Guest: Dr. Thomas E. Keane - Urology
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. Thomas Keane, who is Professor and Chairman of Urology at the Medical University of South Carolina. Dr. Keane, I know you have very strong interest and background in the area of cancer of the urologic system. Let’s start with what is one of the most common cancers for men, prostate cancer. Now at what age should a man begin to be concerned that he might be at risk?
Dr. Thomas E. Keane: It can vary depending on the individual’s ethnic origins. If you are an African-American man, you should probably consider having a PSA check by the age of 45 and if you are an African-American man with a family history of prostate cancer, that should be around 40. If you are a Caucasian with a history of prostate cancer in the family, probably about 45 and if you don’t have one, then about 50 years of age. There has been a lot of debate about PSA in recent times and a lot of people would refer to it as patient stress activators as opposed to a blood test. With this in mind, we now know that you can have prostate cancer regardless of the level of your PSA. So even if your PSA is quite low, that does not rule out the fact that you have prostate cancer.
Dr. Linda Austin: So then, I would imagine that you would recommend not only PSA, but also a screening physical examination.
Dr. Thomas E. Keane: Yes, very good point. A rectal examination should be done once a year. I hear a lot of the time from patients that my doctor doesn’t do rectal examinations and I have asked them that he look in your mouth, or look in your ears, or look in your eyes and if that’s the case, then he should also look somewhere else because it’s just an orifice, just like all the other orifices we have and if you don’t put your finger in it, you may not find what’s in there.
Dr. Linda Austin: And it’s a quick, easy, painless examination, correct?
Dr. Thomas E. Keane: Yeah, a lot of men have a horror of having a rectal examination. Most women don’t mind it because they have gone through childbirth etc., and they have been having them for years.
Dr. Linda Austin: And it doesn’t feel much different than passing a stool, correct?
Dr. Thomas E. Keane: Correct.
Dr. Linda Austin: What are some of the earliest symptoms of prostate cancer?
Dr. Thomas E. Keane: That’s the problem; there are none. Most men may develop some difficulty going to the toilet and passing urine. They may develop some frequency and some occasional urgency. All of those are benign symptoms. They tend to be associated with an enlarged prostrate or some process going on in the bladder. They are not prostate cancer symptoms, but they may serve to make the patient aware of the fact that there is something going on with his prostate, which should be evaluated and even if it is just benign disease, we can help them those symptoms either way. For the prostate cancer patient, it may be the fact that they had those benign symptoms, which leads to the diagnosis of prostate cancer.
Dr. Linda Austin: I have heard it said that ultimately if a man were to live into extremely advanced old age, almost all men would develop prostate cancer, is that true?
Dr. Thomas E. Keane: Correct, up to 20% of the soldiers, who came home from Vietnam having being killed in action, who underwent postmortems were found in their 20s to have prostate cancer. That’s an amazing figure when you think about it because most prostate cancers don’t present typically until old age. It’s as a result of us being more vigilant in looking at PSAs and looking at rectal exams that we have managed to detect these cancers earlier than they would otherwise have been detected, because I say it again, early prostate cancer has no symptoms. Typically, everybody remembers their grandfather or their granduncle who they were told was dying of bone cancer. Typically, that was not bone cancer that was metastatic prostate cancer, which presented as a late stage in an elderly man and was responsible for a very considerable death rate among older patients. In recent years as a result of early detection, we have virtually eliminated the patient who presents with bony metastatic disease as his primary symptom of prostate cancer. We still see that may be one a year or as before up to 35% to 40% of the patients, who presented with advanced incurable disease.
Dr. Linda Austin: If 20% of men in their 20s in that study had evidence of prostate cancer, it must be a very slow growing tumor.
Dr. Thomas E. Keane: Well, that’s true and also is the fact that if you were to look at men, who are in their 60s and 70s and if you were to take out their prostates in step section, then that means cutting them at regular intervals of a couple of millimeters all the way across. The chances of us finding prostate cancer in those men are extremely high. We do know for instance that up to one-third of the early cancers detected today may turn out to be inconsequential cancers, so that makes it a very difficulty situation for detecting expected to see 2,19,000 new cases this year. Well, there are a lot of those patients, who may never die of prostate cancer and that’s where the trick comes in is to identify those patients, who are likely if they live long enough to develop significant problems with prostate cancer.
Dr. Linda Austin: How do you make a definitive diagnosis?
Dr. Thomas E. Keane: Well, it’s not so much -- that is more age guidelines. For instance, if you are 80 years of age, doing very well and you happen to have an elevated PSA, my advice would be stay away from the urologist. If you are 50 years of age, doing very well and you happen to have an elevated PSA, my advice would be to get to your urologist straightaway because the guy, who is 80 years of age, who is doing well and has just an elevation in his PSA is unlikely ever to die of prostate cancer whereas the man who is 50 years of age who has an elevated PSA will live long enough typically to experience side effects of advanced prostate cancer if it’s present.
Dr. Linda Austin: Then in order to make the diagnosis, do you actually have to take a biopsy during surgery as opposed to doing an imaging study?
Dr. Thomas E. Keane: Yeah, you can’t diagnose prostate cancer with an imaging study unless it is very advanced such as a bone scan to show you destruction of bone. An ultrasound will not detect prostate cancer. CT scan or an MRI will not detect prostate cancer. So, you are left with doing a biopsy of the prostate, which is actually depending on whom you read and there has been a lot of literature on this in the lay press, particularly in Charleston where it was said that a man needed a general anesthetic to undergo a prostate biopsy, that’s just not true. What they do need is local anesthetic infiltrator around the prostate and I must admit that we for a longtime did not use local anesthetic and it wasn’t until I met one of my friends who had prostate cancer, who told me that the worst part was the biopsy that I started looking at during local anesthetic and now it is the norm throughout the country that you will be given local anesthetic around the prostate, which showed numb things up and I would compare a prostate biopsy to a dental cleaning in terms of its discomfort.
Dr. Linda Austin: Now just to go back for a movement, you mentioned that it’s possible to have prostate cancer and have a normal PSA.
Dr. Thomas E. Keane: Yes.
Dr. Linda Austin: how about the opposite, at what PSA level -- is it almost likely, almost certain to be cancer, or can you ever say that?
Dr. Thomas E. Keane: It’s very difficult to say with any grade of certainty. There are three causes for an elevated PSA, one is benign prostatic growth, second is prostatic inflammation, and the third is prostate cancer. Very frequently, all three processes are occurring at the same time and as such what has caused your PSA to rise may not be your prostate cancer, it could be benign growth or it could be some inflammation and then the biopsy happened to detect the fact that you had a prostate cancer present also. So, where PSA absolutely comes into its own as a tumor marker is after definitive treatment of prostate cancer. For instance, if you have had a local prostate cancer removed surgically, I have been given radiation, I have had it frozen, or you are on hormones. If the PSA starts to rise after these that is a sure indication, that it’s the cancer that’s activating the PSA and with that being said, then you know the true value of PSA as a tumor marker. While the prostate is still in place and nothing has been done, as I said, there are many causes for an elevation in the PSA, one of them happens to be prostate cancer.
Dr. Linda Austin: Dr. Keane, thank you so much.
Dr. Thomas E. Keane: You’re welcome.
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