Drs. Fronczak and Siegel on breakthroughs in diagnosing prostate cancer

One in nine men living in the U.S. is diagnosed with prostate cancer. In fact, it remains the No. 1 diagnosed cancer and the second leading cause of cancer death among American men.

“Despite its high incidence, if found early, prostate cancer is one of the most survivable forms of cancer. Early detection is key,” said urologist Carolyn Fronczak, MD, of Boulder Medical Center.

In the first part of the two-part BCH lecture series on prostate cancer, she and her co-presenter and practice partner, Stephen Siegel, MD, described the latest technologies for diagnosing cancer, include new technology that provides physicians with high-quality images, giving them the ability to find prostate cancer sooner. The second part, "What's new in prostate cancer treatment" can be found here.

Video: Watch “Breakthroughs in diagnosing prostate cancer”

WHO IS AT RISK FOR PROSTATE CANCER?

Dr. Fronczak began the lecture by reviewing risk factors for prostate cancer, including:

• Male gender and older age: About 6 in 10 cases of prostate cancer are found in men older than 65.
• Ethnicity:
  • African Americans are 1.6 times more likely to get the disease.
  • African Americans are 2.2 times more likely to die of the disease.
• Family history:
  • Prostate cancer seems to run in some families. Having a father or brother with prostate cancer more than doubles a man’s risk of developing this disease. The risk is much higher for men with several affected relatives, particularly if their relatives were young when the cancer was found.
  • Additionally, if you have had a relative with any of the following cancers, have had multiple cancers in your family, or are of Ashkenazi Jewish descent you’re at risk of being diagnosed with prostate cancer.
• Metastatic prostate cancer
• Ovarian cancer
• Male or female breast cancer
• Colorectal cancer
• Endometrial cancer
• Pancreatic cancer
• Germline mutations:
  • Dr. Fronczak emphasized, “Germline mutations, which are changes to your DNA that you inherit from the egg and sperm cell during contraception, are important factors and contribute to aggressive forms of prostate cancer.”

Genetic testing for prostate cancer

Inherited mutations of the BRCA1 or BRCA2 genes, which are linked to an increased risk of breast and ovarian cancers in some families, are also associated with increased risk of prostate cancer in men, especially mutations in BRCA2. “In fact, one study published in the New England Journal of Medicine found that BRACA2 mutation is associated with 44% of cancers that are metastatic,” Dr. Fronczak stated.

Men with HOXB13 gene mutations have a strong association with prostate cancer before age 65.

“We should begin screening for prostate cancer at the age of 40, if you have one of these mutations,” said Dr. Fronczak. “The importance of knowing these genes is that there are certain new treatments with PARP inhibitors – which stands for poly adenosine diphosphate-ribose polymerase, a type of enzyme that helps repair DNA damage in cells – and platinum-based chemotherapy that may offer targeted treatment for men with these gene mutations who develop prostate cancer.”

She said genetic testing is recommended for the following men:

• Family history genetic mutations
• Ashkenazi Jewish ancestry
• Family history prostate cancer
• Multiple cancers in a family

Screening tests

There are two main screening tests for prostate cancer. It’s important to know neither is 100% accurate.

• Digital rectal exam (DRE). During a DRE, a physician inserts a gloved, lubricated finger into your rectum to examine your prostate, which is next to the rectum. Your doctor will assess the size of the prostate and feel for any bumps or hard areas on the prostate that may need to be tested for cancer.

• Prostate-specific antigen (PSA) test. This is a blood test to check the level of prostate-specific antigen in your blood. A PSA value of 4ng/ml or less if often considered normal. But this is not always the case; lower PSAs may also be associated with prostate cancer. If the initial result is borderline, doctors may recommend repeating the test. For higher PSAs, doctors are likely to recommend additional tests.
  
  “PSA has a limited sensitivity for prostate cancer detection. But it is still the best screening test for prostate cancer that we have. It just has to be interpreted wisely. A lower PSA level doesn’t mean a man is free of prostate cancer, and a higher level doesn’t mean he has prostate cancer,” Dr. Siegel explained.

There are many situations that can cause PSA levels to be higher than normal. This includes:

• Large prostates (Benign Prostate Hyperplasia)
• Infections (prostatitis, urinary tract infections, epididymitis)
• Recent ejaculation
• Trauma
• Recent urinary catheterization
• Recent biking
• Prostate cancer

Dr. Fronczak added, “If we see a spike in PSA levels, we will recommend retesting after five days of pelvic rest. We will also perform a digital rectal exam when we see abnormal PSA levels.”

