For many men diagnosed with prostate cancer, the best treatment could be no treatment.
As counterintuitive as that might sound, it’s the reality for at least one in three men, who could
be better off by not going through a biopsy and the difficulty of cancer diagnosis and possible
treatment, which often brings its host of side effects. As doctors, we must identify patients
best served by treatment and others who can avoid the biopsy and treatment. This has been
confirmed in clinical trials (SPCG-4, PIVOT, and ProtecT), which showed that patients placed
under active monitoring (active surveillance) fared the same as those who underwent
treatment.
Prostate cancer is often a slow-moving disease, and many men can live with it. When we
consider that, we have learned to be better screeners and prognosticators on whether
someone should have treatment. For one-third of men, the MRI gives us all the information we
need to confer that prostate cancer is not a short-term health risk, and monitoring is all that’s
needed.
The key is proper screening and, if necessary, testing to ensure this is the case. Left unchecked,
prostate cancer, like other forms of cancer, can be deadly. This is why experts have
implemented a system that has overhauled our goals of screening and treatment. One of the
newest areas of urologic research and treatment is Focal Therapy. Focal therapy uses advanced
imaging techniques, including MRIs, ultrasound, fusion, and PSMA PET imaging, to target the
exact location of a tumor within the prostate. Doing so leaves surrounding tissues untouched,
and side effects such as urinary issues and erectile dysfunction are avoided.
I only wish we had known this years ago when my family was impacted by prostate cancer
screening programs starting in the early 1990s. My father and maternal grandfather suffered
complications from prostate surgeries. My grandfather went from having a suspicious PSA
screening to surgery, where he had contracted hepatitis C from an intraoperative blood
transfusion. He also experienced a clot in his lungs. All this for a case that might not have
needed treatment at all.
My father, a urologist, also had prostate cancer care issues and suffered from significant blood
loss and blood clots in his lungs after his robotic prostatectomy. My father’s case would have
been better managed today with active monitoring and a prostate artery embolization for his
enlarged prostate. This gives me the perspective that nobody should undergo unnecessary
screening and especially unnecessary treatment.
In 2009, as word got out that PSA tests were leading to overdiagnosis and treatment, the PSA
wasn’t needed, many patients and doctors had the wrong reaction. Instead of using the PSA as
a baseline, with an MRI as an excellent first step if needed, many physicians and patients
skipped the PSA screening completely. I believe this could be a life-altering mistake for some because ignoring an elevated level was clinically irresponsible, and the statistics reflect this, as
prostate cancer deaths have risen by 3 percent over the last decade, according to the CDC. This
happened while nearly every other cancer reported a decline in deaths.
The PSA test is an essential piece of the puzzle, and men should get that result as part of their
routine wellness checks. If the results show an elevated PSA, we can analyze why that’s the
case. It could be a non-cancerous cause, such as an enlarged prostate, urinary tract infection, or
prostatitis. We also created an algorithm that looks at other risk factors, such as being over 55,
having a family history, or being of certain ethnic groups with a higher risk for aggressive
prostate cancer. For people who have a slight PSA increase and no other risk factors, an MRI
scan might be all that’s needed. We may even wait a few months and retest the PSA level
before doing anything else. As I explain to patients, not all prostate cancer will kill you. Most
people die with it, not from it. Please stay on top of it and track it.
We’ve also seen significant improvement in how quickly a patient goes from knowing their PSA
is elevated to any further examination. At Northwell, back in 2019, it took more than three
months to conduct all the tests and reviews necessary to find a course of action. While that
didn’t cost lives, it certainly created stress. Within a week of conducting an MRI examination,
they had a doctor’s appointment to discuss the next steps. The RDP system, or Rapid Diagnostic
Pathway, has cut the time needed for care by 70 percent. The care often doesn’t include the same
stress, operative complications, or other issues my family experienced.
Let’s get the word out: Prostate care is more effective than ever and less painful. Letting people
know this will play a significant role in lowering death rates for a cancer we can treat.
Dr. Ardeshir Rastinehad is director of prostate cancer care at Northwell Health.
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