Prostate Cancer Risk Assessment: A Qualitative Approach for the Naturopathic Physician
Introduction:
This article discusses 2 points. First, the current situation regarding prostate cancer assessment and diagnosis is briefly explored. Liability concerns for the naturopathic physician including those now seen with andropause treatments are mentioned. Second, qualitative and quantitative assessment tools that are available to naturopathic physicians are discussed. This includes a special section explaining the benefits for a naturopath in utilizing Trans Rectal Ultrasound of the Prostate (TRUSP) imaging.
The Current Situation:
Prostate cancer is a tricky pathology for the integrative physician to assess. Over the past 30 years, a digital rectal exam (DRE) along with a blood test of Prostatic Specific Antigen (PSA) over 4.0ng/ml was enough to determine one's probable risk of having prostate cancer (CaP). A biopsy was used as a final confirmation. This scenario has changed drastically over the past 8 years with the overall acknowledgement from the medical community that PSA and DRE are not reliable enough to warrant CaP treatment. Therefore allopathic treatments will not occur (nor be reimbursed) without a prostate (TRUSP guided) biopsy. With malpractice issues ever growing, physicians became increasingly nervous about missing a CaP now that their main tool, PSA, was relatively moot. This has translated into much higher incidence of biopsies recommended and performed on patients. At the same time, more patients are seeking less invasive treatment and testing options.
Biopsy Concerns:
Many naturally minded patients dread biopsy due to pain, prostatitis relapse, and heavy antibiotic use following the procedure. On top of these concerns, the needle biopsy may miss a CaP altogether and create a false negative that will often be re-biopsied at a later time until a positive is 'found'. In addition, many patients (and physicians) are concerned about CaP 'seeding' , which is the nosocomial spreading of the cancer through the gland as the biopsy needle is pulled out. Seeding is not a concern for allopaths, understandably, because if the biopsy is negative you do not spread anything. At the same time if it is positive, any seeding is irrelevant since it is assumed the patient will have the prostate removed quickly. This makes sense from that medical point of view. However, if the patient wishes active non-invasive treatments (naturopathic, etc) then the biopsy could have potentially made the first problem worse and hence even harder to treat. These patients therefore are seeking alternatives to not only potential CaP treatments but also the assessment itself.
For the naturopathic physician this situation has created some issues. Since the only legal diagnosis for CaP is from biopsy how do you chart a 'highly suspicious' CaP without the procedure? 'What' do you treat? How do you defend yourself medically if you support the patients right to oppose the 'reflex' ordered TRUSP biopsy?
Lastly, the importance for proper CaP assessment enters two other areas for the treating naturopath. First is the patient population that has been diagnosed with CaP on biopsy. These are patients who are seeing you for natural treatments instead of surgery. In this case, how does the physician confidently track the cancer growth and progress of your selected therapies? Relying simply on PSA levels may not be enough.
The second, and quite recent, issue confronting naturopaths today determining CaP risk is from andropause treatments. Andropause is becoming a large business for some naturopaths as Baby Boomer men are now being 'sold' youth in the form of Botox, Viagra, etc. Andropause treatment #1 tends to be testosterone . The standard and accepted literature at this time is very clear regarding the risk of testosterone upon CaP. Testosterone does not cause CaP but it will make it worse once you have it. Therefore, a push for testosterone in older (and higher CaP risk) men has created a serious need to rule out CaP before treatment. However, since individual PSA results are questionable by themselves, how does the naturopath rule out such risks without an urologist ordering a reflex biopsy?
Naturopathic Assessment of CaP Risk and Disease Tracking
Form the outset, be informed that each of the following tools are accepted and most used to some degree by standard urologists. They are not used however to this extent explained below, not because they disagree with their cumulative validity, but due to the time and cost it takes to add up and congregate this information. Urologists (and allopaths at large) are expected to spend ever less time on a patient case due to insurance concerns. Therefore it is quick, efficient, and financially covered to simply 'cut to the chase' and send for a quantitative biopsy. If a physician prefers to qualitatively determine risk without biopsy, it simply takes more time. This is the role a naturopathic physician can fill.
Basic Risks:
Is the patient of African-American heritage? Are they overweight? Do they have high stress markers (stress hormones or personality indicators)? Is their diet high in carbohydrates and animal protein? These are all risks that should be basic to the treating physician regarding all forms of cancer. Is there CaP in their immediate family? Having CaP in your grandfather or father is significantly high however it is higher still if found in a brother.
American Urological Association (AUA) Symptom Score:
This is a 7 question quantitative 1 page assessment that I give every prostate patient. It scores urologic symptoms between 0 and 35. This symptom score can be found used by most every urologists' office and urology medical text as a quick yet consistent tracking method of symptoms. It is also very useful to determine whether a patient has improved under your care for 'number minded' male patients. This is very important for ruling out CaP. I like to see high numbers (and symptoms) since this points to a more likely pathology of prostatitis or benign prostatic hypertrophy (BPH). CaP can also block urine outflow but normally only when very pronounced. Such CaP would typically be in patients that have not been checked for many years and have PSA values over 20ng/ml or even the hundreds.
