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Prostate Cancer 101
As men age, there is concerns about prostate cancer risk. Dr. John Powell, radiation oncologist, educates all about the prostate.
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Learn more about John Powell, MD
John Powell, MD
Dr. John Powell earned his undergraduate degree in biology from Cornell University and went on to medical school at Upstate Medical University in Syracuse, where he was inducted into the Alpha Omega Alpha Medical Honor Society. He completed his radiation oncology residency at Upstate University Hospital.Learn more about John Powell, MD
Transcription:
Bill Klaproth (Host): So as we men age, it’s time to start thinking about prostate cancer, but it’s not a topic you really want to talk about or learn about, but this is serious, and you should have a common understanding of this. so, it sounds like what we need is prostate 101 and here to teach our class is Dr. John Powell, a radiation oncologist at Cayuga Medical Center. Dr. Powell, thanks for leading our studies today.
John Powell, MD (Guest): Hi Bill. Thank you very much for having me.
Host: So, let’s start with this. It’s a common fact that prostate cancer risk increases with age, is that right?
Dr. Powell: It is. It’s generally a disease that is detected in men over age 50. The age of highest incidence is around age 65. Some research shows that in men at advance age over age 80 or 90, many of them if not most have some abnormal cells that we would classify as cancer growing within the prostate.
Host: So, most of us are going to deal with this in our lifetime.
Dr. Powell: It’s not unlikely at all.
Host: So, what happens to the prostate as we age?
Dr. Powell: The prostate is a small gland located in the pelvis. It’s located just in front of the rectum, just below the bladder and it really is part of our sexual and reproductive system. It produces seminal fluid that is part of the ejaculate and so in normal function; it’s job basically as a gland is to produce fluid. As we age, there’s commonly benign swelling of the prostate referred to as BPH or benign prostatic hypertrophy. That’s not cancer in and of itself and that’s actually where most of the symptoms that men associate with the prostate tend to come from. Slower urinary stream, more frequent urination, having to go more at night or not emptying the bladder completely for example.
As cells in the body grow, and divide, they can develop mutations and if these mutations lead to abnormal growth; those cells can become cancerous. Basically cancer is a problem where cells from a man’s own body in the prostate gain an abnormal growth rate. Normally cells go through a cell cycle. They grow, they divide and then they die off. Cancer cells have the tendency to grow and grow and grow uncontrolled and can in some cases, gain the ability to leave the prostate gland itself and spread to other areas of the body, potentially lymph nodes in the pelvis or even more broadly.
Host: Yeah, that’s what we don’t want to happen. So, prostate cancer is unique in that it has an easy to detect PSA screening when you get a physical and a blood test; they do the PSA screening and the level of PSA determines your risk for prostate cancer. So, Dr. Powell, what are the current guidelines for screening and why is this controversial?
Dr. Powell: Yeah, that’s a great question. One thing that is unique a little bit about prostate cancer is the wide spectrum of disease and our ability to find the cancer means that we can detect many, many prostate cancers that fall into an extremely low risk spectrum. There are very dangerous prostate cancer situations that can be life-threatening, and PSA gives us the ability to detect all of them but at this stage, we don’t have perfect tests to be able to predict how those diseases will behave and so it can be a challenge in terms of decision making and because of the treatment options for prostate cancer; they can have a major impact in terms of quality of life. And so, how men handle a diagnosis of prostate cancer or whether or not you even go looking broadly for prostate cancer with the PSA blood test has been pretty controversial.
Right now, guidelines in the United States suggest that around age 45; men should be considered for some kind of screening for prostate cancer. Depends on family history, depends on race, depends on specific factors, that’s a conversation that individual men should have with their primary care doctor about how they should handle that.
But the ability to detect very low risk cancers has made PSA screening controversial because if we treat all those men; we could be doing more harm than good based on side effects of treatment for diseases that might not be dangerous.
Host: All right, so let’s stay with the PSA tests. If someone does have a high PSA level; what happens then or how do you monitor that person?
Dr. Powell: Yeah, typically, if the PSA is found to be elevated to a level of concern; this is usually a screening test that’s obtained by the primary care physician and that will commonly prompt a referral to a urologist who is a surgical specialist and really the specialist in terms of managing prostate related concerns, both benign and cancer related. And they will if there’s a suspicion of cancer, based on a digital rectal examination or the PSA or the combination consider a biopsy of the prostate.
Host: All right so let’s talk about two things. Prostate cancer is detected but someone chooses to go on surveillance, it’s as we said earlier, some people can live with this and then let’s – after you answer that question, let’s shift to the next one. What happens when someone has an advanced stage and how you treat that. So, if someone does have prostate cancer, it is detected, when do you just let it go and under surveillance just watch it? What is that scenario?
