician to make a screening plan, based on evaluation of multiple risk factors. Over time, as researchers have learned more about the factors that affect your chance of getting prostate cancer, recommendations for when to start screening have started to skew earlier. It’s important for you to take the lead in having a candid discussion with your doctor about your risk factors for prostate cancer.

The following questions can help you decide when to begin this conversation with your doctor.

Do you have a family history of prostate, ovarian, breast, colon, or pancreatic cancers among your male and female relatives? Some families share genetic mutations that make the development of certain cancers more likely. If you know or suspect this is true of your family, begin to discuss screening starting at about 40 years of ageLearn more about genetic factors that affect your risk of developing prostate cancer.

Are you African American? African American men have a greater risk of developing prostate cancer, and of developing aggressive disease, possibly due to as-yet-unknown genetic and socioeconomic factors; unraveling this mystery is an active area of research for the Prostate Cancer Foundation. The National Comprehensive Cancer Network guidelines recommend that you begin joint decision-making with your doctor starting at 40 years of age.

How old are you? The risk of developing prostate cancer in men who do not have other risk factors increases with age. If you don’t have any other risk factors, ask your doctor about screening starting at age 45..

Once you are over about 70 years of age, the US Preventive Services Task Force recommends you stop screening, with the rationale that the potential benefits do not outweigh the harms. Why? Many cases of prostate cancer are very slow-growing, and treatments can be taxing. Statistically, older men are more likely to die of other causes, even when they have prostate cancer. However, if you are a healthy man over 70, the Prostate Cancer Foundation recommends that you continue to discuss screening with your doctor. The decision about whether to screen past age 70 should be made on an individual basis.

The bottom line is that it is never hurts to talk with your doctor about screening. The ultimate goal is to catch active cancer early so it can be successfully treated, to give you the longest, healthiest life possible.

More about genetic factors and their influence on your risk

Genetic screening (called germline genetic testing) can offer powerful insight into your individual risk of developing cancer. Much of the newest research into cancer genetics has focused on identifying germline (ie, inherited) mutations that are positively associated with the development of various types of cancer.

If you have any of the following risk factors, you should discuss them with your doctor and consider genetic screening.

  • A personal history of metastatic prostate cancer
  • A blood relative with a known cancer risk gene mutation, such as a BRCA1/2 mutation or Lynch syndrome
  • Two or more family members with prostate cancer with a Gleason score ≥7
  • One male relative with metastatic prostate cancer and/or one who died of prostate cancer
  • Three or more family members on the same side of the family, with one or more of the following cancers:
    • Breast cancer
    • Ovarian cancer
    • Pancreatic cancer
    • Colon cancer
    • Other cancers, eg, melanoma

If germline genetic screening reveals that you or a member of your family have one of these critical mutations, your genetic counselor may suggest “cascade” screening. This is when many members of a family are screened to determine who else may have the mutation. With more information at hand, each member of the family can better understand their particular cancer risk, options for early detection, and how to reduce their risk for various other forms of cancer. The information you learn could save the lives of your brothers and sisters, parents—and your children.

Prostate Cancer Diagnosis: What’s Involved

This resource was originally published by Everyday Health by Laura Newman, here.

Last Updated: 6/28/2018
A variety of tests are used to help make the diagnosis.
Getty Images

Symptoms are uncommon with early-stage prostate cancer. The majority of men start the diagnostic process for prostate cancer before they become symptomatic. There are several potential tests that may be involved.

Among the most common are:

A Prostate-Specific Antigen (PSA) Test

The prostate-specific antigen (PSA) test is a blood test that may be offered to you as routine screening in the context of a checkup by a primary care physician or urologist.

But using the test for routine screening is controversial. Elevated results on a PSA test may occur for reasons other than cancer, such as an enlarged prostate, benign prostatic hyperplasia (BPH), or an infection in the prostate called prostatitis. Men who receive an elevated result may be referred for further testing. For this reason, the test should only be done after an informed conversation between doctor and patient takes place.

The American Cancer Society uses these parameters to evaluate PSA results:

  • A PSA test result below 4 nanograms per milliliter (ng/ml) means that 85 percent of the time, you won’t have prostate cancer.
  • A PSA between 4 and 10 is associated with a 1 in 4 chance of having prostate cancer.
  • If your PSA is greater than 10, you have a 1 in 2 chance of having prostate cancer.

But doctors have not adopted a uniform system for interpreting PSA. Thresholds for concern and reference ranges vary considerably. (1)

If your PSA test results are elevated you will likely be advised to have more tests.

A Digital Rectal Exam (DRE)

A digital rectal exam (DRE) is a physical exam of your prostate gland administered by a physician in the context of a general checkup or in response to symptoms suggestive of an issue with the prostate gland. During a DRE, a physician places a gloved finger into the rectum and checks for asymmetric areas or nodules and irregularities in the size, shape and texture of the prostate gland, and it may also be used to look for signs suggestive of prostate cancer.

