Selected Podcast
The Nuances of Prostate Cancer Screening
Dr. Ariel Schulman discusses the importance of knowing your risk factors for Prostate Cancer and the nuances of Prostate Cancer Screening.
Featured Speaker:
Ariel Schulman, MD
Ariel Schulman, MD is an Urologic Surgeon at the Maimonides Prostate Center. Transcription:
The Nuances of Prostate Cancer Screening
Caitlin Whyte: Prostate cancer grows slowly and causes few if any noticeable symptoms. So it's important to know your risk factors and have regular prostate cancer screenings. The common first step is a PSA test that detects the level of prostate specific antigen or PSA in your blood. A high PSA level could indicate the presence of prostate cancer.
Here to tell us more about the screening process is Dr. Ariel. Shullman a urologic surgeon at the, my monities prostate center.
This is biomed talk. I'm your host, Caitlin white. Now doctor with symptoms being so few and far between how can someone tell that they even need a screening?
Dr. Ariel Schulman: So prostate cancer screening is really a great question. And one of, in my opinion, the most important issues for a man as he gets into his forties and fifties, most men do not have symptoms of prostate cancer and the evaluation starts with their primary care physician and the decision to have a PSA screening blood test.
Now you
Caitlin Whyte: mentioned men in their forties and fifties are the ones who should be getting the screening. Now, how often should they be getting it?
Dr. Ariel Schulman: So there's a few important guidelines societies that we follow. One is the American neurological association. And the second is the NCCN comprehensive cancer guidelines for the typical man at average risk, we recommend starting PSA screening.
Around the age in the fifties or sixties, the NCCN guidelines recommend starting screening at age 45 with a PSA test. And this can be done every one to two years, depending on your level and your risk factors. The American urological association is a little bit stricter. And for men with average risk PSA screening starts at age 55 up to age 69, and also can be done every one to two years.
Now,
Caitlin Whyte: what kind of tests are there? The different options?
Dr. Ariel Schulman: The first test is an easy PSA screening blood test that's typically done at primary care office, along with your other annual screening labs, some primary care physicians still do a digital rectal exam, but if you get referred to see a urologist.
That would be part of your initial evaluation, a digital rectal exam, a finger exam to evaluate the size and consistency of the prostate and between the PSA level and the digital rectal exam, your urologist would make a further assessment on what would need to be done after that.
Caitlin Whyte: So let's talk about that PSA test.
If it comes back positive, what does that mean?
Dr. Ariel Schulman: So traditionally, the. Uh, PSA levels above four were cause for concern. And what we would tell men about 10 or 15 years ago was that if you had a PSA level between four and 10, with an app, with average risk, there was about a 30% chance that we would find a clinically significant prostate cancer.
If we performed a biopsy. Where things stand today is a little bit different because we've integrated multi-parametric prostate MRI to help us better evaluate the prostate for men with an elevated PSA. And we think that our accuracy on our biopsies are significantly better now adding the MRI to the basic PSA level.
But I would say that most men with an initial elevated PSA would have a repeat screening PSA done by the, their urologist to make sure it's still elevated. And then their workup would progress from there. Now
Caitlin Whyte: the title of this episode is the nuances of prostate cancer screening. Why is that the case?
Why is it such a nuance?
Dr. Ariel Schulman: So over the last 10 or 15 years, there's definitely been a lot of controversy related to PSA screening. This comes from very large trials that were done in both Europe and the United States. There was some debate about whether there is mortality benefit from PSA screening at the population level.
The U S P S guidelines had recommendations even against prostate cancer screening about 10 years ago. And this is the guideline followed by most primary care physicians in the last five or 10 years. There's been a lot of re-analysis of the big data and the big trials, and certainly in the urology community and the cancer community that we think these trials actually did show a significant mortality.
Survival benefit by PSA screening in large groups. Now, this is particularly important in a couple of groups. First of all, African-American men, which make up a very large percentage of men with prostate cancer and second men with a family history. Anyone. Actually with advanced had no carcinomas. In addition to the prostate, if you have a family history of breast ovarian long, or pancreatic, you are at increased risk for prostate cancer and some new information about genetic diseases that increase the risk for prostate cancer.
So the urology community and much of the cancer community, I think feels very strongly about PSA screening and then a more nuanced evaluation after your PSA levels are checked. Now just
Caitlin Whyte: how common is prostate
Dr. Ariel Schulman: cancer. Prostate. The answer is, is extremely common among men. It's, it's certainly in the top three cancers by incidents and certainly in the top cancers by mortality.
