New Jersey has the fifth highest age-adjusted cancer incidence rate in the U.S. Cancer is also the second leading cause of death in NJ — nearly 6,000 residents are killed by preventable cancers each year. But for many cancers, screening can detect cancers at an early stage when treatments are far more effective.
To learn about the latest in prostate cancer screening and treatment, we talked with Evan Kovac, MD, a urologic oncologist at Rutgers Cancer Institute of New Jersey at University Hospital in Newark – here is what you need to know!
About one in six men will be diagnosed with prostate cancer in their lifetime. That is why the work being done by Evan Kovac, MD, a urologic oncologist (doctor specializing in treating prostate cancer), is so important. The best way to identify prostate cancer is to get screened. Men of average risk should ask their doctor for a blood test starting at age 50. If they are at higher risk for developing aggressive prostate cancer, some men may want to consider getting screened at age 45.
We asked Dr. Kovac about screening, prevention, treatment options, clinical trials, and the critical work that he and other cancer researchers and clinicians are doing to help men in NJ communities get informed to make educated decisions about screening and care.
New Jersey Family: Can you tell us about prostate cancer broadly, outline the risk factors, and tell us who is most at risk?
Dr. Evan Kovac: Prostate cancer typically presents with minimal or no symptoms until it becomes very advanced. That’s why screening when a person has no symptoms is so important.
It’s a cancer of the prostate, which is a reproductive gland that sits next to the bladder, and is important for the production of semen. When men reach the age of around 50, the prostate starts to enlarge, which can sometimes cause difficulties with urination, because the urine stream flows through the prostate gland. Cancer can also develop in the gland around this same time – age 45 to 50 – and usually occurs without symptoms in its early stages.
So two things can happen around the same time – you can get an enlargement of the prostate which is not cancerous (“benign”) and you can develop prostate cancer. Aside from skin cancer, it’s the most common cancer and the second most common cause of death in men in the United States.
You are considered at higher risk for prostate cancer if you come from certain genetic, racial, and ethnic backgrounds. For example, having African ancestry increases a person’s risk for prostate cancer. That includes ancestry from the African continent, from the Caribbean who are of African descent, and African Americans. Having the BRCA gene (known as the breast cancer gene) also increases both your risk for developing prostate cancer at an earlier age and for developing more aggressive disease.
Risk Factors for Aggressive Prostate Cancer:
African ancestry
Close family members with breast cancer
Knowing you have the BRCA gene
A father, brother, or child with prostate cancer
NJF: How can you know if you have the BRCA gene?
Dr. Kovac: Anyone with a prostate who has a first-degree relative (parent, sibling, or child) with either prostate or breast cancer should be screened for the BRCA gene and any other genetic mutations; if you have family members with ovarian or pancreatic cancer, also discuss genetic testing with your doctor. There are about 10 different cancer risk genes that we can check for, and if you have any genes that put you at higher risk for developing cancer, you can get screened earlier or more frequently to stay healthy.
NJF: When should you begin screening?
Dr. Kovac: Medical experts recommend starting screening between ages 50 and 55 for most people. Anyone with a prostate who has or had a first-degree relative with prostate cancer, (for example, a father, brother, or child with prostate cancer), should begin screening earlier, at 45. Those high-risk communities that we spoke of, especially individuals of African ancestry, should also consider beginning screening at 45.
NJF: What types of screenings are available?
Dr. Kovac: Usually, screening is done with a blood test called PSA. PSA stands for prostate-specific antigen — It’s a protein that is made in the prostate and is present in the bloodstream at low levels normally. When the amount of PSA in the bloodstream increases, it may be a sign of cancer, but it may also be due to other, non-cancerous reasons. PSA levels can rise if your prostate is enlarging, if you have an infection or inflammation in your prostate, or if you’ve recently had a test that can rub against or disturb the prostate, such as a colonoscopy.
There’s a new way of thinking about prostate cancer screening in that we can now use this PSA test as a predictor of the future. Men with lower PSAs at a younger age have a lower risk of developing prostate cancer later in life. Men with higher PSAs at a younger age, while they may not have cancer now, are at higher risk for developing prostate cancer down the road. We call this baseline PSA testing or screening.
ScreenNJ is a statewide service the provides education about cancer prevention and detection to the community and for professionals. ScreenNJ supports NJ residents to obtain cancer screening through navigation and mobile health services regardless of ability to pay. For more information about ScreenNJ visit screennj.org.
NJF: How reliable is the PSA test?
Dr. Kovac: Like other screening tests, a PSA test may give false-positive results. A high PSA doesn’t necessarily mean you have cancer – you may undergo follow-up tests that reveal that you don’t have cancer. A low PSA doesn’t mean that you don’t have cancer, either. But in general, the higher your PSA, the higher the chance you have prostate cancer – screening is important to helping you and your doctor keep you healthy.
NJF: Most people tend to think of prostate cancer as an older person’s cancer that is highly survivable. Talk us through diagnosis.
Dr. Kovac: Prostate cancer is typically a disease of older men. We’re not really sure why, but the gland has this tendency to develop a cancer as we age. The question is whether that cancer is dangerous. Men that are younger when they develop prostate cancer are more at risk for cancer morbidity (illness) or mortality (death) because they have a longer lifespan ahead of them, whereas men who first develop prostate cancer in their 80s or 90s may not have as long of a lifespan ahead of them for the cancer to cause health problems.
