Prostate Cancer: Is Surgery Always Necessary?
Prostate cancer is one of the most common oncological diseases in men. Although it develops slowly, thousands die from it annually. On average, prostate cancer
Prostate cancer is one of the most common oncological diseases in men. Although it develops slowly, thousands die from it annually. On average, prostate cancer
Vladimir Gershman
Prostate cancer is one of the most common oncological diseases in men. Although it develops slowly, thousands die from it annually.
On average, prostate cancer can be diagnosed in every sixth man, and with age, the probability of the disease only increases.
Thanks to modern diagnostic methods, prostate cancer can be detected today at an early stage, but does it always require intensive treatment, complex diagnostic procedures, and even surgery?
A new revolutionary method of diagnosing the disease and determining its degree of life risk allows a person to be spared from unnecessary worries and, most importantly, from unnecessary surgical or other intervention.
This is exactly what is being discussed today by Vladimir Gershman, leading urologist-surgeon of the Galilee Medical Center in Nahariya and Haifa hospitals "Elisha" and "Asuta." — First of all, I would like to note that the prostate gland — the prostate, as it is commonly called — although a very small organ, plays a critical role in the male body.
It is located beneath the bladder, with the initial part of the urethra passing through it. The main function of the prostate gland is to produce a secretion that is a component of semen; additionally, it acts as a valve — closing the bladder outlet during erection.
Unfortunately, prostate cancer ranks third among other oncological diseases in men, which highlights the particular importance of timely and accurate diagnosis. Why do I emphasize precisely the accuracy of diagnosis? The fact is that in 80 percent of cases, diagnosed prostate cancer, strange as it sounds, has no clinical significance, does not noticeably affect quality of life or its duration. — ?! — Yes, yes, don't be surprised.
Here's an example: about a quarter century ago, one of Europe's medical centers conducted prostate examinations on several hundred men who died from various causes. The results were stunning: many of those examined had malignant tumor cells found in their prostate gland.
Moreover, their number increased depending on the person's age almost geometrically: in 90-year-old elderly, these cells were present in 90 percent of cases. I want to emphasize that this was not about all these people suffering from cancer — they were simply carriers of tumor cells that did not manifest themselves in any way. The person did not even know they were living in his body. — This is reminiscent of the situation with hepatitis C virus: a person can be a carrier for many years and not get sick throughout their life... — Exactly so.
In our case, many carriers of malignant tumor cells in the prostate die not from them but together with them, completely unaware of this. And if the disease does occur, in most cases it proceeds slowly, does not affect life expectancy, and gives no clinical manifestations.
This is the case I mentioned above: the absolute majority of diagnosed cancers have no clinical significance for our patients. — And what follows from this conclusion? — For all these more than two decades, we — doctors, medical scientists, specialists in related fields of science — have been trying to find a solution to the problem, to figure out how to distinguish a clinically significant form of prostate cancer from a clinically insignificant one and, therefore, one that does not require aggressive treatment.
The thing is, when cancer is suspected, we are obligated to conduct a complete and thorough examination of the patient. Early detection of prostate cancer begins with screening of prostate-specific antigen — PSA. If the test result is high, the doctor may recommend a biopsy. However, since the test cannot distinguish aggressive prostate cancer from other less serious conditions, many men often undergo an unnecessary and complex biopsy procedure.
What makes it complex? Imagine a mandarin fruit — exactly the size of a healthy prostate gland. And into this small organ, about five centimeters in diameter, we insert a needle one and a half millimeters thick, and we insert it at least 12 times, and in complex cases twice as many.
That is, we take biopsy samples from ten or more places of the gland. Naturally, the procedure is performed under anesthesia and under strict doctor's supervision, with imaging on a computer screen, but even in one case in hundreds of thousands, an error is possible.
And in one percent of cases, sepsis, a bacterial infection, may develop. Thank God, we have such procedures well-established and they pass without incidents, but after receiving the result, we tell 80 percent of patients that they have cancer cells, but there are few of them, they are practically undeveloped, and therefore not dangerous to life, although there is a minimal risk of their further development.