So if you follow men into their seventies and eighties, we say that most men will develop prostate cancer. But the real challenge for us is to identify. The prostate cancers that are potentially lethal at a time before they have progressed to identify and treat these cancers to avoid death from prostate cancer.
The biggest challenge that we do have. Is to distinguish between the non-aggressive and the aggressive prostate cancers, because we still know that most prostate cancers that we detect, especially in men that get into their sixties and seventies are not lethal. But our biggest challenge is to find the more aggressive.
Cancers and treat them early.
Caitlin Whyte: Is there anything men can do to prevent prostate cancer, any kind of healthy
Dr. Ariel Schulman: ways? I tell all of my patients, the most important things to do is diet and exercise. We don't have a direct link between any particular foods. Or, and prostate cancer, but I really do tell all my patients, a heart healthy diet and regular exercise and maintaining your, your weight at healthy levels.
We don't have strong evidence to support any particular medications to decrease your risk of prostate cancer. The best defense we have right now is regular follow-up with the urologist. Every one to two years for that screening PSA test and a regular digital rectal exam. And if there's any abnormalities to follow the recommendations on further evaluation.
Great.
Caitlin Whyte: Well, Dr. Schulman, anything else you'd like to add about prostate cancer screenings?
Dr. Ariel Schulman: I think the most important thing is that the way that we approach prostate cancer in the last decade has changed significantly. Whereas 20 years ago, all men would get a screening PSA, and then they would get a biopsy and most men would get treated our.
Evaluation and treatment in 2021 is significantly more nuanced. For example, the evolution of the prostate MRI for identifying clinically significant lesions, which we now use to target our biopsy. Additionally, most of our patients do not get treated today, the way they used to do so many patients will be placed on active monitoring.
Where we'll follow them with imaging and biopsies. And we have other new treatments where we just treat part of the prostate rather than the whole prostate and our surgery is a lot safer and we think has better outcomes than it did even 15 or 20 years ago. So, so, whereas 20 years ago we had a, a single catch all approach to all men with an elevated PSA and a prostate cancer diagnosis.
We think there are now multiple prongs of, uh, of a tree that is followed after that screening, PSA evaluation, where many of the men are, are followed and not treated. And it's a much more individualized approach today.
Caitlin Whyte: Such important information for the men in our lives. Thank you so much, Dr. Schulman for joining us, you can learn more online at dot org slash prostate.
This has been my mentor. I'm your host, Caitlin white stay. Well.
The Nuances of Prostate Cancer Screening
Caitlin Whyte: Prostate cancer grows slowly and causes few if any noticeable symptoms. So it's important to know your risk factors and have regular prostate cancer screenings. The common first step is a PSA test that detects the level of prostate specific antigen or PSA in your blood. A high PSA level could indicate the presence of prostate cancer.
Here to tell us more about the screening process is Dr. Ariel. Shullman a urologic surgeon at the, my monities prostate center.
This is biomed talk. I'm your host, Caitlin white. Now doctor with symptoms being so few and far between how can someone tell that they even need a screening?
Dr. Ariel Schulman: So prostate cancer screening is really a great question. And one of, in my opinion, the most important issues for a man as he gets into his forties and fifties, most men do not have symptoms of prostate cancer and the evaluation starts with their primary care physician and the decision to have a PSA screening blood test.
Now you
Caitlin Whyte: mentioned men in their forties and fifties are the ones who should be getting the screening. Now, how often should they be getting it?
Dr. Ariel Schulman: So there's a few important guidelines societies that we follow. One is the American neurological association. And the second is the NCCN comprehensive cancer guidelines for the typical man at average risk, we recommend starting PSA screening.
Around the age in the fifties or sixties, the NCCN guidelines recommend starting screening at age 45 with a PSA test. And this can be done every one to two years, depending on your level and your risk factors. The American urological association is a little bit stricter. And for men with average risk PSA screening starts at age 55 up to age 69, and also can be done every one to two years.
Now,
Caitlin Whyte: what kind of tests are there? The different options?
Dr. Ariel Schulman: The first test is an easy PSA screening blood test that's typically done at primary care office, along with your other annual screening labs, some primary care physicians still do a digital rectal exam, but if you get referred to see a urologist.
That would be part of your initial evaluation, a digital rectal exam, a finger exam to evaluate the size and consistency of the prostate and between the PSA level and the digital rectal exam, your urologist would make a further assessment on what would need to be done after that.
Caitlin Whyte: So let's talk about that PSA test.
If it comes back positive, what does that mean?
