Focal Therapy for Localized Prostate Cancer, Part 3

Killing the Cancer, Not the Prostate

            Focal therapy, although not the standard of care, is emerging as a way to treat localized prostate cancer in carefully selected patients.  I recently interviewed one of the leaders in this field, urologist Arvin K. George, M.D., Director of Prostate Cancer Programs at the Brady Urological Institute at Johns Hopkins.

            Focal treatment is just one part of George’s clinical practice, which spans the diagnosis and management of prostate cancer and other genitourinary cancers; he is an expert surgeon who performs robotic prostatectomy and kidney surgery.  His research focuses on the use of imaging and biomarkers in diagnosis, risk stratification, and management of prostate cancer.

            Why is focal therapy a tricky subject?  As we have discussed here and elsewhere on this website and in the book, Prostate cancer is a multifocal disease:  like dandelions in a field, cancer can spring up in several places within the prostate at the same time.  That is why the gold standard for localized disease is to treat the entire prostate through surgery or radiation.

            Focal therapy – killing, or ablating, only the known spot or spots of clinically significant cancer within the prostate – has been around for decades in various forms; the most common approaches are cryo (freezing) therapy and high-intensity focused ultrasound (HIFU), and other technologies are emerging.  But for years, urologists have had questions about the idea of focal therapy itself, including:

  • What if you kill cancer in one spot, but miss another tiny site or sites of cancer?
  • Urine exits the body through the urethra, which runs right through the prostate, like a road through a tunnel. To protect it during focal therapy, doctors maintain its normal temperature with either a heating or cooling tube.  What if there is cancer near the urethra that is also spared?
  • What if one spot of cancer is ablated, but a new one starts to grow? Can the prostate tolerate multiple courses of the same type of focal therapy, should a different approach be used, or should the patient shift to surgery or radiation?

Why is Johns Hopkins now investigating and offering focal therapy?  What has changed?

            First and foremost, says George, the reason is imaging. “The better imaging gets, the better and more precise our treatments become.”  Improvements in MRI have been game-changing.  “We can see where a lesion is, how far it extends, and apply a treatment to just that area.”  That’s true, although some cancers just don’t show up on MRI, as discussed here. There is also a potential for PSMA-imaging technology to play a role in the treatment of localized disease, although so far it has not routinely been used in patients who are considering focal therapy.  PSMA-PET is more of a “big gun” brought out when it’s suspected that cancer has escaped the prostate.

            Risk stratification has gotten a lot better, too.  PSA density, second-line biomarker tests like the 4K score and Prostate Health Index (PHI,) and molecular pathology findings (from the biopsy tissue) help doctors create a “profile” of the cancer, to evaluate its potential to be aggressive or more slow-growing.

            Thus, says Mohamad Allaf, M.D., Director of the Brady Urological Institute (and, incidentally, the Hopkins surgeon who took out my husband’s prostate and saved his life, thank God!), “as we are understanding the biology of the disease more and our ability to see the cancer has gotten better – even though MRI and PSMA-PET aren’t perfect – there may be a role for focal therapy.”  This remains to be proven, he adds, and “Arvin is perfectly suited to doing this.  Doctors out in the community are already providing focal therapy, and somebody needs to take the lead to study it in a very rigorous way, tracking the cancer control long-term.  We see the Brady as a steward of treatment and as a leader in defining the role of focal therapy.  The unique thing Arvin brings is the academic rigor to study and implement focal therapy and anything image-guided within prostate cancer, including new MRI fusion transperineal biopsies.”

“We Definitely Have Some Bridges to Rebuild”

            One important priority is improving the public understanding of focal therapy, says George. “We definitely have some bridges to rebuild,” because of physicians worldwide over the last 20 years who have not been as responsible or, regrettably, as skillful as they should have been.  “We didn’t know what we didn’t know.  There was a learning curve to this new technology: how we apply it, and how we follow men afterwards.  We have some clarity regarding this with updated surveillance protocols, but we still have much to learn!”

            That said, he adds:  “Some practitioners of focal therapy out there have been frankly sketchy,” he says, “providing inadequate coverage of the cancer, exorbitant out-of-pocket costs, no follow-up, learning on patients as the technology developed, causing fistulas and other complications.  We are still suffering from that hangover of offshore treatments and cash pay.” 

