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Last year, 230,000 American men were diagnosed with prostate cancer, making it the second most common cancer (after skin cancer). Nearly 30,000 died of the disease, making it the second most lethal (after lung cancer). One of the reasons prostate cancer is so deadly is that it rarely produces symptoms in its early stages, when it’s far more curable, and is often detected only after it has spread to other organs. Early detection is therefore critical, and for the past 20 years, it’s been accepted wisdom that men should get an annual PSA (prostate-specific antigen) blood test and digital rectal exam as soon as they hit age 50. The test is recommended at a younger age for men at increased risk. African-American men, for example, have a greater incidence of prostate cancer, as do men with a strong family history.
Recently, however, there’s been considerable controversy and confusion about the value of the PSA test. The New England Journal of Medicine recently published the results of two studies that came to very different conclusions. The first, a National Cancer Institute study, found that while prostate cancer screening led to an increase in diagnoses of the disease, it didn’t have an effect on the mortality rate. The second study found that those who had screenings were 20 percent less likely to die from prostate cancer.
To clear up the confusion, we talked to Dr. David B. Samadi, chief of robotic surgery, department of urology, at Mount Sinai Medical Center in New York City. As a specialist in the diagnosis and treatment of prostate cancer as well as other urologic diseases, what does he think of the PSA test? Moreover, what should men with elevated PSA scores do with this information?
“The studies don’t add anything new,” Samadi says. “Yes, screening can over-diagnose prostate cancer, but a smart doctor isn’t going to treat every PSA reading the same. It’s just one piece of the puzzle. You have to use that information along with the family history of the patient and the medical history of that patient. If he has an elevated PSA, you have to ask if this is the first time that it is elevated. You also want to know the PSA velocity. For example, if a year ago that patient had a PSA of 0.5 and now it’s 1.5, perhaps a year from now, it’ll be 2.5. While all those numbers are normal, the speed that it’s going up is a concern to me.”
As far as treatment options go, Samadi, says, “We’re moving away from seed implant and radiation. Short term, you don’t see a lot of side effects, but long term, you do see effects such as rectal bleeding and secondary cancers like rectal or bladder.”
Prostatectomy by an experienced surgeon, Samadi insists, is by far the better option. “When you remove the prostate, your PSA has to be undetectable or zero six weeks after surgery. The anxiety is gone! While 4 percent will need radiation after surgery, most will avoid it. If you do this the other way around and have radiation first, surgery becomes extremely challenging.”
And when it comes to surgical methods, Samadi, one of the few urologic surgeons in the U.S. trained in all three primary areas of surgery—open, laparoscopic, and robotic—favors laparoscopic, robot-aided surgery, a revolutionary technology offered at Mount Sinai that offers a quicker recovery and shorter hospital stay. “In the hands of experienced robotic surgeons, quality of life and cancer cure rate, sexual function and continence is excellent. It’s not just the robot that counts, of course, it’s the team and the experience you bring on board.”