Basic Knowledge: Test for Prostate Cancer

BY MARK SCHOLZ, MD

While at Pete’s Coffee to write my bi-monthly blog I ran into another regular who occasionally hangs out at Pete’s. Vandana is a professor at Loyola University.  She is an expert in the psychology of learning.  While we were talking I started to bemoan my struggles to educate people about prostate cancer. One of the biggest bugaboos I face is how people overestimate their grasp of the prostate cancer situation. Once I verbalized my complaint, Vandana immediately proposed I create a basic test of prostate cancer knowledge so men could self-assess their level of knowledge.  Thanks Vandana!

 

1.    Which of the following is NOT a Prostate Cancer Staging System?

a.    D’Amico

b.    AJCC

c.    Whitmore-Jewett

d.    Gleason

 

2.    Seed implant radiation compared to surgery causes:

a.    More erectile dysfunction

b.    More incontinence

c.    More urinary symptoms

d.    Lower cure rates

 

3.    Men with Gleason Score:

a.    Less than 7 never metastasize

b.    Over 7 always metastasize

c.    Of  4 or less have undergone surgery

d.    Both a and c are correct 

 

4.    Which of the following is true about robotic surgery compared to standard surgery?

a.    Gives higher cure rates and lower rates of incontinence

b.    Results in quicker recovery after surgery

c.    Improves the chances for preserving erectile function

d.    Causes less shrinkage of the penis

 

5.    Hormonal therapy with Lupron improves survival when combined with:

a.    Radiation

b.    Surgery

c.    Alkaline water

d.    All of the above

 

6.    Which of the following is not true about PSA levels?

a.    Measures cancer cells in the blood

b.    Is affected by testosterone

c.    Rises after sex

d.    Rises with infections in the prostate

 

7.    Incontinence occurs in more than 5% of men who have:

a.    Surgery

b.    Radiation

c.    Hormone therapy

d.    All the above

 

8.    What is climacturia after surgery?

a.    The urge to urinate after climbing

b.    The ejaculation of urine

c.    Goes away with time

d.    Only occurs with unskilled surgeons

 

9.    Which of the specialty doctors listed are  Board Certified in Internal Medicine?

a.    Radiation therapists

b.    Urologists

c.    Medical oncologists

d.    Radiologists

 

10. Which of the specialty doctors listed are least-likely to see patients with early-stage prostate cancer?

a.    Radiation therapists

b.    Urologists

c.    Medical oncologists

d.    None of the above

 

11. The risk of dying within 30 days of having prostate surgery is:

a.    1 in 20

b.    1 in 200

c.    1 in 2000

d.    1 in 20,000

 

12. What does Medicare pay $28,000 for?

a.    Radical prostatectomy

b.    Intensity modulated radiation (IMRT)

c.    Proton therapy

d.    Seed implant radiation

 

13. Patients referred to radiation therapy doctors most frequently come from:

a.    Other patients

b.    Advertisements

c.    Urologists

d.    Medical oncologists

 

14. Biopsy misses high-grade disease in what percentage of men diagnosed with low grade disease?

a.    0%

b.    5%

c.    15%

d.    30%

 

15. Hormone therapy with Lupron does not cause:

a.    Baldness

b.    Weight gain

c.    Osteoporosis

d.    Dry Skin                                                                                                                              

 

Answers: 

1.    d. Gleason is a grading system not a staging system

2.    c. More urinary symptoms

3.    d. Gleason less than 6 on needle biopsy indicates an error in interpretation

4.    b. Robotic surgery is accomplished with smaller incisions resulting in quicker recovery

5.    a. Radiation is the only correct answer

6.    a. PSA is a protein  from cancer cells that rises proportionate to the number cancer cells

7.    a. Surgery is the only type of treatment associated with such a high risk of incontinence

8.    b. Ejaculation of urine occurs in 20% of men undergoing surgery at a center of excellence

9.    c. Medical oncologist are the only cancer doctors with basic internal medicine training