            But focal therapy is not the same today as it was then.  With rigorous follow-up, George says, focal therapy can be a good option for some men with localized cancer.   “Tens of thousands of cases of focal ablation have been performed,” he says.  “While we have less data than that, we do have five- to seven-year median outcomes on more than 1,300 patients that have been published.” He believes focal therapy is here to stay.  “It’s all about choosing the right patient.”

            Right now, the “sweet spot” for focal therapy, as we discussed here,  is a patient with favorable intermediate risk. “Less aggressive cancer may require no treatment at all, and more aggressive disease requires more aggressive treatment.”  The ideal patient “has cancer that is visible on imaging but is not near vital structures like the urethra, rectum, or neurovascular bundles, and has no high-risk features such as extracapsular extension or seminal vesicle invasion.”

            George is the Principal Investigator of two clinical trials of focal therapy. One is the PRESERVE study, involving prostate tissue ablation through irreversible electroporation (IRE).  IRE is largely “athermal.”  It doesn’t use either heat or cold; instead, it generates an electrical field across tissues between two electrodes.  The electricity creates holes in the cells on a microscopic level, causing them to die.  “Because IRE doesn’t harm the scaffolding, or connective tissue, theoretically, it can treat closer to the nerves.”  The other study is the VAPOR 2 trial, using water vapor to destroy tissue.  “This is an extremely hopeful time for men with prostate cancer.”

In addition to the book, I have written about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org.  The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  I firmly believe that knowledge is power.  Saving your life may start with you going to the doctor and knowing the right questions to ask.  I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease.  Many doctors don’t do this, so it’s up to you to ask for it.

©Janet Farrar Worthington

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Focal Therapy for Localized Prostate Cancer, Part 2

            Is focal therapy for every man with localized prostate cancer?  Absolutely not.  In fact, says Northwestern University urologic surgeon Ashley Ross, M.D., Ph.D., it’s not even a good option for the majority of patients.  But for a few carefully selected men, with close follow-up, “it can be a curative option with minimal side effects.”

Ross, one of the leaders in the developing field of focal therapy, is the expert I interviewed for the 5th edition of our book –where we not only talk about focal therapy for localized prostate cancer; we devote a whole chapter to it!   This is a significant milestone, especially if you look at all the previous editions of our books dating back to 1993, where we basically offered zero encouragement for taking this approach.

But – but – focal therapy is out there!  It is here to stay!  It’s available all over the world!  Yes, that’s true.  Does it work long-term?  Nobody knows yet.  The current National Comprehensive Care Network (NCCN) guidelines state that “cryotherapy or other local therapies are not recommended as routine primary therapy for localized prostate cancer, due to lack of long-term data comparing these treatments to radical prostatectomy or radiation.”  Also, except for follow-up biopsy, there is no way to prove cure with focal therapy.  PSA does not become undetectable because much of the prostate is still untouched, and that prostate tissue is still making PSA.

This is why long-term follow-up is critical:  you have to keep watching the PSA, and if it changes, you need a repeat MRI.  So, no matter what anyone says, focal therapy is not the standard of care; it is still considered investigational.

The last post (part 1 of this series) was devoted to all the reasons why men interested in this approach should proceed with a whole lot of caution.  This post starts to look at who might consider focal therapy.

            Why am I talking about it now?  What has changed?  Imaging, for one thing; prostate MRI and targeted MRI fusion (also called mpMRI) biopsies.  Also, there are intelligent blood and urine tests that can help determine whether a cancer is clinically significant (we have updated information on this in the 5th edition of the book).

Taken together, maybe with genetic testing if there’s a strong family history of cancer, it is possible to get a decent idea of the kind of cancer you’re dealing with.  You can’t just say, oh, I have localized cancer!  You need a more nuanced understanding of this cancer, and that requires putting together every available piece of information you can get.  Don’t just put all your faith in the biopsy.  Remember, a biopsy only looks at 1/10,000th of the prostate.  Yes, that’s one ten-thousandth.  Not a lot of tissue!  Just because the biopsy says Gleason 6 doesn’t mean there’s not some higher-grade cancer in your prostate; many men are “upstaged,” that is, a higher grade of cancer is found after prostatectomy when the pathologist examines the removed prostate tissue.