Like the PSA test, suspicious findings on a DRE do not necessarily mean that you have prostate cancer. Rather, the results are considered in combination with PSA test results and symptoms a patient may have.

Concerns have mounted recently about primary care doctors’ ability to use the DRE effectively. A recent study published in the March–April issue of the Annals of Family Medicine found that only one-half of surveyed primary care doctors feel comfortable performing DREs. In fact, the authors of that study recommended against primary care doctors performing them. (2)

Transrectal Ultrasound and Real-Time Biopsy

If you receive an elevated PSA result or have suspicious findings on a DRE, your physician might recommend that you undergo a prostate biopsy. The most common test used for this is a transrectal ultrasound (TRUS), in which an ultrasound probe is inserted into the rectum and sound waves are used to create an image of the prostate gland.

During the ultrasound, biopsy samples are often collected from several areas of the prostate with a hollow needle. This is referred to as a real-time biopsy or a transrectal prostate biopsy. The biopsy samples are then analyzed in a pathology laboratory to see if cancer cells are present.

Important benefits of combining the two procedures include:

  • The ability to better target suspicious areas of high-grade (aggressive areas) and clinically significant tumors.
  • Helping to avoid false-positive diagnoses and overdiagnosis or sampling areas unlikely to contain cancer or aggressive cancer.
  • Getting a high-quality biopsy. (3)

MRI Ultrasound Targeted Prostate Biopsy

Magnetic resonance imaging (MRI) guided biopsies are also being used more frequently, with ultrasound or alone, to help guide a prostate biopsy. MRI scans are capable of revealing potentially cancerous areas in more detail than ultrasound.

Studies have emerged suggesting that fusing the two techniques — using MRI to identify suspicious areas before the transrectal ultrasound and biopsy procedure — might identify cancer more accurately than a TRUS biopsy alone. For example, a landmark study led by researchers at the National Cancer Institute’s urologic oncology branch found that the MRI-fused ultrasound technique detected more aggressive prostate cancer and fewer low-risk prostate cancers.

A joint statement issued by the American Urological Association and Society of Abdominal Radiologists supports fused MRI-ultrasound for men on active surveillance — men who, along with their doctors, have opted to watch a slow-growing cancer rather than treat it aggressively — and for men who have received elevated PSA test result but whose previous biopsies have tested negative for cancer. (4)

Preparing for Your Prostate Biopsy

To prepare you for the test, your urologist should tell you about the risks and benefits of having a biopsy. The most common complications following a prostate biopsy are having blood in the urine, rectum, or semen, a urinary tract infection, and acute urinary retention. These side effects usually pass quickly. Less commonly, erectile dysfunction occurs.

After this discussion with your doctor, you will be asked to sign a consent form. You may also be asked to discontinue some medications, such as anticoagulants, nonsteroidal anti-inflammatory drugs, herbal supplements, and vitamins for one to several days. On the night before the biopsy is scheduled, your doctor may ask you to do an enema at home. Eating lightly the day before is often recommended. You also may be asked to take an antibiotic the day before or on the day of the biopsy. (5)

When you come in for the procedure, you will be asked to lie still on your side with your knees bent. The doctor will insert a small finger-size ultrasound probe into your rectum. The probe lets the doctor see images of your prostate gland and helps determine where to inject a local anesthetic. The images the doctor sees also help guide the biopsy needle. Your doctor will take 10 to 18 tissue samples from the prostate gland, which will then be sent to a pathology lab. The entire procedure takes about 10 minutes. Your doctor will contact you with results usually within about a week.

After the procedure, your rectum may feel sore. You may see small amounts of blood in your stool, urine, or semen that last for several days or weeks. Antibiotics might be prescribed for several days to prevent infection.

Making Sense of Prostate Biopsy Results

If your biopsy reveals that some cells look abnormal, but may or may not be cancer, your doctor might recommend another biopsy. If your biopsy comes back positive, it means cancer cells were detected.

Your pathology report will include:

  • A Gleason score, which helps doctors predict how fast-growing the prostate cancer is
  • The number of biopsy samples that contain cancer out of the total number sampled
  • A diagnosis of each core or biopsy sample
  • The percentage of cancer in each sample
  • Whether the cancer is on one or both sides of the prostate gland (6)

Understanding Your Gleason Score

Your Gleason score is the sum of various “grades” the pathologist has given samples taken from the prostate gland. The more aggressive the cancer looks, the higher the grade. The lowest Gleason score you can receive for prostate cancer is a 6. These cancers are considered low-grade and unlikely to be aggressive. A Gleason score of 8 to 10 is more aggressive and more likely to grow and spread quickly. A cancer with a Gleason score of 9 to 10 is likely to be even more aggressive. (6)

Genetic Testing for Prostate Cancer

This video was originally published by the Prostate Cancer Foundation on November 21, 2018, here.

