Screening Still Important But Sometimes Best Treatment is Watching and Waiting Says Utah Expert

Jess Gomez

 801-507-7455

 9/19/2011

MURRAY, UT – Prostate cancer screening. It’s rare that three words can cause so much controversy. But in the medical community, the number of opinions on when and how to screen for prostate cancer are varied and strong.

And when it comes to the best way to treat men with prostate cancer symptoms, the chasm grows even wider. But despite all the treatment options available today, sometimes the best option is doing little or nothing.

Jay T. Bishoff, M.D., medical director of the Intermountain Urological Institute at Intermountain Medical Center, is an advocate of early screening, and despite the fact that he is a surgeon, favors a treatment approach known as “active surveillance” over more radical, and potentially damaging, options. He points to Roger Holtan’s case as an example.

Holtan was diagnosed with an enlarged prostate in 1999 when he was 57 years old. A biopsy produced negative results for prostate cancer, even though his PSA was slightly elevated. While he had regular check-ups over the next 10 years, his prostate was not biopsied again.

A little over two years ago, a digital rectal exam during a routine physical caused alarm bells to ring. A biopsy of Holtan’s prostate found cancer cells. The cancer on one lobe of his prostate was “scored” at a 6 on the Gleason scale on one lobe, and a 7 on the other.

A Gleason scale measures prostate cancer tumors much like a Richter scale measures earthquakes, only on a microscopic level. While a “6” is an indicator that doctors and patients can hold off on seeking aggressive treatment, a ”7” indicates the presence of cancer cells that are either far more aggressive, or far more widespread, and is likely to shake everyone into action. A Gleason “8,” indicates a very aggressive cancer that will need attention and can rarely be ignored.

Holtan’s score meant he had some time, but needed to start investigating treatment options.

He received lots of advice from friends and from physicians – some of it mainstream and sensible – some not. Some recommendations included costly procedures, others had the potential to produce lasting complications for his sexual and urinary health.

“I was more conflicted than ever,” says Holtan. “Everyone had a different solution. I was upset. My family was upset. I really needed some direction.”

To add to his confusion, a follow-up PSA test showed a significant drop in his PSA level – from 3.59 to 1.57.

And that’s where controversy comes in.

While inexpensive, (roughly $94) a PSA test is not foolproof. It simply measures elevated levels of the PSA protein in the blood. And, an elevated PSA level can be caused by several things, including benign prostate enlargement (also known as benign prostatic hyperplasia, or a prostate infection. It can also indicate the presence of cancer cells.

But it’s the possibility of false positives, and the costs associated with additional testing, that sometimes keeps physicians from recommending prostate screenings to their patients.

“This is dangerous thinking,” says Dr. Bishoff. “Do we tell women not to get a mammogram, or tell others to skip their colonoscopies just because there ‘might’ be a false positive? No, we don’t.”

A trusted family physician suggested that Holtan see Dr. Bishoff at Intermountain Medical Center, who performed another biopsy. This time, the results showed no signs of cancer.

Together, they determined that the best course for Roger – now 68 years old – was to be on “active surveillance,” a slightly more aggressive approach than doing nothing, which entails regular check-ups and biopsies to monitor the progression of the disease.

“I’m rather happy that we’ve continued doing what we’re doing,” says Holtan. “I’m going to be 70 this year, and as they say, I may die with this disease, but probably not from it.”

Dr. Bishoff says there are two factors – besides confusion about guidelines – that keep men from seeking advice on prostate issues: embarrassment and fear.

Holtan scoffs, “No one wants to talk about it. But all men have prostates, and all men may be in my situation someday. They need to get checked, and if they find something,they need to get a biopsy. Don’t wait,” he says. “ Go get it done.”

If you have insurance, call your provider to determine your coverage level for prostate cancer screenings and make an appointment for a check up. If you don’t have insurance, or your provider won’t cover a prostate cancer screening, and you are at high risk for prostate cancer, call Intermountain Medical Center at 801-507-3800 to schedule an appointment.
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