And don’t put all your faith in the MRI.  As good as MRI is, some prostate cancers still don’t show up on it; they’re spread out, like plankton on the ocean, instead of all knotted up in one dense ball.  But if you put the imaging, the biopsy, and the other tests together, you can get a pretty good handle on the kind of cancer you have.

            Do you have the kind of cancer that needs to be treated right away?  If not, active surveillance is a great initial option.  It buys you time and has zero side effects.  If you have Gleason 3+3 (low-risk or very low-risk) or 3+4 (favorable intermediate-risk cancer), with not a lot of pattern 4, and the cancer seems safely contained within the prostate, then be thankful!  You have some breathing room.  Plenty of time to make a treatment decision when and if your cancer needs to be treated.

            If you have localized cancer but there’s a lot of Gleason pattern 4, or any Gleason pattern 5, (4+3=7, 4+4=8, 4+5, 5+4 or 5+5), then you have cancer that is not only clinically significant, but likely to spread, and the prostate needs to go – either with surgery or radiation, and if it’s higher-grade, higher-volume, and close to the borders of the prostate and you are deemed at high risk, you may need to escalate with a temporary course of hormonal therapy, as well.   We discuss all of these scenarios in detail in the book.

Who is the Ideal Candidate for Focal Therapy?

            Ross believes there is a “sweet spot” for focal therapy:  men with high-volume low-risk disease (Gleason 3+3) and favorable intermediate-risk prostate cancer (a little bit of Gleason pattern 4), “provided their disease is localized to one area of the prostate,” he says.  Preferably with just one lesion and ideally, “a lesion that is more anterior (above the urethra), as that allows for sparing of the neurovascular bundle.”

            Ideal candidates for focal therapy, he continues, should have a life expectancy of 10 years or greater.  They should be willing and able to undergo an MRI and biopsy, or should consider a saturation biopsy to make sure there aren’t areas of higher-grade cancer lurking in the prostate.  “Men also have to be willing, in my opinion, to undergo a confirmatory biopsy,” to make sure the focal treatment worked.  “They must have a very low chance of lymph node involvement, because obviously you’re not going to treat with focal therapy a disease that has spread to the pelvis.”

            The bullet points here:

  • 10-year or higher life expectancy
  • Unilateral cancer (one area, or focus), preferably away from the neurovascular bundles on both sides. A man who has multifocal disease (several bits of cancer sprouting simultaneously within the prostate; like seeds on a strawberry) “has a higher propensity for developing more prostate cancers,” and should not be considered for focal therapy.
  • You need a follow-up biopsy to make sure you’ve been cured.
  • Also, says Ross, you should undergo genetic testing if recommended. In the book, Ross mentions two kinds of genetic tests:  one looks for mutations in genes such as BRCA2, which raise the risk of developing aggressive cancer.  “Patients with genetic risks are potentially poor candidates for focal therapy,” says Ross.   There’s another kind of genetic test: one that looks for multiple genetic variations that are known to raise the risk of getting prostate cancer.  These are not mutated genes, but mutated sequences of DNA.  Men with high polygenic risk scores are more likely to have multifocal disease, and “also may be poor candidates for focal therapy.”

            Here is a case study Ross presented at Northwestern, which we used in the book.

            “Daniel” is 74, with a PSA of 7.1  No cancer was felt on his rectal exam, but an MRI showed one lesion, with a PI-RADS score of 5, in the right transitional zone.  His MRI-targeted prostate biopsy found cancer, Gleason 3+4=7 – but not much of it.  Cancer was only found in three out of 12 cores of the biopsy, but in two of those cores, 40 percent of the cancer was Gleason pattern 4.

            Daniel is still working and fairly active.  Ross estimates his life expectancy to be around 10 years.  Daniel has some health issues, including atrial fibrillation, and is on a blood-thinning drug, Eliquis.  Before coming to see Ross, he met with another urologist to discuss robotic prostatectomy, and with a radiation oncologist.  “He wasn’t interested in radiation therapy,” says Ross.  “He was worried about bleeding episodes” because of the Eliquis.  “He also worried about surgery.”

