The diagnosis and treatment of prostate cancer is the source of much debate and controversy. The question of the overuse of prostate-specific antigen (PSA) testing, has been questioned repeatedly, and resulted in the United States Preventive Services Task Force (USPSTF) in 2012
issuing a "D" grade for this test, as well as recommending against PSA based screening for prostate cancer. Yet despite this recommendation, PSA is continuing to be used in non-screening scenarios. The young patient who clearly has greater than a 10-year survival, often times may benefit from the knowledge of what is going on with his prostate. Biopsies will often be undertaken. There are also patients who have very high-grade disease who will also benefit from its diagnosis, so treatment needs to be undertaken.
Recommendations to patients with regards to the treatment of prostate cancer are based upon the expectation of patients living 10 years after the treatment. This is because many of the survival advantages of radical surgery occurs after 10 years. However a recent study in Cancer, suggested that men who are less than 89 years old at the time of their diagnosis, who have life expectancies of less than 20 years, often receive overly-aggressive treatment for low-risk and intermediate- risk prostate cancer. The importance of these findings is that many men receiving this aggressive treatment will not live long enough to benefit from the treatment.
Along with aggressive surgical intervention comes the potential for complications that are associated with surgery, namely the risks of urinary incontinence and erectile dysfunction. Today, as a result of refined techniques, these risks are decreased but still can occur beckoning the question of if we are doing more harm than good.
If overtreatment of prostate cancer occurs, then eliminating treatment in those who will not benefit from it would decrease the incidence of incontinence and erectile dysfunction after treatment. The question of surveillance for low-grade prostate cancer should be discussed with patients, which will help decrease subsequent risks from treatment. There are also lab tests that analyze RNA that help to assess the aggressiveness of the prostate cancer. These tests will give patients greater confidence when deciding upon surveillance.
Despite all efforts to decrease over-testing and overtreatment, many patients will still undergo treatment and some will develop these the complications. Erectile dysfunction can be treated with prescription medications, and patients failing treatment can be treated with penile prostheses that will provide a satisfactory erection.
However, urinary incontinence that occurs as a result of treatment of prostate cancer is more challenging to treat than sexual dysfunction. Medical therapy does not work, as the problem is a deficiency in the male urinary sphincter. But surgical treatment options do exist, and can involve either the placement of sling that helps compress the urethra against the undersurface of the pubic bone, or the placement of an artificial urinary sphincter.