Prostate biopsies sometimes 'understage' cancers, hotline docs say

SALT LAKE CITY — With controversy swirling around screening for prostate cancer, some patients believe they just need to be observed once the diagnosis of cancer is made. But it's more complex than that, according to two urologic specialists who fielded 50 calls in two hours during the Deseret News/Intermountain Healthcare Hotline Saturday.

"Everyone's jumping on the observation bandwagon — and it's very appropriate for some," said Dr. Michael Mangelson, chief of the urology division at LDS Hospital. "But sometimes observation under appreciates the volume of cancer."

Once cancer is suspected based on an elevated prostate-specific antigen (PSA) test and a digital rectal exam, a biopsy is done to determine the volume of cancer cells and they are examined at the cellular level to see which characteristics are present, since there are five categories and that offers clues as to how aggressive a cancer will be. The resulting calculation is called a Gleason score.

But it's not all straight-forward from there, said Dr. Richard Matern, a urologist and surgeon at LDS Hospital. When prostate cancer is removed and examined by a pathologist, it often shows that the degree of cancer was "understaged on the biopsy." And that's what doctors try to be sure patients understand as they discuss treatment options, they said.

Mangelson likens it to showing a small section of a person's photograph. "Oh yeah, it's Phil." But when you're shown the entire picture, it might be "Oh no, it's actually Pete."

The big picture helps when determining treatments. Other factors that are considered include age, health, tumor type and volume, risk factors and what a patient is comfortable with. For some, potential complications of treatments are devastating. Fortunately, such complications are less common than they were, though they may still occur.

Many of the callers wanted a second opinion on whether the treatments they're undergoing make sense. A couple of callers have metastatic prostate cancer that has spread well beyond the prostate and they wanted to talk about realistic treatment options. One of them, in his 50s, said his cancer was more aggressive and deadly than it at first appeared to be.

Still, most people will die of something else. Prostate cancer is usually fairly slow in its progression. The trick is finding the cases where it's not.