We generally don’t check for prostate cancer in older men because prostate cancer takes a long time to develop and grow and spread. It can take upwards of 10 to 15 years for an early prostate cancer to start causing health problems. We focus our screening efforts on younger, healthier men because they are more likely to benefit from screening and from detecting the disease at an earlier stage. When those younger-onset, more aggressive cancers are detected at an earlier stage, survival rates are excellent, above 90% at 5 years.
NJF: What about treatment once you are diagnosed with prostate cancer?
Dr. Kovac: It really depends on the “grade group” that you’re in, which measures the prostate cancer’s level of aggressiveness. These groups go from 1 to 5, with 1 being the least aggressive and 5 being the most aggressive.
Group 1 typically does not get treated immediately because it is so slow-growing. The preferred way forward for those men is surveillance, where we monitor the disease. If there are signs that the disease is getting more aggressive, then we recommend treatment. This type of follow-up schedule has been proven to be extremely safe with survival rates upwards of 99.7%.
Now, it begs the question, why wouldn’t you treat all prostate cancers? That’s because prostate cancer treatments can have side effects. Those side effects can be sexual in nature. They can also have effects on a man’s urinary function or control.
The two main treatments for prostate cancer are surgery to remove the prostate and radiation to slow the growth of or kill cancer cells. Both of these treatments have equal survival rates, but there are differences in side effects which can be significant. Importantly, these treatments can impact the person’s quality of life. Typically, patients at highest risk for prostate cancer mortality – generally younger, healthier men – undergo treatment. But because prostate cancer is slow-growing in some men, sometimes an ‘active surveillance’ approach with regular monitoring is taken instead to balance the benefits and harms of treatment.
NJF: Are there clinical trials about prostate cancer screening and treatment? What is your advice for people who might be invited to participate in a clinical trial on this topic?
Dr. Kovac: At Rutgers Cancer Institute in Newark and at Rutgers Cancer Institute in New Brunswick, patients have access to numerous clinical trials that are investigating the treatment of both early-stage and late-stage disease. In a clinical trial, we are investigating a new treatment and comparing it to the current “standard of care” (best currently-available treatment). Patients who enroll in clinical trials will always get the best available treatment – the clinical trial may also provide them with a new experimental treatment that may or may not be better than the current standard of care.
It’s a very exciting time in the world of prostate cancer because over the last 10 years, we have developed exponentially more treatments for early and late-stage prostate cancer, both in terms of advances in surgical and radiation techniques and also medications for late-stage disease that are helping men live longer than they would have otherwise lived 10 or 15 years ago. Nowadays, we treat advanced or metastatic (cancer that has spread) prostate cancer like a chronic disease. We’re managing it more like high blood pressure or diabetes where many men can live many years with metastatic prostate cancer.
NJF: Can you talk about the latest prostate detection innovations that you and your peers are using?
Dr. Kovac: In addition to the PSA, there are additional screening tests that can be performed to know if a man is at higher or lower risk for prostate cancer. We’re thinking harder about our individual patients, what are their risk factors, their family history, their comorbidities, and then helping them to make a decision that is personalized and right for them.
There are other follow-up tests to the PSA that may help us to decide whether a patient will require a scan or a biopsy of their prostate to diagnose prostate cancer. We call these tests “molecular biomarkers.” This allows us to deliver personalized medicine to our patients, and move away from the one-size-fits-all model (since one size doesn’t fit all!).
Interested in learning more or getting screened but not sure where to start? Contact ScreenNJ patient navigators for free help scheduling your cancer screening regardless of your income or health insurance status. Email patientnavigation@cinj.rutgers.edu or call (833) 727-3665 or text SCREEN to 43386.
NJF: If you get screened and have prostate cancer detected early, what do survival rates typically look like?
Dr. Kovac: For early-stage disease, where the cancer is contained within the prostate, survival rates are excellent (over 95%). As I mentioned earlier, many cancers do not require immediate treatment and can be safely monitored (called “surveillance”). For surveillance, survival rates are over 99%, as long as the cancer remains slow-growing and not aggressive. For late-stage or advanced disease, and metastatic disease, survival rates are continually improving because we are developing newer, better treatments that are helping men to survive longer. Every day, treatments are getting better.
We want people to know that they have an entire team that’s going to support them to ensure that they have the best possible outcome. The first and most important step you can take to protect your health is to talk to a doctor about your personal risk factors and when you should consider getting screened.
Thinking about screening for yourself or someone you love? Start by talking to your primary care doctor about screening options or contact ScreenNJ, a cancer prevention, screening, and early detection program brought to you by Rutgers Cancer Institute of New Jersey, the NJ Department of Health, and healthcare and community organizations statewide.
Dr. Kovac is a board-certified and fellowship-trained urologic oncologist, specializing in the evaluation and treatment of cancers of the urinary tract, including prostate, kidney, bladder, testicular, adrenal, and penile cancers. Dr. Kovac earned his medical degree at McGill University in Montreal, Canada. He is experienced in the latest diagnostic modalities and has specific expertise in transperineal, MRI-ultrasound-fusion biopsy for the diagnosis of prostate cancer. His surgical proficiency is broad, and he is highly skilled in open, endoscopic, and single-port robotic techniques for the treatment of genitourinary cancers.