Prostate cancer presentation 2024.

1. Prostate Cancer Basics:
Screening, Diagnosis, and Treatment Considerations

2. What is the prostate?
The prostate is a gland found only in males. It makes some of the fluid that is part of
semen. The prostate is below the bladder and in front of the rectum (the last part of the
intestines).
Just behind the prostate are glands called seminal vesicles, which make most of the
fluid for semen. The urethra, which is the tube that carries urine and semen out of the
body through the penis, goes through the center of the prostate.

3. Prostate cancer occurs when cells in the prostate gland start to grow out of control.
What is prostate cancer?
What are possible symptoms?
According to the Center for Disease Control and Prevention, most people do not experience any
symptoms at all. Possible symptoms may include:
• Difficulty starting urination
• Weak or interrupted flow of urine
• Urinating often, especially at night
• Trouble emptying the bladder completely
• Pain or burning during urination
• Blood in the urine or semen
• Pain in the back, hips, or pelvis that doesn’t go away
• Painful ejaculation
These symptoms may be caused by conditions other than prostate cancer.

4. Cancer screening tests — including the prostate-specific antigen (PSA) test to look for signs of prostate
cancer — can be a good idea. Prostate cancer screening can help identify cancer early on, when treatment
is most effective.
The PSA test is not diagnostic. Rather, if results of the test are elevated, think of it as a “check engine light”
warning you to pay attention because something may be going on with the prostate.
Some possible causes of an elevated result include:
• Age: PSA levels tend to increase as a man ages
• Prostate size: Larger prostates produce more PSA than do smaller prostates
• Medications: Certain medications affect PSA measurements
• Infections: Your doctor may prescribe an antibiotic to see if it lowers your PSA
• Activities: Anything that puts pressure on the prostate (cycling, horseback riding, sexual intercourse, etc.)
If there are often no symptoms, how do I become aware I might have prostate cancer?

5. Given the limitations of the PSA test, should I even bother getting one?
• Yes, but understand:
• PSA is a starting point.
• PSA is one tool in the screening process, and there are other tools and factors to consider.
• PSA can be used to guide treatment. PSA testing is only controversial when being used to screen
for prostate cancer. In men with known cancers, it is an undeniably useful staging tool and way
of monitoring after treatment. How PSA levels respond after treatment tells a lot about the
aggressiveness of the cancer you’re dealing with.
• Doctors can work through any confusion with you. There’s an industry poised behind cancer
screening that many agree leads to too aggressive a treatment, often for forms of harmless (we’ll
get to this in a minute) prostate cancer. Be sure to discuss with your medical team.

6. At what age should I get a PSA test?
• Conflicting recommendations have caused confusion and controversy on when, or even if, to test
• The American Urological Association recently updated its screening guidelines and recommends that
clinicians:
• Begin prostate cancer screening and offer a baseline PSA test to men between the ages of 45 to 50
years of age
• Offer prostate cancer screening beginning at age 40 to 45 years for those at increased risk of
developing prostate cancer based on the following factors: Black ancestry, germline mutations,
strong family history of prostate cancer
• Offer regular prostate screening every 2 to 4 years to men aged 50 to 69 years
• Personalize the re-screening interval based on patient preference, age, PSA, prostate cancer risk,
life expectancy and general health

7. Is PSA testing the only way to screen for prostate cancer?
• PSA testing is the easiest and most affordable way to screen at this time:
• Simple blood test
• Costs about $35
• PCSANM offers voucher for free PSA test at Any Lab Test Now (to establish a baseline, if
provider insists you don’t need a test, if you have no health insurance, have symptoms)
• Theoretically, a patient could go directly to getting an MRI to screen for prostate cancer, but MRIs
are much more expensive than PSA tests. So:
• Start with a PSA test
• If result is elevated, discuss possible causes with doctor and attempt to address
• Then, get another test
• If PSA is still elevated or is rising, schedule an MRI in an attempt to discover any lesions that
should be investigated
• If no suspicious lesions and PSA remains elevated, get another MRI in a year

8. But will waiting a whole year for another MRI cause a problem?
• Assuming your MRI was reviewed by an experienced reader, if a lesion is too small to be seen on an MRI,
it will not become problematic in a year.
• Even if cancer is present but not seen on an MRI right away, prostate cancer is an unusual subtype of cancer:
• Metastatic rates are far less than that of most other cancers
• Growth rates are often slower
• Especially when PSA is less than 10, patients are typically not dealing with metastatic disease
(rare exceptions exist)
• If diagnosed, there is a mindset that the clock is ticking and cancer must be treated right away to reduce any
chance of metastasis– this is not necessarily true with prostate cancer.
• If your PSA is elevated, take your time and do your research.

9. PSA testing is sometimes combined with a digital rectal exam (DRE) to feel the prostate for abnormalities.
What about the dreaded digital rectal exam (DRE)?
Do I really need one?
If you’re getting an MRI, a DRE likely will not be adding much. Prostate cancer not large enough to be
detected on an MRI will be not be detectable through a DRE.
In some cases, if a tumor is large enough and causing enough irregularity, and if it is growing on the outer
area of the prostate the doctor can reach, a DRE theoretically could lead to the ordering of an MRI.