Dr. Powell: Yeah great questions and probably some of the most challenging conversations that I have with men is to try to understand where their specific situation falls in terms of this spectrum of risks. So, we have some tools that we can look at to help predict how a prostate cancer is likely to behave. The PSA level gives us information, probably one of the most important things in terms of how severe the cancer may be if the PSA level is less than 10 when cancer is found; that’s considered lower in terms of the risk spectrum. PSA 10-20 for a localiz4ed prostate cancer is considered intermediate in terms of risk and if the PSA is found to be higher than 20; even if the prostate cancer is localized; we consider that a high risk situation.
There is also an evaluation that’s made from the biopsy. So specimens are taken from the prostate using a needle that’s placed with ultrasound guidance to get a sample specifically from different regions of the prostate to get a good sampling to make sure that we have a good evaluation. If cancer is present, those biopsy specimens are then sent to a pathology lab where a pathologist evaluates them in detail. They are evaluated under a microscope. You can see the pattern of cells in cancer under a microscope. And the pathologist has a scoring system that’s been standardized called the Gleason Score. It’s a score that is basically how aggressive the pattern of growth of the prostate cancer appears to a pathologist. And it is used all over the world to standardize our evaluation of prostate cancer. That score can go from basically 2 to 10, so a Gleason 6 and below prostate cancers are considered lower in terms of risk. A Gleason 7 prostate cancers are considered intermediate in terms of risk and if the Gleason score on that cancer is 8,9, or 10; it’s considered high risk.
Host: So, what do you do then with that information and are there any other factors involved?
Dr. Powell: We also risk stratify patients based on their examination, the amount of tumor that we feel, the amount of biopsies positive, small amount of cancer is less of a concern than a large amount. Individual factors, the man’s age and overall state of health is going to be very important. Our guidelines specifically separate out recommendations for how prostate cancer should be managed and screening based on predicted longevity. And as everyone knows, that’s a bit of a crystal ball question. We don’t know for sure, but we do have some ways that we can predict based on a man’s age and overall health how likely they are to live for a given period of time.
If a Gleason 6, low risk prostate cancer is found in a gentleman who is around the age of 75 or 80; it’s very, very unlikely that that’s going to cause them harm. Whereas if a Gleason 7 or a Gleason 8 cancer is found in a younger man; that’s much more likely to require treatment. And there are guidelines that help us to go through this information. There’s also very, very good research recently completed in the United Kingdom comparing active surveillance which is a strategy of initial monitoring for prostate cancer as opposed to initial treatment. That was compared to surgery and also compared to radiation therapy in men generally felt to be at a low risk.
And they found that with good follow-up, many of the men who chose active surveillance wouldn’t need treatment. More than half over the course of time did go on to prostate cancer treatment but they didn’t start immediately. So, active surveillance doesn’t mean that you are not going to do treatment, it means that if you are in a low risk category, you would only do treatment if the cancer proves that it’s going to behave in a more serious fashion. Mostly, that means that some of those risk factors are going to increase. The PSA going up over time or particularly if repeated biopsies show that the Gleason Score has increased into the intermediate risk spectrum.
Host: That’s really good information. So, a lower Gleason score generally you’ll be put on active surveillance. So, then if you have a higher Gleason score, is that when you would have an advanced disease and go on active treatment and then what is active treatment? How do you treat someone with advanced disease?
Dr. Powell: Yeah, good question. So, when the cancer is found initially, we look at risk. If there is concerns that the cancer appears to be in the more significant risk spectrum, often information is obtained through scans to look for cancer outside the prostate. As I said, prostate cancer can leave the prostate gland and spread to other areas. That’s referred to as an advanced prostate cancer problem. So, we have a big separation in terms of how we manage prostate cancers that are found when it’s localized within the prostate or that region or when it’s found to have spread elsewhere.
The most common pattern of spread for advanced prostate cancer is into the bone. Which sometimes can cause symptoms, sometimes it’s something we find when we do diagnostic testing to evaluate that patient. In advanced prostate cancer; most of the treatment is focused on anticancer drugs. Some men live with advanced prostate cancer for many, many, many years but it’s not a situation where those drugs are expected to permanently eliminate the cancer.
Whereas if a cancer is just in or around the prostate; with treatment, in many cases, the cancer can be eliminated completely. And when we talk about active treatment, for localized prostate cancer, it’s typically surgical removal of the prostate or radiation therapy which is an x-ray treatment directed specifically to the prostate to try to kill off the cancer using very high energy, very focused and specific x-rays.
