The Future Is Here: New Guidelines, Diagnostics and Approaches to Prostate Cancer

Waltzer Wayne Waltzer, MD
Chair, Department of Urology
Stony Brook University Cancer Center 

June is Men’s Health Awareness Month, which is the ideal time to get the word about the dramatic changes in the way prostate cancer is diagnosed and treated. Stony Brook urologist Dr. Wayne Waltzer explains these major medical advances and what they mean for you.

Who should get screened for prostate cancer?
With prostate cancer being the number one solid organ cancer in the country, it is important for all men to be vigilant. However, recently revised guidelines by the American Urological Association recommend that unless there is a family history or other risk factors present, only men between the ages of 55 and 69 should speak with their doctor about screening, which includes a digital rectal exam and a PSA blood test. This discussion should include benefits and harms of testing with patients proceeding based on their values and personal preferences. Routine PSA screening is not recommended in men over the age of 70 or with less than 10 to 15 year life expectancy. If PSA levels are elevated, cancer may be present. In the past, the next step would entail biopsy and, if positive for cancer, treatment. However, the problem with this approach is that there has been no way to tell if the cancer detected is aggressive, requiring similarly aggressive treatment, or slow growing, which may only involve active monitoring. A newly developed series of genetic tests now offers a more accurate and individualized approach in identifying and treating prostate cancer.

What are the new genetic screening tests?
Currently there are various blood tests in use. One is called the Prostate Health Index (PHI) and the other is called the 4K test. Both measure the variance of the PSA in the blood and are designed to reduce the number of unnecessary negative biopsies that detect only low-grade cancer. This means that not all men with elevated PSA levels will require a biopsy, with its potential for complications and side effects.

What if a biopsy is required?
There are also new tests available that help to further individualize the approach. If the biopsy is positive for cancer, two tests — the Polaris and the Genomic Prostate Score — help doctors distinguish between aggressive cancers that need treatment and those that are slow growing and may need only the “watch and wait” approach. These tests work by measuring a series of genomic patterns to reveal how the cancer cells are wired to behave. 

If the biopsy is negative but you still have elevated PSA levels, there is now a test called Confirm MDX that helps ensure that cancer cells were not missed during the biopsy. For example, the biopsy may have sampled tissue that was in an area where there were no cancer cells. This could give you a false negative. This new test looks for hyper methylation, which indicates the presence of individual prostate cancer tissue near the site of the biopsy. If no hyper methylation is detected, the biopsy is considered negative. If some is detected, additional testing will be needed. Another test, the PCA3 test is also available in case of negative biopsy. This gene-based urine test offers additional information on the probability of finding prostate cancer in the biopsy. 

In addition, if you have had prostate cancer surgery, there are genetic tests post-surgery that help determine whether additional treatment is needed based on the genetic composition of the cancer cells and the risks associated with it.

Is this the future of cancer diagnostics and treatment?
Absolutely — and not just for prostate cancer. These innovations are happening for almost every form of cancer, with more on the horizon. Gene analysis of tissue, the study of genetic markers, patterns, sequencing and abnormalities, is providing us with unprecedented information on who to treat and how to treat them. Not only is it helping us to find the most appropriate approach and treatment for people with cancer, but it also keeping many people with the less aggressive forms of the disease from undergoing the rigors of treatment unnecessarily. This is both a health issue and a quality of life issue. The fact that we can take such a highly individualized approach for very specific forms of cancer also means that we can look forward to better and more predictable outcomes.

Does Stony Brook offer all these genetic tests?
These tests are available at all top major medical centers across the U.S. like Stony Brook University Hospital. Through Stony Brook University Cancer Center, we are committed to remaining on the forefront of cancer research, diagnostics, treatment and innovation. We are leaders in cancer care, serving more than 3,000 newly diagnosed patients each year. We offer state-of-the-art treatment and procedures, including robotic-assisted, minimally invasive radical prostatectomy, sophisticated radiation therapies such as intensity-modulated radiation therapy (IMRT), immunotherapy, chemotherapy and cryotherapy for recurring prostate cancer.