If your urologist seems busier than usual, well, there’s a reason for that…actually, there are three reasons
Urologists tend to fly under the radar. As a rule, their patients are not keen on discussing the problems and procedures with which they are involved in social situations. And, let’s face it: you don’t see a urologist unless you have to. Indeed, most people receive their AARP card before scheduling their first urological visit. So it’s worth paying attention when the profession pushes its way into the news—as it has in the last year or so.
Recent breakthroughs—and controversies—promise to alter the way urology practices interact with patients and conduct their business. Although these are topics that we don’t like to discuss, from prostate cancer to bladder cancer, there is actually quite a bit to talk about.
The Prostate-Specific Antigen (PSA) blood test measures the presence of an enzyme which is present in small quantities of men with healthy prostates, but is often elevated in men with prostate cancer or other prostate problems. The test has been in general use since the late-1980s. Around a third of patients who have high PSA turn out to have prostate cancer. The American Urological Association (AUA) in Maryland recommends the test for men 55 to 70. However, the American Cancer Society and some in the U.S. Preventative Services Task Force (USPSTF)—an independent panel of experts in prevention and evidence-based medicine—are recommending against using the PSA test for screening.
“Almost all urologists agree that PSA testing benefits far more people than it hurts,” says Andrew Bernstein, MD, adding that the AUA and USPSTF will eventually meet somewhere in the middle. “It is just a blood test. Doctors and patients together make the decision on what to do about the results. In years prior, it was a reflex to proceed with further biopsy work, surgery, or aggressive treatment. We know that is not necessarily mandatory now, but the cost of a blood test is far less than the cost of treating a disease after it has spread.”
“At this time, since there are no other commercially available blood tests, PSA coupled with a Digital Rectal Exam (DRE) are still recognized as a good screening method for prostate cancer,” Alan Krieger, MD, Division Chief of Urology at Trinitas, points out. He believes the USPSTF “got it wrong”—using the PSA test, early detection of prostate cancer has decreased cancer-specific death by approximately 30 percent.
Because an elevated PSA does not necessarily mean a man has prostate cancer, urologists are careful to track the rise in a patient’s PSA value (aka PSA velocity) over time, which can also indicate the possible presence of prostate cancer that is not always detected on a DRE.
Cancer Treatment Strategies
Not all prostate cancers are alike. Urologists use the Gleason Grading System to evaluate tissue removed through a biopsy and assign a score that measures how aggressive the cancer is. Gleason scores range from 2 to 10. Scores of 6 and under are associated with less-aggressive cancers. Patients falling into this range—particularly those over age 65—are now being advised to take an “active surveillance” approach to slow-growing tumors rather than immediately going under the knife.
According to Dr. Krieger, it’s not always that simple. Two men may have the same Gleason 6 score, but the biology of their individual tumors may behave differently. “New biologic genome testing has been developed and when used in the proper circumstances, men who may benefit from active surveillance can be identified and placed on protocols which involve sequential PSA testing and repeating prostate biopsies to see if the amount/volume or aggressiveness of a given tumor has changed,” he says.
“Every case is tailored to the patient’s cancer, as well as his personal opinion on whether he wants to be aggressive or not,” adds Dr. Bernstein. “Certainly, elderly patients with low-grade cancer can be followed with surveillance. This is also true of younger patients with a small volume of disease—as long as they are willing to be followed closely and undergo repeat biopsies.”
Bladder Cancer Breakthrough
Bladder cancer is among the 10 most common cancers in the U.S. and, by some estimates, ranks fourth among males. A study conducted at the Stanford University School of Medicine recently identified a single type of cell in the lining of the bladder for most cases of invasive bladder cancer. Not only does this research suggest that most bladder cancers arise from one specific (and common) kind of cell, it also may explain why bladder cancer often recurs after successful therapy.
The study holds great promise for understanding and treating the roughly 30 percent of bladder cancers that occur in the muscles around the bladder. This cancer can be very aggressive compared to the more typical kind, which is confined to the bladder lining. It is also extremely difficult and expensive to treat.
Editors Note: Dr. Bernstein and Dr. Krieger are both affiliated with Trinitas Regional Medical Center. Dr. Bernstein is a member of the Premier Urology Group in Pompton Plains. Dr. Krieger is a member of the Urology Group of New Jersey, which has a dozen locations in Central New Jersey.