Choosing the right course for prostate cancer care
It can be tough to decide whether to get a PSA test, and what to do with the results. Here’s what to consider.
After Ira Baxter was diagnosed with prostate cancer in the fall of 2014, he tried just about everything to treat it.
He had his prostate-specific antigen levels tested and retested. He sought a second opinion, then a third— consulting physicians in Nashville, Los Angeles and Houston.
For a time, he ate an all-organic diet, trying to eliminate sugar and carcinogens. He changed his deodorant and soap.
“I started meditating, I started doing affirmations, just really … physically, spiritually and mentally trying to do everything I could to fight the cancer,” he said. “I was taking 47 supplements a day at one time.”
Faced with a big decision — options included removing his prostate and risking serious side effects or spending years keeping an eye on the cancer and risking it spreading outside of the gland — Baxter turned to David Penson, M.D., MPH, director of the Center for Surgical Quality and Outcomes Research at Vanderbilt University Medical Center.
“When I met him, it just clicked,” said Baxter, who was 62 years old at the time.
A doctor before Penson had looked at Baxter’s cancer cells under a microscope and determined the severity (Gleason score) was a 6 on a scale of 2 to 10. That made him a reasonable candidate for active surveillance, or close medical supervision of what may be a non-lethal, slow-growing cancer. But Penson, the Paul V. Hamilton M.D. and Virginia E. Howd Professor of Urologic Surgery and chair of the department, asked to do his own assessment of the Gleason score. Baxter agreed.
“He was just very patient,” Baxter said. “He spent a long time with me. I think the first time we talked an hour.
“He said, ‘Although you’re a little older than me, we both have young daughters, and we need to make sure we’re doing the best thing for you. And I want to make sure you’re around for them. I want to see you walk down the aisle for them.’ I said, ‘Yeah, I want to be around, too.’ ”
Baxter learned the results of Vanderbilt’s assessment during spring break in 2015. Penson and his family were at the beach, and he called Baxter. He told Baxter that further analysis showed his cancer was actually the more aggressive form of Gleason 7.
Active surveillance of the cancer was no longer an option, Penson advised. Baxter could have the cancer removed or undergo radiation. Each option carried the significant risk of side effects such as incontinence and impotence.
None of that sounded good to Baxter. But he was having trouble doing his usual two-hour workouts with his stringent diet. “I was struggling on the amount of nutrition I was taking,” he said.
A nutritionist he was seeing suggested he should drop endurance sports. But Baxter, a long-distance bicyclist, didn’t want to give up the sport he loved.
MRI fusion biopsy technology
Penson told him that advances in robotic surgery could minimize the side effects of surgery. He recommended doing an MRI fusion biopsy that uses a robotic arm to get more data on the tumor. The fusion technology available at Vanderbilt combines 3-D images with real-time ultrasound imaging, MRI and advanced robotic technology to achieve very accurate biopsies.
The biopsy result revealed the tumor was still inside the prostate and confirmed the Gleason score of 7.
Penson discussed the alternatives with Baxter in detail, and they decided that the robotic prostatectomy was the best option.
“I just decided that regardless of the outcome, that was the best thing to do,” Baxter said. “I was tired of the roller-coaster ride, the highs and the lows, that ‘maybe you’re doing good, maybe you’re not doing good, you can do this, you can’t do that.’”
Baxter’s screening eventually led to a successful surgery. He hasn’t suffered any incontinence, and he still has sexual function. It went so well, he said, he was able to participate in a 65-mile cycling event in Atlanta eight weeks after surgery with no problems.
“I felt really good about the surgery,” he said. “I felt good about Dr. Penson. I felt good about where my body was and the fact that I was pretty sure that I put it behind me.”
Finding your happy medium
Diagnosing and treating prostate cancer isn’t always an exact science. Having a doctor you trust and making a shared decision based on evidence is essential, Penson said.
“What I always say is you have to be comfortable with your physician,” he said. “You can’t ignore it. Doing absolutely nothing and pretending that it’s not there is as bad as being overly aggressive, going crazy and checking your PSA every month. There’s a happy medium.”
While some men are anxious to have any cancer removed, other men feel better about keeping a slower-growing cancer under active surveillance. For someone diagnosed with prostate cancer that has not spread, researching many options and thoroughly understanding the pros and cons of different types of treatment, while keeping an eye on the cancer, may give them the most peace of mind. They should come to this decision weighing the advice of their doctor.
PSA test to check for prostate cancer: Yes or no?
Deciding between surgery and active surveillance is one of many ambiguities in the detection and treatment of prostate cancer. Another is deciding whether to have a PSA test at all. Different medical groups issued different recommendations about this in recent years.
Penson said the contradictory advice boils down to balancing early detection with overdiagnosis. For many years, doctors advised men over the age of 50 to get a PSA test and a digital rectal exam on a regular basis. African-American men such as Baxter are more at risk, and are advised to be tested in their 40s, as Baxter was. So are men who have first-degree relatives — a father or brother — who have had prostate cancer, which was also true for Baxter. (Most doctors advise against screening once a man reaches his 70s, Penson said.)
If the PSA reading or exam causes alarm, a biopsy can be done, which has a proven track record of detecting cancer at a stage early enough to be treated.
“But the other thing we found is that [the PSA] finds a lot of cancers that never needed to be treated, that had they been left on their own, the guys never would have had a problem with prostate cancer” and would have ultimately died from some other cause, not their prostate cancer, Penson said.
In addition, other factors can raise PSA levels. Digital rectal exams and biopsies are uncomfortable. Men suffer stress and anxiety waiting and considering test results, and prostate surgeries can lead to lifelong side effects such as incontinence and sexual dysfunction.
In 2018, the United States Preventive Services Task Force made the recommendation that men age 55 to 69 should talk with their doctors and make a well-informed individual decision whether or not they want to be screened based on their personal feelings about the potential harms and benefits of PSA screening.
A choice: To screen or not to screen
“It’s not really about prostate cancer screening,” Penson said. “It’s about an individual understanding of the pros and cons of screening, and then choosing whether or not he wants to be screened.”
Looking back at his experience, Baxter favors PSA tests. His earlier PSA tests gave him a baseline for comparison for future ones, he said.
“I think that more knowledge is better,” he said. “For me it was just another tool to go ahead and assess what was going on. I was familiar with how it came about. Sure, there can be false positives, but it’s just a real simple blood test.”
Now 52 years old, Penson is facing the same situation he has guided his patients through. He decided to get screened for prostate cancer.
“I’ve weighed the pros and cons,” he said. “I think that the good outweighs the bad. It didn’t outweigh it when I was 45, but I think in my 50s, it does. Turns out I have a low PSA, so I probably won’t get it checked every year going forward. Maybe every two or three years.”
With cancer behind him, Baxter has become an advocate for prostate cancer screenings. He’s leading a prostate cancer support group and is starting one at his church. His advocacy includes recommending PSA tests.
“It does force some people to maybe make some hasty decisions or look at some additional treatment that might be costly,” Baxter said. “But you’re playing with a guy’s life. You’re playing with a guy’s family. You’re playing with his quality of life. So, especially for African-American men, with it affecting us so much more and they still don’t know why — I mean, why not go ahead and make sure that you’re doing something?”
Matt Batcheldor is an information officer at Vanderbilt University Medical Center. This story initially appeared in Vanderbilt-Ingram Cancer Center’s Summer 2016 issue of Momentum magazine.
Photo of Ira Baxter by John Russell
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