Dr. Ariel Schulman: So traditionally, the. Uh, PSA levels above four were cause for concern. And what we would tell men about 10 or 15 years ago was that if you had a PSA level between four and 10, with an app, with average risk, there was about a 30% chance that we would find a clinically significant prostate cancer.
If we performed a biopsy. Where things stand today is a little bit different because we've integrated multi-parametric prostate MRI to help us better evaluate the prostate for men with an elevated PSA. And we think that our accuracy on our biopsies are significantly better now adding the MRI to the basic PSA level.
But I would say that most men with an initial elevated PSA would have a repeat screening PSA done by the, their urologist to make sure it's still elevated. And then their workup would progress from there. Now
Caitlin Whyte: the title of this episode is the nuances of prostate cancer screening. Why is that the case?
Why is it such a nuance?
Dr. Ariel Schulman: So over the last 10 or 15 years, there's definitely been a lot of controversy related to PSA screening. This comes from very large trials that were done in both Europe and the United States. There was some debate about whether there is mortality benefit from PSA screening at the population level.
The U S P S guidelines had recommendations even against prostate cancer screening about 10 years ago. And this is the guideline followed by most primary care physicians in the last five or 10 years. There's been a lot of re-analysis of the big data and the big trials, and certainly in the urology community and the cancer community that we think these trials actually did show a significant mortality.
Survival benefit by PSA screening in large groups. Now, this is particularly important in a couple of groups. First of all, African-American men, which make up a very large percentage of men with prostate cancer and second men with a family history. Anyone. Actually with advanced had no carcinomas. In addition to the prostate, if you have a family history of breast ovarian long, or pancreatic, you are at increased risk for prostate cancer and some new information about genetic diseases that increase the risk for prostate cancer.
So the urology community and much of the cancer community, I think feels very strongly about PSA screening and then a more nuanced evaluation after your PSA levels are checked. Now just
Caitlin Whyte: how common is prostate
Dr. Ariel Schulman: cancer. Prostate. The answer is, is extremely common among men. It's, it's certainly in the top three cancers by incidents and certainly in the top cancers by mortality.
So if you follow men into their seventies and eighties, we say that most men will develop prostate cancer. But the real challenge for us is to identify. The prostate cancers that are potentially lethal at a time before they have progressed to identify and treat these cancers to avoid death from prostate cancer.
The biggest challenge that we do have. Is to distinguish between the non-aggressive and the aggressive prostate cancers, because we still know that most prostate cancers that we detect, especially in men that get into their sixties and seventies are not lethal. But our biggest challenge is to find the more aggressive.
Cancers and treat them early.
Caitlin Whyte: Is there anything men can do to prevent prostate cancer, any kind of healthy
Dr. Ariel Schulman: ways? I tell all of my patients, the most important things to do is diet and exercise. We don't have a direct link between any particular foods. Or, and prostate cancer, but I really do tell all my patients, a heart healthy diet and regular exercise and maintaining your, your weight at healthy levels.
We don't have strong evidence to support any particular medications to decrease your risk of prostate cancer. The best defense we have right now is regular follow-up with the urologist. Every one to two years for that screening PSA test and a regular digital rectal exam. And if there's any abnormalities to follow the recommendations on further evaluation.
Great.
Caitlin Whyte: Well, Dr. Schulman, anything else you'd like to add about prostate cancer screenings?
Dr. Ariel Schulman: I think the most important thing is that the way that we approach prostate cancer in the last decade has changed significantly. Whereas 20 years ago, all men would get a screening PSA, and then they would get a biopsy and most men would get treated our.
Evaluation and treatment in 2021 is significantly more nuanced. For example, the evolution of the prostate MRI for identifying clinically significant lesions, which we now use to target our biopsy. Additionally, most of our patients do not get treated today, the way they used to do so many patients will be placed on active monitoring.
Where we'll follow them with imaging and biopsies. And we have other new treatments where we just treat part of the prostate rather than the whole prostate and our surgery is a lot safer and we think has better outcomes than it did even 15 or 20 years ago. So, so, whereas 20 years ago we had a, a single catch all approach to all men with an elevated PSA and a prostate cancer diagnosis.
We think there are now multiple prongs of, uh, of a tree that is followed after that screening, PSA evaluation, where many of the men are, are followed and not treated. And it's a much more individualized approach today.
Caitlin Whyte: Such important information for the men in our lives. Thank you so much, Dr. Schulman for joining us, you can learn more online at dot org slash prostate.
This has been my mentor. I'm your host, Caitlin white stay. Well.