Weighing treatment options can be a difficult task for any cancer patient and their doctor. In a realm of constantly evolving therapies and medical tools, it’s natural for a patient’s decision to be influenced by anxiety or misunderstanding.
For men diagnosed with prostate cancer, their most common first reaction is to want it out, immediately.
But the cancer alarm might be causing patients and even doctors to jump the gun for surgery and heavy treatments. In India, although most cases are discovered at an aggressive state, it’s important for patients to know their cancer type so they can make the right decisions. Not everyone needs surgery, sometimes a watchful eye is enough.
Prostate cancer is a slow-growing disease, which means more men die with it than from it, even when left untreated. This situation has doctors questioning: how do we effectively distinguish indolent cancers from the aggressive ones? And, what should we do when we find them?
In the cancer world, there’s been a lot of discussion round new tools for diagnosis that can tell doctors more about a patient’s disease. Much of the interest has stemmed from the fact that PSA blood tests, the mainstay of prostate cancer screening, can give out false positives and cause confusion. Muddying maters further is the mounting evidence that biopsy, the definitive test doctors use to offer a cancer diagnosis, has been proven to have its own pitfalls.
New research is saying that biopsy tissue samples can fail to give doctors an accurate understanding of a cancer. In fact, one study showed that up to 35% of prostate cancers are totally missed on a patient’s first biopsy. While trans-rectal ultrasound (TRUS) guided biopsies have been the standard tool for some time, they are limited to randomly sampling areas of the prostate for cancerous cells. That means a clean pathology report might just be the result of a doctor physically missing the tumorous lesion.
Image-guided biopsies have now become the hot topic in tumour identification, especially since advanced MRI technology has become capable of capturing lesions. A targeted method that combines traditional and newer technologies merges the images of an MRI scan with those from an ultrasound. In a “fusion biopsy,” tumorous lesions can be pinpointed with a software programme and sampled in the clinic for much more accurate results.
The use of “liquid biopsies,” blood and urine tests for cancer biomarkers, has also been on the up over the last few years as a non-invasive alternative for biopsy. The 4kScore, for example, can measure cancer aggressiveness through both clinical and scientific data. The Patient Health Index uses PSA information to estimate the likelihood an early stage cancer might progress to a more advanced stage.
While it’s debatable whether these tests are capable of providing a definitive cancer diagnosis, they are undoubtedly effective in characterizing the prognosis. As of yet, such tests haven’t gained traction in India but could have tremendous potential in a population at risk for high-grade prostate cancer. Even in the US, their role in the clinical setting hasn’t been totally established, and most are still out-of-pocket options.
As with many areas of medicine, the tool that everybody has their eye on is genomic testing. Currently approved tests include the Onctotype Dx, ProstaVysion, Prolaris and the Decipher, all of which doctors use to uncover intel on the genetic make-up of a tumor. Oncotype DX, for example, tests for the expression of 15 genes in a prostate tumor to determine the percent probability that the tumor will spread. Even post-surgery prognostics have improved with genetic information, and tests like the Decipher can be used to evaluate cancer outcomes after a patient has undergone treatment.
Do I need surgery?
Ultimately, every tool or test helps a doctor determine one thing: whether or not a patient should receive treatment. Undergoing radiation therapy or surgery is a major life decision that can serve as a huge blow to anyone’s quality of life. The most common surgical procedure, “radical prostatectomy,” entails the prostate being surgically removed from the body. After surgery, patients typically have difficulties controlling their bladder or maintaining an erection at least for a temporary period of time.
However, prostate cancer is multifaceted, so no hard guidelines exist to tell doctors when the time is right for treatment. A combination of better judgment and test results allow them to decide whether a patient should be placed on “Active Surveillance,” where treatment can be postponed without decreasing a patient’s chance for cure. For this route to be effective, patients have to come in regularly for physical exams, bloodwork, imaging and biopsies. Most importantly, they must be diligent about changing their lifestyles and checking up on their disease from time to time.
Dr Ashutosh K. Tewari is the chairman of urology at the Icahn School of Medicine at Mount Sinai Hospital in New York City; Sonya K. Prasad is a clinical research assistant at Mount Sinai Hospital
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