Screening Recommendations—PSA Testing Has Decreased Mortality Rates

“If you’re younger than 45 it’s not necessary to screen for prostate cancer. For those men 40 to 54 who are at average risk, you still don’t need to screen. If you’re at an increased risk based on the factors mentioned above, you should be screened annually. Those who are 55 to 69 are most susceptible to prostate cancer and will benefit the most from the PSA test, and will be diagnosed earlier,” said Dr. Siegel.

He added, “After 70 there are various factors to consider that involve life expectancy; you would discuss these with your physician to decide the best option for you.” If you are 70 or older and active, Dr. Siegel would recommend continuing with regular PSA testing unless your numbers have been very low.

“Once the PSA test became available, overall detection and earlier detection increased and, conversely, mortality rates from prostate cancer decreased,” said Dr. Siegel.

PSMA PET Scan

PSMA-PET scans provide high-quality images and more specificity for detecting prostate cancer than traditional imaging. This enables physicians to diagnose and treat prostate cancer more effectively. Dr. Fronczak explained, “What’s nice about this technology is that it combines a CT and PET scan so patients only need to go in for imaging once instead of multiple times.”

Dr. Siegel added, “We are excited to share that BCH and Rocky Mountain Cancer Centers have entered into a joint venture for a PSMA PET scanner housed at Rocky Mountain Cancer Center on the Foothills Medical Campus, making it easily accessible to many of you.”

Biopsies

A prostate biopsy involves using thin needles to take small samples of tissue from the prostate. The tissue is then looked at under a microscope to check for cancer. If cancer is found, the biopsy results will show how aggressive it is – in other words, how likely it is to spread outside the prostate.

Dr. Siegel explained, “Biopsies are not our first choice and are typically used at the end of an evaluation process. They are, however, the only way we can truly diagnosis prostate cancer and understand the best treatment to recommend.”

He added, “Before recommending a biopsy we look to noninvasive options, like magnetic resonance imaging (MRI), to get a better look at the prostate, and determine if a biopsy is necessary. For example, we can see otherwise undetectable lesions and follow their growth over time, and if we feel a nodule, the MRI can help determine the status of that nodule. Conversely, we may see that even though you have an elevated PSA there is no evidence of cancer or a lesion.”

MRI/Ultrasound Fusion

The MRI/Ultrasound fusion technique combines a specialized MRI scan with an ultrasound image to help physicians precisely target the area of the prostate that needs to be biopsied. “Our offices receive referrals from throughout the state because we have access to this advanced technology,” Dr. Siegel stated.

Biomarkers and Genomic Testing

“We also do optional testing to look at biomarkers. These,” said Dr. Fronczak, “are called genomic tests.” Genomic tests have become very important. They look at biomarkers, a protein secreted by a tumor or put into the bloodstream by a tumor. Dr. Fronczak and Dr. Siegel use these tests to help determine the status and aggressiveness of a cancer and whether it needs to be treated or not. Blood and urine tests may also be used.

SelectMDx Test

The test that is often used for genomic testing is the noninvasive SelectMDx urine test. It’s done immediately after a rectal exam. Dr. Fronczak said she particularly likes this test because, “it separates low risk from a possible prostate diagnosis, or a clinically significant prostate cancer diagnosis, has an excellent negative predictive value, and is accurate 93% of the time.”

Decipher Testing and Scores

Decipher testing is an important genomic test performed on tumor tissue to help inform treatment decisions. The test reports a score that indicates a patient’s risk of metastasis (the spreading of the cancer) within five years and provides risk estimates of prostate cancer outcomes. “Decipher testing and scores are important both for those who will need surgery and those who will undergo radiation treatment,” said Dr. Siegel.

PROSTATE CANCER GRADING—GLEASON SCORES

“The Gleason score is a rating that is provided based on cell patterns. When the gland looks more normal the Gleason score is a 1 with neither 1 nor 2 being cancerous. The Gleason system has transitioned to something called the Grade Group to create a simpler system. Both systems however are complicated,” said Dr. Siegel. “But these scores are important for helping us to understand how aggressive the cancer is, what a patient’s risk is, and how to best treat our patients."

MAKE AN APPOINTMENT

Click here to view/download a PDF of slides shown during this lecture

To schedule an appointment with Carolyn Fronczak, MD or Stephen Siegel, MD, call (303) 440-3093.

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