Of course, after such a statement, a man, as a rule, wishes to undergo treatment to prevent the worst. And the doctor himself often, not wanting to take responsibility for the patient's life, offers treatment. — And what does it consist of? — As a rule, radical treatment is removal of the prostate or its irradiation.
But it entails a number of physical and emotional inconveniences — erectile dysfunction, partial urinary incontinence. — What first symptoms indicate the possibility of cancer? Not everyone is immediately indicated for biopsy... — Of course. But a man after the age of 50 is simply obliged to undergo an annual check-up with a urologist specialist.
This is as mandatory as periodic visits to a gynecologist for a woman of this age. During the examination, the urologist can detect certain prostate problems in the patient and in this case refers him for specific blood analysis and other studies.
If the analysis reveals a high level of PSA antigen, this indicates a possible pathological process in the prostate, which, in turn, gives the doctor grounds to refer the patient for a deeper examination — laboratory, ultrasound, computed-resonance tomography (MRI), and biopsy.
However, it should be noted that an elevated PSA level does not necessarily indicate the presence of a malignant disease. This level can also rise due to other reasons — after physical impact on the perineum (for example, when cycling or during prostate massage), as a result of regular inflammation, or simply after recent intimate contact.
But this analysis does not give us the exact cause of the increase in PSA, and therefore, to avoid error, we perform a biopsy. — But you said that in most cases this procedure can still be avoided? — Yes, and today this problem is finding its solution. OPKO, one of the leading US medical companies headquartered in Miami, Florida, has discovered markers that allow, based on a blood test, even before performing a biopsy, to determine with 95 percent accuracy the probability of dangerous prostate disease.
Blood for this analysis, called 4KSCORE, can be taken in any laboratory and sent to the specified medical center. Here, specialists test four proteins that are markers of the presence of a cancerous tumor with the risk of aggressive malignancy.
These markers are summed up using an algorithm that gives a clear result: what are the patient's chances of developing prostate cancer and, equally importantly, what is the risk of death from this type of cancer in the next 20 years. America has already accumulated extensive experience in conducting such testing — over 100,000 people with suspected prostate disease take it annually.
And just recently, a few months ago, we, Israeli doctors, also gained the opportunity to conduct such a test. When prostate disease is suspected, we take blood for analysis from our patient — of course, with his consent — send it the same day by plane to the USA, and within three to four days receive a result indicating the statistical possibility of dangerous cancer. — And what do you decide based on it? — Prostate cancer has several levels of tumor development risk — from low to medium and high.
Until recently, a patient who received a "label" of cancer patient based on biopsy results was subjected to treatment, regardless of the risk level. In reality, a low level of the disease does not require it — with the presence of cancer cells, a person can live, as I noted, until old age without noticing them.
At the same time, it is worth remembering that prostate treatment itself is accompanied by many side effects — urinary incontinence, dysfunction of the genitals... The 4KSCORE test identifies only high- and medium-risk tumors, that is, only those cancerous tumors that need to be treated and that pose a danger to life.
Thus, unnecessary biopsies, excessive diagnosis of clinically insignificant cases can be prevented, and unnecessary treatment methods can be abandoned. — Is this analysis included in the "health basket"? — Not yet, but patients with additional medical insurance in healthcare funds receive a significant discount for such a test. — At what level is oncological care in urology generally in Israel?
At one of the highest by world standards. Unlike many other countries, this care is available to us not to a select few but to all citizens. At the heart of any medical care is diagnosis, and we are witnesses to a tremendous breakthrough in the early and accurate diagnosis of dangerous forms of prostate disease.
This will allow us in the near future to apply more organ-preserving treatment measures. If today, with a serious diagnosis, we are sometimes forced to remove the entire organ, now we are on the threshold of the revolutionary discovery of active local treatment methods for affected parts of the organ, preserving the integrity of its healthy part.
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