Host: Well, this has been very informative Dr. Powell. I hope I score well in our classroom today. Prostate 101. Thank you so much for your time. For more information or to get connected with one of our providers, go to www.cayugahealthsystem.org, that’s www.cayugahealthsystem.org. And if you found this podcast helpful, please share on your social channels and be sure to check back in soon for our next episode. This is Your Health from Cayuga Medical Center. Be sure to subscribe wherever you listen to your podcasts. I’m Bill Klaproth. Thanks for listening.
Bill Klaproth (Host): So as we men age, it’s time to start thinking about prostate cancer, but it’s not a topic you really want to talk about or learn about, but this is serious, and you should have a common understanding of this. so, it sounds like what we need is prostate 101 and here to teach our class is Dr. John Powell, a radiation oncologist at Cayuga Medical Center. Dr. Powell, thanks for leading our studies today.
John Powell, MD (Guest): Hi Bill. Thank you very much for having me.
Host: So, let’s start with this. It’s a common fact that prostate cancer risk increases with age, is that right?
Dr. Powell: It is. It’s generally a disease that is detected in men over age 50. The age of highest incidence is around age 65. Some research shows that in men at advance age over age 80 or 90, many of them if not most have some abnormal cells that we would classify as cancer growing within the prostate.
Host: So, most of us are going to deal with this in our lifetime.
Dr. Powell: It’s not unlikely at all.
Host: So, what happens to the prostate as we age?
Dr. Powell: The prostate is a small gland located in the pelvis. It’s located just in front of the rectum, just below the bladder and it really is part of our sexual and reproductive system. It produces seminal fluid that is part of the ejaculate and so in normal function; it’s job basically as a gland is to produce fluid. As we age, there’s commonly benign swelling of the prostate referred to as BPH or benign prostatic hypertrophy. That’s not cancer in and of itself and that’s actually where most of the symptoms that men associate with the prostate tend to come from. Slower urinary stream, more frequent urination, having to go more at night or not emptying the bladder completely for example.
As cells in the body grow, and divide, they can develop mutations and if these mutations lead to abnormal growth; those cells can become cancerous. Basically cancer is a problem where cells from a man’s own body in the prostate gain an abnormal growth rate. Normally cells go through a cell cycle. They grow, they divide and then they die off. Cancer cells have the tendency to grow and grow and grow uncontrolled and can in some cases, gain the ability to leave the prostate gland itself and spread to other areas of the body, potentially lymph nodes in the pelvis or even more broadly.
Host: Yeah, that’s what we don’t want to happen. So, prostate cancer is unique in that it has an easy to detect PSA screening when you get a physical and a blood test; they do the PSA screening and the level of PSA determines your risk for prostate cancer. So, Dr. Powell, what are the current guidelines for screening and why is this controversial?
Dr. Powell: Yeah, that’s a great question. One thing that is unique a little bit about prostate cancer is the wide spectrum of disease and our ability to find the cancer means that we can detect many, many prostate cancers that fall into an extremely low risk spectrum. There are very dangerous prostate cancer situations that can be life-threatening, and PSA gives us the ability to detect all of them but at this stage, we don’t have perfect tests to be able to predict how those diseases will behave and so it can be a challenge in terms of decision making and because of the treatment options for prostate cancer; they can have a major impact in terms of quality of life. And so, how men handle a diagnosis of prostate cancer or whether or not you even go looking broadly for prostate cancer with the PSA blood test has been pretty controversial.
Right now, guidelines in the United States suggest that around age 45; men should be considered for some kind of screening for prostate cancer. Depends on family history, depends on race, depends on specific factors, that’s a conversation that individual men should have with their primary care doctor about how they should handle that.
But the ability to detect very low risk cancers has made PSA screening controversial because if we treat all those men; we could be doing more harm than good based on side effects of treatment for diseases that might not be dangerous.
Host: All right, so let’s stay with the PSA tests. If someone does have a high PSA level; what happens then or how do you monitor that person?
Dr. Powell: Yeah, typically, if the PSA is found to be elevated to a level of concern; this is usually a screening test that’s obtained by the primary care physician and that will commonly prompt a referral to a urologist who is a surgical specialist and really the specialist in terms of managing prostate related concerns, both benign and cancer related. And they will if there’s a suspicion of cancer, based on a digital rectal examination or the PSA or the combination consider a biopsy of the prostate.
Host: All right so let’s talk about two things. Prostate cancer is detected but someone chooses to go on surveillance, it’s as we said earlier, some people can live with this and then let’s – after you answer that question, let’s shift to the next one. What happens when someone has an advanced stage and how you treat that. So, if someone does have prostate cancer, it is detected, when do you just let it go and under surveillance just watch it? What is that scenario?
