Prostate cancer remains the most common cancer diagnosed in men and the second leading cause of cancer-related death after lung cancer, according to the American Cancer Society. Early detection can save lives as screening and treatment options have dramatically evolved over the past several decades, moving from a one-size-fits-all approach to a more nuanced, personalized strategy.
The Prostate-Specific Antigen (PSA) screening, a blood test used to screen for prostate cancer, remains the best screening biomarker for the disease but the key is implementing it more strategically. While the test dramatically decreases deaths from prostate cancer by enabling earlier detection when cancers are still confined to the prostate, it can also lead to overtreatment.
Experts have learned that treating patients with low-risk prostate cancers can potentially expose them to risks without meaningful benefits as opposed to treating patients with significant health issues or limited life expectancy. The Smarter Screening Program at UC San Diego Health was created to help identify patients who merit treatment, while implementing guideline-directed active surveillance protocols for those who can be safely monitored. The team focuses on tailoring screening based on ethnicity, family history, and baseline PSA levels.
In honor of Prostate Cancer Awareness Month, we've asked Aditya Bagrodia, MD, professor of urology at University of California San Diego School of Medicine and urologic oncologist at UC San Diego Health, about the importance of personalized prostate cancer screening combined with the most innovative diagnostic and treatment therapies available in the region.
Can you explain what the UC San Diego Health Smarter Screening Program entails?
The program is really about learning from 50 years of prostate cancer screening experience and applying those lessons more skillfully. Our smarter screening approach centers around what we call "shared decision making," that actively includes patients in care decisions with their doctor including our colleagues who often see patients first in internal medicine, family medicine, and geriatrics. We've developed collaborative guidelines that are organized around two age groups: patients between 45 and 60, and those between 61 and 75 years of age.
For the younger group, we normally recommend a first PSA test somewhere between the ages of 45 and 60. The test provides a score that refers to the level of prostate-specific antigen (PSA), a protein made by the prostate in the blood. If the patient's baseline score is less than one (on a scale of one to ten), we can recheck in five years. If it's between one and two, we want to check it again in six to 12 months.
If there's a strong family history of prostate cancer, breast cancer, endometrial cancer, lymphomas, or leukemias, patients are referred to a urologist and we recommend a multi-parametric MRI of the prostate to provide much more detailed information before the referral visit.
For patients between the ages of 61 and 75, it's almost the same approach but we are more likely to do an MRI and referral with PSA levels up to three.
What is the next step if the PSA test and MRI show the likelihood of cancer?
At that point, we would do a biopsy, a procedure that has substantially evolved over the years. We can now merge MRI imaging with extremely safe biopsy protocols, to complete what is basically a five to 10-minute in-office procedure with minimal risk. All of our biopsies at UC San Diego Health use both MRI and ultrasound for more informed results and many are done through the perineum, which decreases the risk of complications as compared to rectal biopsy.
And what options do patients have for personalized care if treatment is required?
First, we approach the entire process as shared decision making. We want to ensure patients understand that prostate cancer is very common, but the bulk of prostate cancers are not aggressive, and many don't require treatment. For these patients, active surveillance is all that is required and even recommended. What we really want to do is identify prostate cancers that do pose a threat to someone's life with the understanding that a diagnosis doesn't always mean it has to be treated.
"We want to ensure patients understand that prostate cancer is very common, but the bulk of prostate cancers are not aggressive, and many don't require treatment."
— Aditya Bagrodia, MD, urologic oncologist, UC San Diego Health
If we decide together that treatment is required, it should be high quality and maximize the chance of resolving the prostate cancer while minimizing any harm, specifically related to urinary and sexual health impact. These days, we have many tools, including a range of minimally invasive focal therapies, state-of-the-art radiation oncology approaches, including proton radiation therapy and low-session radiation therapy and robotic prostatectomy.
With all these treatment options, I like to remind patients that statistically, you're substantially more likely to die with your prostate cancer than of your prostate cancer. In fact, the five-year survival rate for prostate cancer caught at the local level is more than 99%.
How do you help men feel comfortable with active surveillance when they've received a cancer diagnosis?
It's absolutely a source of anxiety when a patient hears they have prostate cancer, even low-risk prostate cancer. We do several things to address this.
The most critical thing is basing the conversation in data. Large-scale population studies demonstrate that in men with newly diagnosed prostate cancer who are appropriate candidates for active surveillance, we can safely monitor them. Starting on a surveillance program doesn't put you at higher risk of developing metastases.
We also have a multidisciplinary cancer clinic where patients can meet with different specialists, and we advocate for patients to engage in support groups and attend our annual prostate cancer patient summit to ensure they are informed and get the support they need.
What advice do you have for patients regarding self-advocacy?
We encourage patients to be their own advocates. Bring up the topic for themselves and for loved ones, because sometimes we hear that screening wasn't ever discussed or brought up, and when it comes to light, the cancer can be so far along that successful treatment is more difficult. Don't wait for someone else to bring it up — take an active role in your health care discussions.
What makes you optimistic about the future of prostate cancer screening and treatment?
When you look at the current criteria for effective screening programs, UC San Diego Health is making excellent progress on all fronts. We're getting more accurate with MRI and second-generation screening tests and biopsies are now very safe.
Be Your Own Prostate Cancer Advocate Today
Even though prostate cancer remains the most common cancer diagnosed in men and the second leading cause of cancer-related death, today’s screening tools are more effective than ever at differentiating the cancers that need to be treated from the majority of cases that can be actively monitored.
Aditya Bagrodia, MD, FACS
- Urologic Oncologist
- Professor of Urology
- Disease Team Co-Leader, Genitourinary Cancer