10. c. Fewer than 1% of medical oncologists in US consult on men with early-stage PC

11. b. Mortality risk of prostate surgery in the US is one in 200

12. b. IMRT is $28,000, Medicare pays far less for either surgery or seed implants

13. c. Urologists refer most of the prostate patients to radiation docs.  That’s why radiation docs never say a bad word about surgery

14. c. 15% of men with low grade disease have higher grade disease that the biopsy missed

15. a. Men with baldness treated with hormone therapy  often notice a return of their scalp hair

A Breakthrough Study in Prostate Cancer

BY MARK SCHOLZ, MD

Ten years ago everyone agreed that surgery was the “Gold Standard” to which every other kind of treatment should be compared.  Now as we approach 2013, you rarely encounter the Gold Standard argument to bolster surgery as the preferred treatment approach.  What has led to the change in perspective and why has it taken so long for this change to come about?

Good Science Finally Leads to a Clear Answer

The primary cause for the changed perspective about surgery is the result of a well-performed scientific study published this year by Dr. Timothy Wilt in the New England Journal of Medicine.  The study has been a long time coming.  It was first conceived way back in the early 1990s when Dr. Wilt and others designed a definitive trial to test whether or not radical prostate surgery improves survival compared to observation. Even back then, researchers knew that prostate cancer can often behave benignly and were questioning the benefits of radical surgery.  Therefore, between 1994 and 2002 over five-thousand men were invited to participate in a study comparing immediate surgery with no treatment.  To make the comparison totally fair, individuals volunteering for the study had to be willing to have either surgery or observation based on the flip of a coin.  Most of the more than five thousand men who were invited to participate in the study refused. Ultimately, however, 731 men agreed to participate.

Modest Benefits for “Bad” Cancer, No Benefit for “Good” Cancer

At the start of the study the average age of the men participating was 67 and the median PSA was 7.8. After ten years the difference in prostate cancer mortality was essentially the same in both groups, i.e., within the expected range of statistical variation: 5.8% died in the surgery group and 8.4% died in the observation group.  However, subgroup analysis of the 251 men in the study who started off with PSA levels above 10 showed a modest improvement in survival for the men undergoing surgery: 5.5% died in the surgery group and 12.8% died in the observation group.

Validation of the Right Way to Look at Prostate Cancer

This picture of how different types of prostate cancer behave over long periods of time (having a high PSA for example versus having a low PSA) has been slowly forming in the minds of the prostate cancer experts over the years.  Dr. Anthony V. D’Amico, MD, PhD, Professor of Radiation Oncology at Harvard Medical School, is credited with developing the modern staging system that divides men into Low, Intermediate and High-Risk categories (At the PCRI we call them Shades of Blue, i.e., Sky, Teal and Azure).  Dr. Wilt’s study conclusively validates the fact that favorable prostate cancer—termed Low-Risk—can be safely monitored without immediate treatment, whereas men with High-Risk disease derive a modest benefit from immediate treatment.  His study also reported an intermediate outcome for the men with Intermediate-Risk disease: After 10 years, men in the Intermediate category showed no improvement in cancer survival with surgery.  However, there was a 10% lower incidence of metastases in the men with Intermediate-Risk who had surgery.   

Conclusion

Dr. Wilt’s study is an important breakthrough because it is the first modern, large, long-term, prospective, randomized study comparing treatment versus no treatment in men with relatively early-stage disease, i.e. diagnosed via PSA screening.  This study provides critically important scientific confirmation validating the policy of withholding radical treatment in men with Low-Risk disease.  The study also validates the predictive accuracy of the D’Amico staging system which functions by dividing men into Low, Intermediate and High-Risk categories.  Lastly, Dr. Wilt’s study provides a quantifiable measure of the degree of benefit associated with immediate surgery in men with Intermediate-Risk and High-Risk disease.  Using this information, individuals with High-Risk disease can better understand the rather modest survival advantages of surgery, and weigh them against the probable deleterious side effects, enabling them to determine for themselves whether or not they want to proceed with radical treatment.