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Prostate cancer screening: 'Make an informed choice,' says Dr. Fronczak

  • Category: Cancer, General
  • Posted On:
  • Written By: Boulder Community Health
Prostate cancer screening: 'Make an informed choice,' says Dr. Fronczak

Other than skin cancer, prostate cancer is the most common cancer in men. In fact, 1 out of 8 men living in the U.S. today will eventually develop prostate cancer, and about 1 in 41 will die from the disease.

“Despite its high incidence, if found early, prostate cancer is one of the most survivable forms of cancer. Early detection is key,” said urologist Carolyn Fronczak, MD, of Boulder Medical Center during a free online health lecture.

Video: Watch “Breakthroughs in detecting prostate cancer”

Risk factors for prostate cancer
Dr. Fronczak began the lecture by reviewing risk factors for prostate cancer, including:

  • Male gender and older age:
    • About 6 in 10 cases of prostate cancer are found in men older than 65.
  • Ethnicity:
    • African Americans are 1.6 times more likely to get the disease.
    • African Americans are 2.2 times more likely to die of the disease.
  • Family history:
    • Prostate cancer seems to run in some families. Having a father or brother with prostate cancer more than doubles a man’s risk of developing this disease. The risk is much higher for men with several affected relatives, particularly if their relatives were young when the cancer was found.
    • Family history of these type of cancers:
      • Metastatic prostate cancer
      • Ovarian cancer
      • Male or female breast cancer
      • Colorectal
      • Endometrial cancer
      • Pancreatic cancer
  • 5-Alpha reductase Inhibitors:
    • “This is a group of drugs used in the treatment of an enlarged prostate gland. Interestingly, they have been associated with an increased risk of aggressive prostate cancer,” Dr. Fronczak warned.

Genetic testing for prostate cancer
Several inherited germline mutations, or cells that pass on their genetic material, raise the risk of aggressive prostate cancer:

  • Inherited mutations of the BRCA1 or BRCA2 genes, which are linked to an increased risk of breast and ovarian cancers in some families, are also associated with increased risk of prostate cancer in men, especially mutations in BRCA2.
  • Men with HOXB13 gene mutations have a strong association with prostate cancer before age 65.

“We should begin screening for prostate cancer at the age of 40, if you have one of these mutations,” said Dr. Fronczak. “The importance of knowing these genes is that there are certain new treatments with PARP inhibitors – which stands for poly adenosine diphosphate-ribose polymerase, a type of enzyme that helps repair DNA damage in cells – and platinum-based chemotherapy that may offer targeted treatment for men with these gene mutations who develop prostate cancer.”

She said genetic testing is recommended for the following men:

  • Family history genetic mutations
  • Ashkenazi Jewish ancestry
  • Family history prostate cancer
  • Multiple cancers in a family

Screening tests
There are two main screening tests for prostate cancer. It’s important to know neither is 100% accurate. These tests can sometimes have abnormal results even when a man does not have cancer (a false-positive result), or normal results even when a man does have cancer (a false-negative result):

  • Prostate-specific antigen (PSA) test. This is a blood test to check the level of prostate-specific antigen in your blood. A PSA value of 4ng/ml or less if often considered normal. But this is not always the case; lower PSAs may also be associated with prostate cancer. If the initial result is borderline, doctors may recommend repeating the test. For higher PSAs, doctors are likely to recommend additional tests.

    “PSA has a limited sensitivity for prostate cancer detection. But it is still the best screening test for prostate cancer that we have. It just has to be interpreted wisely. A lower PSA level doesn’t mean a man is free of prostate cancer, and a higher level doesn’t mean he has prostate cancer,” Dr. Fronczak explained.