            Daniel underwent cryoablation, killing cancer cells with extreme cold – creating an “ice ball” of tissue, which then dies).  This focal procedure spared both neurovascular bundles (the nerves on either side of the prostate that are responsible for erection) and, because of the location of the tumor, did not affect the urethral sphincter.  It was done as an outpatient procedure, and Daniel went home the same day.  “He had an uneventful recovery, had immediate continence, which was complete, when the catheter was removed in seven days.  He had no decline in sexual function,” although Daniel had already experienced some ED before the procedure.  Three months later, Daniel’s PSA dropped to 0.94.  “We will continue PSA monitoring, and have an MRI and confirmatory biopsy at 12 months.”

            Part 3 of this series will be my interview with Johns Hopkins urologist Arvin George, M.D., who is investigating several different types of focal therapy and believes this treatment is going to be helpful for a wider window of patients.

In addition to the book, I have written about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org.  The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  I firmly believe that knowledge is power.  Saving your life may start with you going to the doctor and knowing the right questions to ask.  I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease.  Many doctors don’t do this, so it’s up to you to ask for it.

©Janet Farrar Worthington

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Focal Therapy for Localized Prostate Cancer, Part 1

Why I agonized over writing about it, and why I have (cautiously and for very selected men) altered my opinion.  In three parts.

            Four years ago, I wrote a VJ post on focal therapy.  I didn’t publish it.  I just couldn’t.  It started off:  “Dear Readers, if you ever want to start a veritable spitstorm in the world of prostate cancer, here’s a grenade:  it’s called focal therapy.  It’s like the idea of a lumpectomy; just treating the part of the prostate with cancer, and leaving the rest alone.”

Back then, in 2020, I wrestled with the story for months.  A wonderful man named Bill had contacted me on Facebook and wanted to tell his story.  A happily married man in his early 50s with young kids and an active life, he had undergone focal cryotherapy and was thrilled with the results.  He wanted me to write his story so he could help other men.

I turned him down.

Why would I do that?  I will tell you, but first, a couple things you need to understand:  First, if you don’t know it already, I agonize over you guys.  I do.  I worry about so many men, some I know personally, some I have interviewed, and some I’ve just corresponded with or talked to on the phone.  I’ve been writing about this disease for a long time, and I have known way too many men who died of it.  That’s why I push for you to get screened for prostate cancer, to get a second opinion if your PSA is going up and there’s no good reason for it, to get MRI or second-line blood tests even though your doctor says “it’s probably fine,” and that’s why I have been very cautious about any treatment that sounds too good to be true.  I have been very wary of focal therapy because there aren’t long-term results and, although it is becoming more common, I don’t know that it’s a long-term cure.

            Second:  On this website, I answer only to you, to myself, and to God.  Not in that order.  But nobody else.  I don’t make a dime from VitalJake.com.  As you may have noticed, I don’t accept medical ads.  Actually, I don’t have any advertising; I don’t even know how to go about it.  I’m not saying I would turn down an ad for clothing, or dog toys, gardening tools or fishing lures.  In fact, it would be a novelty to actually make money from this site, but that’s not why I do this; I do have a day job.  What I will turn down, and have turned down many times, are medical ads.  I get a lot of offers, and I always say no.  Because if I let somebody else sponsor these pages, they might think they get to control the content.  No. It’s just me, agree with me or not.

Now… back to the grenade.

I told Bill what Patrick Walsh and I said in our book – back then, the 4th edition – about it.  Actually, we devoted 10 pages of the 4th edition (I keep mentioning this because the 5th edition discussion of focal therapy is different, as we will discuss).  The bottom line is this:  Prostate cancer is a multifocal disease:  like dandelions in a field, cancer can spring up in several places within the prostate at the same time.  That is why the gold standard for localized disease is to treat the entire prostate through surgery or radiation. 

The average prostate specimen, when examined by a pathologist after prostatectomy, has between three and seven separate sites of cancer cells.

Focal therapy doesn’t kill the whole prostate, and thus it has minimal side effects.  That’s why so many men are really interested in it.  I would be, too.

