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Men with newly diagnosed prostate cancer – a primer

When most men are told that they have prostate cancer, their brain essentially shuts off. The initial conversation can produce shock, fear and sadness. Allow your self time to absorb the information. Resist the temptation to search the internet for cures or answers – you need more information than the biopsy to know how serious the problem is. Try to remember that prostate cancer is a complex disease with a wide range of outcomes.

Ideally, new prostate cancer patients should receive “multidisciplinary care.” This typically means meeting with a radiation oncologist, a urologist who specializes in prostate cancer, and in some cases a medical oncologist. When you talk to different specialists, you will get a more accurate picture of potential side effects and perspectives.

When I meet with new patients, I usually start by describing prostate anatomy and showing illustrations of the various stages of prostate cancer. I cannot emphasize how important it is to visually understand progression of prostate cancer. It is not a static disease. When your biopsy shows prostate cancer in 1 or 2 areas, it is easy to assume that the other areas have no prostate cancer. If this was the case, then a biopsy could actually cure you (which it obviously does not). Prostate cancer exhibits what we call a field effect, which means that normal appearing areas are not really completely normal.

Prostate cancer staging currently factors your Gleason score, PSA, and size or extent of your prostate cancer to determine whether you are stage I, stage II, stage III or stage IV. Stage I is limited to patients with Gleason 6 disease (or lower) who have a PSA of less than 10 ng/mL. Stage I patients are often good candidates for active surveillance. Stage II patients have Gleason scores of between 7 and 8, or have PSAs between 10 and 20 ng/mL. Stage III means that there is a high probability that the prostate cancer has started to extend through the capsule or through the boundary of the prostate edge. This group includes patients with Gleason scores of 9 or 10, or PSAs greater than 20 ng/mL, or patients with either an MRI or a physical exam suggesting that the prostate cancer has penetrated into surrounding tissue. Stage IV means that there is evidence that the prostate cancer has spread to either lymph nodes or bone (or other sites). Your prostate cancer stage will help you and your team make the best decision for you. These stages are treated differently from one another. One size does not fit all men.

Questions to ask your physician:
– What stage is my prostate cancer?
– What is my Gleason score?
– Can you arrange for me to meet with a surgeon who specializes in prostate cancer and a radiation oncologist who specializes in prostate cancer?
If someone says, you have to have surgery right away, and wants you to schedule — red flags should go off. This is not what should happen.
Fear based decision making results in inferior outcomes.

Resources:
NCCN.org
National Comprehensive Cancer Network – navigate to the tab titled: “Treatment of Cancer by Site”

Do men over age 75 have less aggressive disease?

An interesting study published in 2020 looks at the genomics of “low grade” (Gleason 6 or less) in men aged 75+. They find that aggressive genomics signatures were found in approximately 40% of men over 80. This reinforces the idea that we need to fully evaluate men who fall into this category. Information is power. https://pubmed.ncbi.nlm.nih.gov/32156491/.