    She added, “Just because you have an elevated PSA, doesn't mean you have prostate cancer. There are many situations that can cause PSA levels to be higher than normal.” This includes:
    • Large prostates (Benign Prostate Hyperplasia)
    • Infections (prostatitis, urinary tract infections, epididymitis)
    • Recent ejaculation
    • Trauma
    • Recent urinary catheterization
    • Recent biking
    • Prostate cancer
       
  • Digital rectal exam (DRE). During a DRE, a physician inserts a gloved, lubricated finger into your rectum to examine your prostate, which is next to the rectum. Your doctor will assess the size of the prostate and feel for any bumps or hard areas on the prostate that may need to be tested for cancer. Dr. Fronczak said, “A DRE should be done in all men with an abnormal PSA.”

Informed shared decision-making
While screening for prostate cancer can find prostate cancer early, leading medical organizations disagree about who should — and who shouldn't — get screened. “Men should have full, thoughtful conversations with their doctors about the uncertainties, risks and potential benefits of screening. Together, you and your doctor can decide whether screening is right for you,” said Dr. Fronczak.

The American Urological Association (AUA) has developed the following screening guidelines for early detection of prostate cancer:

  • Age 40‐54 years - Screening as a routine is not recommended, unless risk factors discussed above.
  • Age 55‐69 years – Proceeding with screening based on a patient’s values and preferences. “This is the population with greatest benefit. We weigh the benefit of preventing one prostate cancer death per 1,000 screened over a decade versus the harms of screening and treatment,” Dr. Fronczak stated.
  • Age 70 years and older. Recommend against routine PSA-based screening in men age 70+ years, or in any patient with less than a 10-to-15-year life expectancy. Dr. Fronczak clarified, “Yet men over age 70 years who are in excellent health may benefit from prostate cancer screening.”

Non-invasive pre-biopsy tests for prostate cancer
According to Dr. Fronczak, a standard initial evaluation combines PSA testing with DRE to help identify men at risk for prostate cancer. If the results of the PSA and DRE suggest that you may have prostate cancer, years ago, a prostate biopsy would have been the next step. However, we have new non-invasive methods to help determine who would benefit from a biopsy and who may not.

“A standard biopsy has risks of pain, infection and may miss the lesion,” Dr. Fronczak warned. “Because of this, the new school of thought is to first recommend non-invasive pre-diagnostic tests that are done to determine whether a man needs a biopsy.” Non-invasive pre-biopsy testing includes MRI and looking for biomarkers:

  • Multiparametric MRI - At BCH, urologists and radiologists collaborate in using Multiparametric (mp) MRI technology for prostate cancer diagnosis. mpMRI helps not only determine who needs a prostate biopsy but also assists urologists in performing targeted and precise biopsies. “We also use it to follow men with prostate cancer who want to watch it over time. We're determining if those lesions change over time on the MRI to see if there's possibly a more aggressive tumor,” said Dr. Fronczak.

    There is, however, the potential for inter-observer variability with prostate MRI, where one radiologist scores prostate lesions one way and another radiologist scores the lesion another way. “BCH is where I get most of my MRIs done, and the radiologists who read my MRIs are simply outstanding. There are two radiologists that read each of my prostate MRIs so this really reduces that inter-observer variability,” stated Dr. Fronczak.
     
  • Novel biomarkers - Urologists are also using biomarkers — molecules secreted by a tumor in blood and in prostate tissue — to better diagnose prostate cancer. This technology helps to distinguish between insignificant and significant prostate cancer, as well as identify particularly aggressive cancer.

    “Several biomarkers are available through each stage of the decision-making process. Biomarkers can be found in blood tests and urine tests. The beauty of these is they've really helped us decrease unnecessary biopsies but also helped us find lethal types of prostate cancer,” said Dr. Fronczak.

Treatment

If prostate cancer is found, treatment options depend on several factors, including how fast the cancer is growing, how much it has spread, the patient’s overall health, as well as the potential benefits or side effects of the treatment. Treatment for prostate cancer can include active surveillance, radiation therapy, chemotherapy, hormone therapy and surgery to remove the prostate, including robot-assisted prostatectomy surgery.


To make an appointment with Carolyn Fronczak, MD, call 303-440-3093.

Click here to view/download a PDF of slides shown during her lecture.