This form of treatment – killing, or ablating, only the known spot or spots of clinically significant cancer within the prostate – has been around for decades in various forms; the most common approaches are cryo (freezing) therapy and high-intensity focused ultrasound (HIFU), and other technologies are emerging.  But it doesn’t kill the whole prostate.  So there is the strong possibility that some cancer could be missed, or inadequately treated, and $30,000 out-of-pocket later, there you are looking down the barrel of surgery or radiation.

In the first edition of our book, back in 1993, we wrote about the side effects of cryotherapy, and there were a lot.  There was a huge learning curve, and it was often not pretty.  There were also many cases of men who paid a lot of money for HIFU, whose PSAs didn’t go down because there was still cancer in their prostates.  Also they had some of the key side effects they were trying to avoid; in this study, at one year, nearly 30 percent were impotent after HIFU and 27 percent still had cancer in their prostate.

Then, for Discovery, a magazine I write and edit for the Brady Urological Institute at Johns Hopkins, I interviewed a urologist for whom I have great respect:  Michael Gorin (now at Mount Sinai), who saved my husband’s life with his amazing biopsy skills.  To my great surprise, he was doing studies of focal therapy.  He believed MRI imaging had gotten good enough for urologists to see what was actually clinically significant disease in the prostate, and to kill it.

So, I got on Facebook, messaged Bill and said, “I think I owe you an apology.”  I told him they’re doing this at Hopkins, and asked if his offer to let me interview him was still open.  He agreed.

But then, in the ping-pong nature of this saga, for the Prostate Cancer Foundation’s website, I happened to be interviewing a University of Michigan radiation oncologist and Prostate Cancer Foundation (PCF)-funded investigator, Daniel Spratt, M.D., on a different subject.  I asked him what he knew about focal therapy.  He knew plenty; he has had to treat men for whom focal therapy has failed.  I’m including some of what he had to say below.  This, in turn, prompted a man named Greg to write to me here at Vital Jake.  He had seen the story on the PCF website and was not happy with it.  He was a fan of focal therapy.

Enough with the Backstory

             Let’s get to it.  This three-part series is my effort at a balanced discussion.  The rest of this first part is from the interview with Dan Spratt.  If you’re looking for the quick story, it’s a no on focal therapy.  But stay with me.  Parts two and three are a qualified yes.  For some men.  Some very selectively chosen men.  Men who must then receive rigorous, long-term follow-up monitoring.  The bottom line here is that this story is evolving.  Here’s that PCF interview:

If It Sounds Too Good To Be True…

            If you have been diagnosed with cancer that is contained within the prostate, you may be thinking:

            “Hey, there’s just a spot of cancer that showed up on the MRI,” or:

            “Only three of the needles came back with any cancer at all.”

            And this may lead you to think:  “Why do we have to treat the whole thing?  Why can’t I just get a prostate version of a lumpectomy?”

            Or:  “Why not just zap that one spot of cancer?”

            Wouldn’t that be great? 

            This is called focal therapy – just treating part of the prostate.  In just a few seconds’ search on the internet, you can see that there’s a lot of this focal therapy out there, and it all sounds great!  No erectile dysfunction (ED) or urinary incontinence!  If your PSA rises, no problem!  Treat it again!  A lot of doctors are offering focal treatment, using methods including cryotherapy (freezing the tissue), high-intensity focused ultrasound (HIFU), or even with highly focused radiation.

            There’s just one problem with every type of focal therapy for prostate cancer, says University of Michigan radiation oncologist and Prostate Cancer Foundation (PCF)-funded investigator Daniel Spratt, M.D.:  “I would say, strongly, that it’s experimental.  There’s a very high risk of recurrence, usually within the first three years and it may increase your risk of side effects if you later need curative treatment.  There is a reason it is not considered a standard-of-care treatment by most national and international guidelines.”

            Prostate cancer is usually a multi-focal disease, meaning it is in more than just 1 or 2 spots in your prostate.  This is true even if your biopsies or MRI show only 1 area being involved with cancer.  Some studies suggest more than 40 percent of patients have MRI- invisible tumors, and standard prostate biopsies sample less than 1 percent of your prostate gland.  This is why focal therapy is often ineffective:  it treats only part of your cancer.

