When an ache turns into a pain or when feeling tired becomes persistent fatigue, most of us decide to visit the doctor. But not all health issues are obvious. Some sneak up on us, developing over time. Take prostate cancer. This slow-growing disease affects 1 in 8 men at some point in their lives, often without symptoms.

Thanks to earlier detection and more effective treatments, the mortality rate for this disease has decreased in recent years and most men whose cancer is caught before it has spread beyond the prostate gland are alive five years or more after diagnosis.

Diagnosing Prostate Cancer

In 2017, Joe Forbus went in for his annual checkup, which included a prostate-specific antigen — or PSA — blood test. PSA is a protein produced normally by the prostate gland, but a higher reading can indicate the presence of cancer cells. Joe’s PSA was elevated, but not to the point where his doctor was alarmed. The following year, after landing a new job, moving into a new house and taking a long-planned family vacation, Joe went in for his annual medical visit and learned that his PSA level had risen. He decided to transfer to the Froedtert & the Medical College of Wisconsin health network, where he met with Scott Johnson, MD, MBA, urologic oncologist and MCW faculty member.

Because an elevated PSA alone cannot confirm the presence of cancer cells, Dr. Johnson recommended a biopsy, which confirmed Joe had prostate cancer.

“The first decision is whether we are going to treat or just watch things,” Dr. Johnson said. “In the past, more men got treatment than probably needed it. Now, with low-risk patients, we generally practice active surveillance, which includes periodic PSA testing and rectal exams, as well as a biopsy every two to five years. Joe had intermediate risk and was relatively young, so we recommended treatment with surgery or radiation therapy.”

The decision, of course, was Joe’s to make.

“You can play the waiting game, but if you wait too long you face the possibility of the cancer spreading, and then it’s a totally different ball game,” Joe said. “I don’t like to guess; I like to know. I wanted to take an aggressive approach.”

Coordinated Treatment

Ultimately, Joe opted for surgery to remove the whole prostate gland, which Dr. Johnson performed at Froedtert Hospital in 2018 using a robotic surgery system. The surgery went well and Joe had an uneventful recovery. But his PSA, while low at first after surgery, began to rise, indicating that cancer cells could still be present at the site or had traveled to the pelvis or elsewhere. Joe’s PSA level did not indicate he had metastatic disease, but some men who have surgery will have a biochemical recurrence postoperatively. In those instances, Dr. Johnson said radiation therapy is recommended.

“He had a very good chance for cure with surgery, but when PSA remains detectable, it usually indicates residual disease,” said Michael W. Straza, MD, PhD, radiation oncologist and MCW faculty member. “If it rises, as it did in Joe’s case, we talk about radiation therapy.”

Dr. Straza ordered a seven-week course of external beam radiation therapy, in which cancer cells are destroyed by radiation fields generated by a device outside the body. Joe also had antihormonal therapy, also called antigen deprivation therapy (ADT), with Thomas Giever, DO, MBA, medical oncologist and MCW faculty member.

“With ADT, we drive down the production of testosterone because prostate cancer cells can use testosterone inappropriately to grow,” Dr. Giever said. “By depriving those prostate cancer cells of testosterone, we cause them to die off. The addition of ADT therapy is also advantageous because it can address cancer cells that may have moved beyond the radiation therapy field.”

ADT is administered via injection. Joe had two treatments over the course of six months. He received all treatment, except surgery, at the Cancer Center at Drexel Town Square Health Center, part of the Froedtert & MCW health network.

“He did quite well,” Dr. Giever said. “His PSA dropped to become undetectable and it stayed there. With the combination of surgery, radiation therapy and antihormonal therapy, our hope and expectation is that he has completed all his anticancer therapy.”

Clearly, Joe benefited from a coordinated team approach.

“Even before I decided on surgery, Dr. Johnson made sure I met with the medical oncologist and the radiation oncologist so I understood the benefits, downsides and long-term aspects of every treatment,” Joe said. Although he good humoredly admitted that the ADT left him knowing what hot flashes and night sweats are, he said he was up and about after surgery and that the radiation therapy was a “nonevent.”

Looking back at his experience, he is happy he took the course he did.

“This cancer does not go away unless you take action,” he said. “It’s not a broken arm. Or a cold. Some things you just have to deal with.”