10. So your PSA is elevated, you’ve gotten an MRI, and they found some suspicious lesions.
Now what?
Targeted biopsy:
• As of 2024, coverage is fairly easy to access
• More likely to find the kind of cancer that needs treatment with MRI guided biopsy
• Different ways to do targeted biopsy:
• Fusion biopsy with ultrasound
• In-bore MRI targeted biopsy
• Cognitive fusion biopsy– doctor sees suspicious lesion and attempts to target that area of
prostate for most effective result
Random needle biopsy (grid pattern):
• May miss some clinically significant lesions
• Often find clinically insignificant cancer that does not need treatment
Biopsy: What kind of biopsy is being offered?

11. Gleason score
• Describes level of cell abnormality, gives an idea
of likelihood of cancer spreading
(metastasizing) beyond the prostate gland
• Gleason made up of two numbers (most
present cells followed by 2nd most present)
• 1s: Normal cells
• 3s: Somewhat abnormal but not likely to spread
• 4s & 5s: Abnormal cells with higher likelihood
of spreading to other parts of the body
What is clinically insignificant
vs
clinically significant prostate cancer?
Grade and Stage: What Do The Numbers Mean?
Prostatic Adenocarcinoma
(Histologic Grades)

12. Clinically insignificant vs clinically significant prostate cancer, continued…
Prostate cancer cells are only problematic if they have the potential to spread/metastasize.
If the cancer cells will not metastasize, they are considered clinically insignificant.
Gleason 6— (Clinically insignificant)
• (3+3): Will not metastasize
Gleason 7— (Clinically significant)
• (3+4): “Favorable intermediate risk,” likelihood of metastasizing dependent on multiple factors, to
treat or not to treat dependent on those factors
• (4+3): “Unfavorable intermediate risk,” higher likelihood of metastasizing
Gleason 8, Gleason 9, and Gleason 10— (Clinically significant)
• (4+4), (4+5), (5+4), (5+5): Even higher likelihood of metastasizing
• Does not mean metastasis will definitely occur
• Not necessarily a death sentence (even with metastasis)

13. Doesn’t ALL cancer need to be treated?
• True Gleason 6 is clinically insignificant and will not spread.
Without the potential to spread, it will not cause problems and does not require treatment.
• True Gleason 6 does not turn into aggressive cancer. Much like with skin cancer:
• Harmless skin cancers (basal cell, squamous cell): comparable to Gleason 6 cancers
• Melanomas: comparable to Gleason 7 and above
• Basal cells and squamous cells never turn into melanomas. Gleason 6 cells do not turn into other cells.
• But like with skin cancer, you can have more than one kind of prostate cancer in your lifetime.
• Some argue it is best not to detect Gleason 6. For example, in Sweden, researchers have spent millions
trying to find ways to diagnosis less Gleason 6. Why?
• When people hear they have cancer, they become afraid and may seek unneeded treatment
• Serious risk of side effects with treatment, side effects may be lifelong and worse than the “cancer”
• Impact on mental and emotional health (anxiety, stress, etc.)
Doing random needle with targeted biopsy doubles the incidence of finding Gleason 6.

14. What if the prostate cancer is staged at Gleason 7 or higher?
• Gleason 7 and above is clinically significant cancer and needs to be treated.
• Possible exception is 3+4 Gleason 7: Depending on situation, active surveillance may be appropriate
because of potential negative impact of possible side effects of treatment on quality of life
• Gleason 7 (4+3) and higher treatment options will depend on if disease is localized (contained
within the prostate) or metastatic (spread to lymph nodes, seminal vesicles, bones or elsewhere)
• PSMA PET scans may be used following diagnosis to identify location of any metastases.
• Likelihood of metastasis (Gleason) considered when considering appropriate treatments

15. Possible Treatment Options (depend on circumstances & priorities)
• Surgery: Removal of entire prostate. Types include:
• Robotic prostatectomy
• Laparoscopic radical prostatectomy
• Radical prostatectomy (open, not common)
• Radiation: Radiate entire prostate. Types of radiation therapy include:
• Intensity modulated radiation therapy (IMRT)
• External beam radiation therapy (EBRT)
• Stereotactic body radiation therapy (SBRT)
• Focal therapy: Treatment aimed at the tumor itself, likely with a margin of protection. Lower incidence of
side effects vs treatment of entire gland, but only for unilateral disease and must find skilled provider.
Some examples of focal therapy include:
• High-intensity focused ultrasound (HIFU)
• TULSA-Pro
• Cryotherapy
• Focal laser ablation

16. Possible Treatment Options (continued) & Considerations
• Androgen deprivation therapy (ADT, aka hormone therapy
• Chemotherapy (for advanced metastatic disease)
• No one-size fits all treatment for prostate cancer
• Talk with your medical team and consider all options to make an informed treatment decision appropriate
to your circumstances and priorities
• Talk with members for the Prostate Cancer Support Association of New Mexico (PCSANM) for peer support
and the perspectives of others who are coping with prostate cancer. PCSANM offers:
• Support group meetings on the first and third Saturdays of most months
• One-on-one support
• A buddy list of names, contact information and treatments received- may help in choosing treatment
most appropriate for you
• Resources (online and in office)

17. Prostate Cancer Support Association of New Mexico (PCSANM)
• Our mission as a nonprofit is to provide support and information to those affected by prostate cancer:
• Office hours: Monday through Thursday from 10 to 2, no appointment necessary
• Calls answered 24/7, (505) 254-7784
• Website: www.pcsanm.org
• Email: pchelp@pcsanm.org
THANK YOU