            Also, a lot of what they promise about not having side effects is not true.  “Side effects are often lower than men experience with a radical prostatectomy, but there are side effects,” says Spratt.  “There’s still the potential for erectile dysfunction (ED) and other side effects, and one of the biggest concerns is that with subsequent treatment, if the patient needs surgery or radiation, sometimes you can have severe or unexpected side effects.  I’ve seen it in patients who previously had focal therapy,” including one man after HIFU, whose entire urethra (the tube that carries urine from the bladder through the prostate and into the penis) became necrotic – the tissue died.   “He had to have emergency surgery.  They killed healthy tissue.”

            That’s why focal therapy for prostate cancer is still considered experimental. As molecular biologist and medical oncologist Jonathan Simons, M.D., then-CEO of PCF put it:  “’Experimental’ means ‘not proven.’”

            How does something become proven?  It requires well-designed studies to see how patients do in the short run and then over several years.  “There’s so little evidence in the literature,” says Spratt and most are retrospective studies or small single arm trials.  “No well-powered trials with long-term follow-up have been done to even inform us of how effective these therapies are, and to show the safety of doing subsequent curative treatment (surgery or radiation).”

            Spratt has seen many men in recent years who have come from around the country to see him after focal therapy has failed.  “Most of the patients I see who have had it are very upset.  Insurance often does not cover it, and they have spent $20,000-$30,000 out of pocket, thinking they’re going to get a cure with no side effects.  But some do get side effects and all of them who see me were not cured.  And when I tell them, ‘Look, you need a second treatment and you’re at a higher risk of having more side effects,’ they are very upset.”

            The best way to try focal therapy, Spratt continues, is in a clinical trial, “where you are fully informed of all the risks.  Many top centers offer focal therapy, and they should be offering it in the context of a clinical trial.  If not, this is concerning.  These trials are critical to learn how to quantify and optimize focal therapy.  Maybe if they improve it, in the years to come, it will be better than surgery or radiation.  But right now, it’s definitely not.  We’re learning.  There’s a lot of misinformation out there. We must remember that if patients want a non-invasive option other than radical surgery, there are multiple forms of radiotherapy that are completely non-invasive and have better cure rates and long-term potency rates than focal therapy.”

            In a recent trial of HIFU, “within one year, about 30 percent of men developed ED and 25 percent still had cancer in their prostate.  Most of these men had low- or intermediate-risk disease, and could safely have been monitored on active surveillance.  In comparison, in a similar risk group of patients receiving radiotherapy one would expect close to zero percent chance of recurrence within one year, no incontinence, and fewer than 10 percent would experience ED so soon.  Similarly, surgical removal of the prostate would also have excellent long-term cure rates.

            “So why do centers and providers offer focal therapy?  This is very complex.  I fear it comes back to money, trying to advance one’s academic career with something different, and the pervasive avoidance of working as a multi-disciplinary team.  A lot of doctors are trying to offer something less invasive than removal of the prostate for patients looking to avoid the risks of incontinence or impotence, rather than simply offering radiotherapy.  Focal therapy is new and it entices patients – like they found the magic bullet.  However, external-beam radiotherapy has extensive, high-quality evidence with very long-term follow-up beyond 20 years, and has essentially zero percent incontinence and superior erectile function outcomes compared to the focal therapy literature.”

            Spratt says, “Bottom line:  the two standard-of-care treatments for prostate cancer are surgery and radiotherapy.  Lots of emerging treatments and technologies, including focal therapy and proton-beam therapy, may have a role for the management for prostate cancer.  Well-done randomized trials are necessary to determine what, if any, role they will have in the management of prostate cancer.  Until then…proceed with caution.”

Still with me?  Okay, next, let’s look at two centers where they are proceeding with caution, with studies of focal therapy for localized prostate cancer.

In addition to the book, I have written about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org.  The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  I firmly believe that knowledge is power.  Saving your life may start with you going to the doctor and knowing the right questions to ask.  I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease.  Many doctors don’t do this, so it’s up to you to ask for it.

©Janet Farrar Worthington

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