Prostate Cancer and Decision Making

Prostate Cancer

In 2012 the National Cancer Institute estimated there were 241,740 new cases of prostate cancer and 28,170 deaths from prostate cancer. There are some individuals that are at heightened risk for developing the disease. These include African American men, men who are older than 60, and men with a first-degree relative with prostate cancer. Despite the high rates of disease, prostate cancer in general is highly curable. Unlike some other cancers (e.g., ovarian caner, pancreatic cancer), there are certain preventative/screening measures that can be taken. 

Prostate Cancer Screening
 

The Prostate-Specific Antigen (PSA) blood test the most common screening method. It is recommended to begin at age 50. This test measures the amount of PSA, a protein secreted by the prostate gland, in the blood. Elevated PSA levels are considered to be a marker of prostate cancer. However, not all individuals with prostate cancer evidence elevated PSA levels Digital rectal exams (DRE) are typically used in conjunction with PSA tests. During DREs, a provider inserts a gloved finger into the rectum to feel the prostate for abnormal or hard areas. The American Urological Society recommends annual DREs begin at age 40.  These are the follow-up assessments that are conducted when a PSA level is > 4.0 (ng/mL) and/or findings are abnormal from DRE:

  • Imaging techniques such as x-rays, transrectal ultrasound, or cytoscopy (a thin, tube-like camera is inserted into the urethra to view internal organs) may be recommended.
  • Prostate biopsy to assess for cancerous cells followed by cancer staging via pathology
  • High risk prostate cancer is identified if the PSA test is greater than 20, the Gleason score is 8 or greater, or the clinical stage is identified as T2c-3a.

Prostate Cancer Diagnosis and Staging

Following the initial testing, a Urologist (and sometimes Oncologist) and colleagues from Radiology (where imaging is reviewed) and Pathology (where biopsies are analyzed) come up with a "cancer staging." Staging differs for all cancers. For prostate cancer, here is an example of staging for T2 and T3 Tumours

  • T2a – The tumour is in only half of one of the lobes of the prostate gland
  • T2b – The tumour is in more than half of one of the lobes
  • T2c – The tumour is in both lobes but is still inside the prostate gland
  • T3a – The tumour has broken through the capsule (covering) of the prostate gland
  • T3b – The tumour has spread into the seminal vesicles

 

Prostate Cancer Treatment Options

Depending on the staging, your doctor may recommend a non-invasive approach such as Active Surveillance, or something more invasive such as a Prostatectomy procedure. If localized to the prostate, most individuals are able to be cured with one or a combination of treatments (see below). If metastasized, curative treatments are still available, but prognosis is worse. If incurable, hormonal therapy is often used to prolong lifespan by slowing the growth of the tumor. The most common treatment options for Prostate Cancer include:

  • Active surveillance (for early stage)
  • A prostatectomy may be conducted to remove the prostate gland and its surrounding tissues (for early stage)
  • Radiation (5 days/week for 7-8 weeks)
  • Brachytherapy
  • Cryoablation
  • Hormone therapy when prostate cells primarily fueled by, testosterone.
  • Androgen-deprivation therapy (ADT) prevents testosterone to reach the prostate cells, leading to the cancer cells to die.
  • Chemotherapy  
  • Estramustine (an oral medication) and mitoxantrone (an agent given through an IV).

Decision Making and Prostate Cancer

Decision making in the context of cancer often involve concepts that are hard to grasp, such as health risks and probabilities, technical medical information, and a host of options that can be overwhelming. Selecting a treatment option can be especially difficult while in the midst of intense emotions such as fear, sadness, or anger. Which treatment option you select is a highly personal choice and one that should be made after careful considerations. Factors to consider when weighing the costs and benefits include:

  • Duration of symptom-free survival
  • Time spent with toxicity due to treatment
  • Time to relapse
  • Impact on quality of life and on functional status

My experience has been that when men are facing difficult medical decisions, they can sometimes take an overly passive role in the decision process ("WHATEVER YOU SAY DOCTOR"), or an overly anxious approach that can lead them to feel OVERWHELMED and PARALYZED by the decision. Fortunately there are resources such as Online Decision Aids that are uniquely tailored to the needs of men facing difficult decisions about their cancer care. Decision Aids have shown to be effective in improving knowledge, creating more realistic outcome expectations, reducing decisional conflict and uncertainty, and possibly improving communication.

While an online Decision Aid is a convenient resource, many men find it helpful to speak other men who have faced similar decisions, and/or with a Psycho-Oncologist who is familiar with prostate cancer decision making process. Whichever treatment path you choose, and however you reach this decision, it is my recommendation that you remain attentive to your personal values and emotions, and make the decision in partnership with your loved ones.  


The author, Dr. Ben Felleman, is a licensed clinical psychologist and director of Behavioral Medicine Services of San Diego. Dr. Felleman specializes in providing psychological services to cancer survivors and caregivers. Please visit www.bmedsandiego.com or call 858-433-5283 to learn more.