Total PSA (tPSA) values:
Despite the growing trend, especially amongst alternative providers, to distrust this lab value, it has been determined by the AUA to be useful still in 3 instances. 1. To track CaP post-radical prostatectomy. 2. To mark the severity of BPH. 3. To be used as CaP assessment only when incorporated as a data point to show rate of change. This is known as PSA velocity (PSAv). By itself, a PSA may be a guide as I use in the following: 0.0-2.0ng/ml is relatively very low risk. 2.0 – 10.0ng/ml requires further workup. 10.0ng/ml+ is very likely CaP or a substantial BPH.
PSAv:
tPSA values should not increase more than 0.75ng/ml/year. If they do then a positive velocity exists and CaP is suspect. If the rate is greater than 2.0ng/ml/year then this suggests an aggressive pathology. A negative velocity can track positive progress regarding treatment strategies.
Percent Free PSA (%fPSA):
While the tPSA is a quantitative value, the %fPSA is a qualitative one that indicates the % chance that the tPSA value you collected is coming from a CaP or some other etiology (BPH). I use this test for initial visits for a baseline and to help track treatment progression.
PSA Density (PSAD):
After determining the prostate size/volume on TRUSP (described below), you may divide the tPSA by the volume in cubic centimeters (cc). Reference tables exist to determine if the proper (expected) PSA is being secreted per prostate cell. Higher density cells suggest higher metabolism that is associated with CaP.
Gleason Score:
If a patient has had a previous positive biopsy result, this information is nonetheless useful in determining the CaP aggressiveness. Remember, a value under 7 is preferred (more differentiation/ less aggressive) rather than one over 7 (less differentiation/ more aggressive)
Trans Rectal Ultrasound of the Prostate (TRUSP) and Power Color Doppler Imaging:
Up until now I have referenced TRUSP with biopsy. This is because a diagnostic ultrasound is needed to quickly guide the biopsy needle to each quadrant the urologist wishes to sample. This is a very quick procedure. TRUSP can be used without the goal of biopsy but instead for a qualitative image assessment of the prostate. Although most radiation centers may provide a simple TRUSP, they are not read nor interpreted by an urologist for CaP diagnosis again due to insurance reimbursement only for biopsy. The few centers that do implement this procedure are few but slowly growing. Nevertheless, TRUSP with Color Doppler has become an incredible tool to quickly visualize my patients' progress.
Volume:
Using TRUSP, an accurate volume measurement can be taken of the prostate gland in ccs. This is accomplished by three measurements of the gland (X, Y, Z axis) multiplied together with a volume coefficient of 0.523. This value allows calculation of your patients' PSAD as well as gives greater meaning to the AUA symptom score.
Suspicious Lesions:
Suspicious areas suspect for CaP are identified, mapped, and measured to the millimeter. These suspect areas are of varying density, often hyperechoic (darker compared to surrounding tissue), contain irregular borders, and often reside in areas of high risk within the gland. These high-risk areas tend to be the bilateral lateral posterior corners of the midgland (compared to the base and apex regions). This is because the main arterial flow into the prostate enters here.
Location Risk:
A CaP nestled deep within the gland is less of a current threat to metastasis than one that is either at the capsular edge or especially if bulging outwards. The latter would constitute a potential T3 tumor and substantially higher risk to the patient. This is important to detect since the PSA and other measurements may suggest a low aggressive cancer but its location may drastically alter your timeframe for treatment.
Identification of Other Prostate Pathology:
BPH and prostatitis are both fairly easily identified on TRUSP. BPH visualizes large prostatic mounds often bilaterally and symmetric with many blood vessels within each lobe. These regions also predictably demonstrate increased blood flow on Color Doppler (explained below). Urinary retention in the bladder can also easily be identified in more progressive cases. Prostatitis can be inferred from increased blood flow in tandem with large prostatic stones. Prostate stones are similar to a urolithiasis but do not flow out. Instead they are imbedded within the gland and continually aggravate the surrounding tissue. Sometimes a positive DRE is actually picking up large calcium aggregates that a TRUSP can rule out.
Blood Flow:
Often the most critical of qualitative assessment tools when using a diagnostic ultrasound is the Power Color Doppler. With this capability, the physician can in real-time qualitatively track and visualize blood flow quantity, velocity, and location throughout the gland. This helps determine patterns often seen in BPH or prostatitis compared to CaP. The latter patterns are often unilateral, asymmetric, and reside around or at hyperechoic regions identified on TRUSP. In addition the flow rates, when qualitatively tracked, can determine possible CaP aggressiveness and progress. The later is very important when tracking my patients healing and improvement during our treatment protocols.
Conclusion:
CaP is difficult to diagnose or assess for any doctor without resorting to (ongoing) biopsies. The qualitative assessment for prostate pathology is perfectly suited for the naturopathic physician knowledgeable in this field since it utilizes true integration of allopathic and naturopathic principles and licenses (depending on your State). It also allows the education of the patient during the assessment process so he is completely aware of his individual CaP risk and overall becomes empowered : the first step toward true healing.