Thanks to research funded by the Prostate Cancer Foundation, we now know that some prostate cancers are caused by genetic mutations. In 12%-20% of families, certain cancer-causing genes are passed down from mothers and fathers to sons and daughters. These are referred to as germline genetic mutations.

A genetic mutation is a change in part of the normal DNA that makes up a gene. Most mutations are hereditary, meaning that they are passed down from one family member to another. Mutations can also be caused after birth by various lifestyle and environmental factors, such as smoking or the UV rays from the sun.

Genetic mutations can be passed down from father to son, father to daughter, mother to son, or mother to daughter. Since we now know that some of the same genes that cause prostate cancer also cause other forms of cancer (such as breast, colon, stomach, etc.) – and vice versa – it can be important to be screened early if you have a history of cancer in your family, even if it’s not prostate cancer. Screening, referred to as germline genetic testing, is easy and can be done with a simple saliva test or blood test.

All men with metastatic prostate cancer are now encouraged to speak to their physician about whether they may need germline genetic testing.

Prostate Cancer Screening: Informed Decision Making

This video was originally published by the American Cancer Society on October 11, 2011, here.

This video from the American Cancer Society discusses informed decision-making options on prostate cancer. For more information about prostate cancer and different treatment options, please visit cancer.org

Coping With Scanxiety: Practical Tips from Cancer Patients

“Every three to four months I get a wake-up call that my life has taken an unexpected turn. Believe me, there are daily reminders of how different I am now; but scan time is big time scary time, mentally. It takes living with cancer to yet another level of heighten sense of mortality and anxiety.  So MANY thoughts and what ifs course through my brain.  SO hard to shut it off.”  – Katie Edick, METASTATIC AND MAKARIOS.

It may not be officially part of the medical lexicon yet, but “scanxiety” is no less real for those of us who have experienced a diagnosis of cancer.   Pamela Katz Ressler, RN, MS, HNB-BC, founder of Stress Resources, describes scanxiety as “the anxiety, worry and fear that accompanies the waiting period before and after a medical test.” She says it is a common side effect of modern medicine. “As our medical system has become more technologically adept at measuring indicators of disease so too has our anxiety” she says. “Scanxiety is an unintended consequence of medical testing, yet it is one that is rarely discussed by medical professionals with patients.”

Writing in Time magazine in 2011, lung cancer survivor, Bruce Feiler, characterized scans as “my regular date with my digital destiny.  Scanxiety, he wrote, arises from the feeling of “emotional roulette wheels that spin us around for a few days and spit us out the other side. Land on red, we’re in for another trip to Cancerland; land on black, we have a few more months of freedom.”

One of the most common emotional and psychological responses to the experience of cancer is anxiety.  Cancer is a stressful experience and normal anxiety reactions present at different points along the cancer journey.  Did you know that the word anxiety comes from the Latin word anxius, which means worry of an unknown event? Worry, in turn comes from the Anglo-Saxon word “to strangle” or “to choke” – which may very well convey the feeling we have right before a scan, or whilst waiting for its results.

Anxiety is a natural human response that serves a biological purpose – the body’s physical “fight or flight” (also known as the stress response) reaction to a perceived threat. Symptoms vary for each person.  You may experience a racing or pounding heart, tightness in the chest, shortness of breath, dizziness, headaches, upset tummy, sweating or tense muscles. Alongside these physical manifestations, you may feel irritable, angry or apprehensive and constantly on the alert for signs of danger. All of these signs indicate that sympathetic arousal of our nervous system has been activated, preparing us to stand our ground and fight or take flight and run away from danger.

Scanxiety, points out Katz Ressler, can be intense and may mimic symptoms of Post-traumatic stress disorder (PTSD). PTSD is an extreme anxiety disorder that can occur in the aftermath of a traumatic or life-threatening event. Symptoms of PTSD include re-experiencing the trauma through intrusive distressing recollections of the event, flashbacks, and nightmares. As Susan Zager, founder of the non-profit organization, Advocates for Breast Cancer (A4BC), points out “MRIs are very noisy – and because my recurrence was found through an MRI biopsy, I have many memories of scary results from that test.”

It’s been over ten years since I was diagnosed with breast cancer and while my scans are less frequent these days, the anxiety never fully goes away. As blogger and patient advocate, Stacey Tinianov writes, “This is reality even after almost five years with no evidence of disease. I’m not a worrier or a hypochondriac. I’m just a woman whose body once betrayed her by growing a mass of rouge cells that, if left unchecked, have the potential to bring down the house.”

If you are facing an upcoming scan and feeling anxious about it, you may find the following tips helpful. Based on my own experience and the experience of others in the cancer community, these tips are some of the ways in which we have learned to cope with scanxiety.