Dr. Powell: Yeah great questions and probably some of the most challenging conversations that I have with men is to try to understand where their specific situation falls in terms of this spectrum of risks. So, we have some tools that we can look at to help predict how a prostate cancer is likely to behave. The PSA level gives us information, probably one of the most important things in terms of how severe the cancer may be if the PSA level is less than 10 when cancer is found; that’s considered lower in terms of the risk spectrum. PSA 10-20 for a localiz4ed prostate cancer is considered intermediate in terms of risk and if the PSA is found to be higher than 20; even if the prostate cancer is localized; we consider that a high risk situation.
There is also an evaluation that’s made from the biopsy. So specimens are taken from the prostate using a needle that’s placed with ultrasound guidance to get a sample specifically from different regions of the prostate to get a good sampling to make sure that we have a good evaluation. If cancer is present, those biopsy specimens are then sent to a pathology lab where a pathologist evaluates them in detail. They are evaluated under a microscope. You can see the pattern of cells in cancer under a microscope. And the pathologist has a scoring system that’s been standardized called the Gleason Score. It’s a score that is basically how aggressive the pattern of growth of the prostate cancer appears to a pathologist. And it is used all over the world to standardize our evaluation of prostate cancer. That score can go from basically 2 to 10, so a Gleason 6 and below prostate cancers are considered lower in terms of risk. A Gleason 7 prostate cancers are considered intermediate in terms of risk and if the Gleason score on that cancer is 8,9, or 10; it’s considered high risk.
Host: So, what do you do then with that information and are there any other factors involved?
Dr. Powell: We also risk stratify patients based on their examination, the amount of tumor that we feel, the amount of biopsies positive, small amount of cancer is less of a concern than a large amount. Individual factors, the man’s age and overall state of health is going to be very important. Our guidelines specifically separate out recommendations for how prostate cancer should be managed and screening based on predicted longevity. And as everyone knows, that’s a bit of a crystal ball question. We don’t know for sure, but we do have some ways that we can predict based on a man’s age and overall health how likely they are to live for a given period of time.
If a Gleason 6, low risk prostate cancer is found in a gentleman who is around the age of 75 or 80; it’s very, very unlikely that that’s going to cause them harm. Whereas if a Gleason 7 or a Gleason 8 cancer is found in a younger man; that’s much more likely to require treatment. And there are guidelines that help us to go through this information. There’s also very, very good research recently completed in the United Kingdom comparing active surveillance which is a strategy of initial monitoring for prostate cancer as opposed to initial treatment. That was compared to surgery and also compared to radiation therapy in men generally felt to be at a low risk.
And they found that with good follow-up, many of the men who chose active surveillance wouldn’t need treatment. More than half over the course of time did go on to prostate cancer treatment but they didn’t start immediately. So, active surveillance doesn’t mean that you are not going to do treatment, it means that if you are in a low risk category, you would only do treatment if the cancer proves that it’s going to behave in a more serious fashion. Mostly, that means that some of those risk factors are going to increase. The PSA going up over time or particularly if repeated biopsies show that the Gleason Score has increased into the intermediate risk spectrum.
Host: That’s really good information. So, a lower Gleason score generally you’ll be put on active surveillance. So, then if you have a higher Gleason score, is that when you would have an advanced disease and go on active treatment and then what is active treatment? How do you treat someone with advanced disease?
Dr. Powell: Yeah, good question. So, when the cancer is found initially, we look at risk. If there is concerns that the cancer appears to be in the more significant risk spectrum, often information is obtained through scans to look for cancer outside the prostate. As I said, prostate cancer can leave the prostate gland and spread to other areas. That’s referred to as an advanced prostate cancer problem. So, we have a big separation in terms of how we manage prostate cancers that are found when it’s localized within the prostate or that region or when it’s found to have spread elsewhere.
The most common pattern of spread for advanced prostate cancer is into the bone. Which sometimes can cause symptoms, sometimes it’s something we find when we do diagnostic testing to evaluate that patient. In advanced prostate cancer; most of the treatment is focused on anticancer drugs. Some men live with advanced prostate cancer for many, many, many years but it’s not a situation where those drugs are expected to permanently eliminate the cancer.
Whereas if a cancer is just in or around the prostate; with treatment, in many cases, the cancer can be eliminated completely. And when we talk about active treatment, for localized prostate cancer, it’s typically surgical removal of the prostate or radiation therapy which is an x-ray treatment directed specifically to the prostate to try to kill off the cancer using very high energy, very focused and specific x-rays.
Host: Well, this has been very informative Dr. Powell. I hope I score well in our classroom today. Prostate 101. Thank you so much for your time. For more information or to get connected with one of our providers, go to www.cayugahealthsystem.org, that’s www.cayugahealthsystem.org. And if you found this podcast helpful, please share on your social channels and be sure to check back in soon for our next episode. This is Your Health from Cayuga Medical Center. Be sure to subscribe wherever you listen to your podcasts. I’m Bill Klaproth. Thanks for listening.
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