January 18, 2022

To Your Good Health: Choosing not to treat prostate cancer

Every year, I used to get a physical, which included a prostate exam, as well as blood tests with PSA. When my doctor retired, I had a hard time finding a new one I liked. It has been three or four years since my prostate was checked, but my new doctor doesn’t do the prostate exams. I am 63. He says that recent studies do not recommend them, and I have seen news reports about the unreliability of the PSA test. How do you find out if you have prostate cancer if you don’t look for it? My brother-in-law found out he had it at 52, and it was successfully treated. I don’t really want to wait until I am showing symptoms, and there is no history in my direct family. What do you think about this?

Prostate cancer isn’t really one disease. It can be very aggressive — both with local invasion and spreading to bones quickly — but it also can be very indolent, hardly growing at all over years.

Yearly prostate cancer screening with PSA is more likely to find the slower-growing cancers, since they are around for a long time. The goal of screening is to find aggressive cancers, the fast-growing ones that can go from undetectable to too-late-to-do-anything-about in a very short time.

But a downside is that screening may lead to unnecessary treatment of the more indolent cancers, most of which can be carefully monitored and will not need surgery or radiation, at least not for years.

If a man elects to undergo prostate cancer screening, he should understand the benefits, finding prostate cancer early enough it can be cured, and the risks, treatment for prostate cancer causes complications frequently; these can include incontinence and loss of sexual function. Not treating low-risk prostate cancer reduces the risks.

Low-risk prostate cancer is defined by a PSA below 10, a very small or non-detectable tumor by palpation or imaging and a low Gleason score, which is based on how the tissue looks to the pathologist. Six or less is low risk. Most men in this situation do not need immediate treatment.

Some men have difficulty not treating cancer, but treatment does not appear to improve the already good prognosis. Choosing not to treat is hard for some men.

Hypnopompic Hallucinations

I received a lot of mail from readers about a column in which a reader described realistic hallucinations upon awakening. I was concerned about Lewy body disease, a form of dementia with prominent visual hallucinations.

The most common condition readers were concerned about was Charles Bonnet syndrome, a type of visual hallucination found in people with vision loss. It’s not well known, so I was surprised that so many people wrote to me about it, particularly when the original letter didn’t say anything about vision loss.

The answer, as diagnosed by my reader’s neurologist, turned out to be hypnopompic hallucinations — hypnagogic hallucinations are a similar issue, but these occur upon falling asleep.

A sleep technician wrote to me with the same diagnosis. These can occur in sleep apnea, which several people wrote about, and several said treatment stopped these hallucinations. They can also be associated with neurological disease, such as Parkinson’s disease, Guillain-Barre syndrome and narcolepsy.

Keith Roach

Dr. Keith Roach

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu. © 2022 North America Synd., Inc.