1. Identify your body’s stress response

How we experience stress is individual to each of us. Learning to tune into what happens in your body when you perceive a stressful situation is the first step in understanding your individual stress response. Does your jaw clench? Is your breath shallow? Are your muscles tense? When you become more aware of your physical response to stress, it will help regulate the tension when it does occur.

2. Pay attention to your breathing

When we are stressed we tend to breathe more shallowly.  Shallow breathing, which does not allow enough oxygen to enter our bodies, can make us even more anxious.   When you feel stressed, practise taking some slow deep abdominal breaths.  Deep abdominal breathing slows the heart down and lowers blood pressure. The advantage of focussing on the breath is that it is always there with us. We can turn to it anytime we are feeling anxious.

3. Stay focussed on the present

Focussing on the past or future can increase your anxiety. Katz Ressler recommends staying focused on the present moment as a way to quieten anxious thoughts. “Methods that have proved successful for scanxiety focus on tools of resilience, often based on mindfulness strategies,” she says. “Key in these methods is to focus on the present moment and not on the outcome of a test or scan.” Focusing on each and every breath is an excellent way to begin to increase your awareness of the present moment.  If you would like to try some short mindfulness meditations to increase resilience and help decrease anxiety, you will find some on Katz Ressler’s website.

4. Use visualization

By enhancing your relaxation skills, you are can lower the fight or flight response that is often triggered during times of increased anxiety. Visualization involves using mental imagery to achieve a more relaxed state of mind. Similar to daydreaming, visualization is accomplished through the use of your imagination. Karin Sieger who has recently received a diagnosis of cancer for the second time, shares this advice, “I certainly keep my eyes shut when inside the machine; focus on my breathing; remind myself this has a start and finish; and then generally try and go in my mind to a calm meadow and have a snooze. Because for once there is nothing else I can or should do for the next minutes.”

5. Practical coping tips

Karin also points to the claustrophobic feeling of being enclosed in a scanning machine as a contributor to anxiety.  Stage IV breast cancer patient, Julia Barnickle recommends an NLP (Neuro Linguistic Programming) process, called the “Fast Phobia Cure” which worked for her. “I still don’t like enclosed spaces,” she says, “but I certainly don’t panic like I used to.” Blogger Margaret Fleming also recommends asking the attendants for any items that can make you more comfortable, such as ear-plugs or a blanket.

6. Break the worry habit

Worry can be a habit and like all habits can be broken.  As soon as that worry voice starts in your head, examine it before it takes hold. Ask yourself, will worrying about this help me in any way?  Julia writes, “For me, worrying is a choice – as is happiness. In the same way that I choose to be happy, regardless of what happens around me or in my own life, I also choose not to worry about – or fear – what might happen in the future. I tend to believe that things will work out for the best. And besides… what will happen will happen, regardless of whether or not I worry about it – so I don’t see the point of spoiling my enjoyment in the meantime. I prefer to get on with my life.”  Jo Taylor, who is living with secondary breast cancer agrees. “I have taken the view that nothing will change the outcome, therefore there’s no point in worrying,” she says.

7. Create an anxiety worry period

Many patients speak about the most anxious period of time being the time you are waiting for scan results. As stage IV blogger and patient advocate, Susan Rahn, writes, “Waiting for the results of any scan that will tell you if the cancer is active and taking up residence in new parts of your body is just as  anxiety inducing, if not worse, as the time leading up to and the day of the actual scan.”

You won’t be able to break the worry habit entirely and ignoring anxious thoughts and feelings can sometimes make them worse.  It’s still important that you acknowledge your worry but not let it control your life. One tip is to designate one or two 10-minute “worry periods” each day, time to fully focus on your anxiety. The rest of the day is to be designated free of anxiety. When anxious thoughts come into your head during the day, write them down and “postpone” them to your worry period.

8. Take Some Exercise

Exercise is one of the simplest and most effective ways to reduce stress and anxiety –providing a natural outlet for your body when you are exposed to too much adrenaline. Jo Taylor, who runs an Exercise Retreat To Recovery program in the UK, finds that staying physically active is helpful. “I am still very nervous in the time between scan and reporting, “she says, “but throwing myself into work or exercise or anything else I do is helpful.”

Virtually any form of exercise, from aerobics to yoga, can act as a stress reliever. The important thing is to get moving, even if that means just walking around the block. Movement with flow and rhythm can also help calm the body and mind. Katz Ressler recommends gentle yoga and walking meditation as proven ways to decrease the stress response and increase the body’s natural calming mechanism. “Finally, remember”, she says, “while you cannot control the outcome, you can work to control the experience and that starts with building resilience.”

I hope you will find these tips helpful and if you have any other coping tips please feel free to add your advice in the comments below.