LTD / ERISA Disability Lawyers: OC, Riverside & San Bernardino
Prostate Cancer
Prostate Cancer and Disability in Younger Men
Prostate cancer typically affects older men, but young men get it too. The average age at diagnosis is 66 years, but about 40% of men are diagnosed with prostate cancer below the age of 65 and 10% of men under the age of 55. Even young men in their 20's and 30's develop prostate cancer, which is often more aggressive than in older men The 5-year survival is 30% in men diagnosed with prostate cancer when they are 15 to 24 years old, 50% in those aged 20 to 29 years, and 80% in those aged 25 to 34 years. (This is in comparison to the 95% to 100% overall 5-year relative survival rate in the United States for men diagnosed with prostate cancer between ages 40 and 80 years.)
[Ref: Bleyer A, et al. “Prostate cancer in young men: An emerging young adult and older adolescent challenge.” Cancer. 2020 Jan 1;126(1):46-57.]
Therefore, men under the age of 65 may require disability benefits for prostate cancer under the Social Security Administration (SSDI) and/or under a private long-term disability (LTD) group plan governed by ERISA.
Diagnosis
Prostate cancer is frequently diagnosed in men after a blood test called the PSA (prostate specific antigen) starts going up. That can lead to a needle biopsy of the prostate gland, which is the only definitive way of diagnosing (or ruling out) prostate cancer.
It is important to note that an elevated PSA does not automatically mean a man has prostate cancer. Elevations of the PSA may occur with benign enlargement of the prostate gland that occurs with age.
For example, men who are in their 40's usually have a PSA from 0 to 2.5. In the 50's, it can go up to 3.5. In the 60's, up to 4.5, and in the 70's, up to 6.5.
The question arises as to what is a “normal” PSA? That depends on age, of course, but for many years, doctors regarded a PSA up to 4.0 as being “normal.” In recent years, many doctors have used 2.5 as the cut off. However, it's not only how high the PSA, it's also whether the PSA is increasing slowly or rapidly. When the PSA doubles in one year, that is a ‘red flag.'
The PSA test is sometimes combined with measurements of other biomarkers in the blood or urine such as kallikrein-related peptidase 2, prostate cancer antigen 3 (PCA3), and the TMPRSS2-ERG gene fusion test.
Imaging studies, including ultrasound scans, CT and MRI, and PET scans, are also used to help with diagnosis and to determine whether the cancer has spread.
Gleason Score
When the prostate gland is examined for cancer, the cancer cells are “graded” in accordance with the Gleason scale. In the 1960s. Dr. Donald Gleason was a pathologist at Johns Hopkins. He found that prostate cancer cells fell into 5 distinct patterns, and he graded them on a scale of 1 to 5.
Grade 1 cells resemble normal prostate tissue. Grade 5 cells are very abnormal looking and disorganized. When a biopsy specimen is examined under the microscope, the most predominant cellular pattern will be given a Gleason “grade,” and the second most predominant pattern will be assigned its own Gleason grade. The two grades are added together to give a Gleason “score.”
In general, prostate cancer is considered relatively low grade and non-aggressive if the Gleason score is 6 (3+3) or less. Many doctors may recommend “watchful waiting” or “watchful surveillance” rather than treatment with Gleason 6 cancers. It is often said that most men with prostate cancer die with prostate cancer rather than from prostate cancer. About 80% of men who reach age 80 have cancer cells in their prostate, but they die from something else.
The worst prostate cancers are Gleason 10 (5+5) cancers. They often require aggressive treatment and carry a guarded prognosis. Gleason 9 (5+4, 4+5) and 8 (4+4) cancers are also potentially bad cancers.
Gleason scores of 7 are intermediate. A Gleason 7 prostate cancer, when it is a 3+4 cancer, often behaves as a Gleason 6 cancer, meaning it tends to be less aggressive and more amenable to treatment. Some doctors will even “watch” a Gleason 3+4 cancer and not always treat it. However, a Gleason 4+3 cancer behaves more like a Gleason 8 cancer, and usually requires more aggressive treatment.
One of the first things you want to know about a diagnosis of prostate cancer is what is the Gleason score. Treatment and prognosis often depend greatly on the Gleason score.
Risk Groups
In order to better assess risk and determine optimal treatment, prostate cancer patients are divided into “risk groups.”
Low risk: Tumor is confined to the prostate, the PSA is <10, and the Gleason score is 6 or less.
Intermediate risk: Tumor is confined to the prostate, the PSA is between 10 and 20, and the Gleason score is 7.
High risk: Tumor extends outside the prostate, the PSA >20, or Gleason score is 8 to 10.
Treatment
There are only two ways to cure prostate cancer: surgery and radiation therapy. All other treatments, such as with hormonal, immunotherapy, or chemotherapy, may control the growth of prostate cancer, but they are not curative.
Radical prostatectomy (RP) is the surgical removal of the prostate gland. It can be done by open surgery or by robotic surgery. The recovery time after robotic prostatectomy is typically shorter than with open prostatectomy. Whether the results are better is still being debated.
Radiation therapy (RT) with curative intent is usually performed in older men who may not be able to tolerate a surgical procedure.
Salvage RT is performed in men who have had a previous prostatectomy and at some point, after surgery developed a rising PSA. A rising PSA indicates a probability of cancer recurrence. When RT is performed for a rising PSA, the procedure is referred to as “salvage” RT and can be curative.
After successful RP, RT, or salvage RT, the PSA ideally should ideally go down to undetectable levels.
Salvage RT should be performed “early” rather than “late”, meaning it should be done when the PSA hasn't gone up to more than 1.0. Otherwise, the prostate cancer may have spread outside the pelvis by that time and would not be cured by salvage RT. Many urologists recommend doing salvage RT when the PSA is 0.1 to 0.5, or even sooner.
Radiation therapy may be administered by external beam treatments (“ERT”) or as “brachytherapy,” where radioactive seeds are implanted into the prostate gland, or a combination of both. Radium-223 may be used for symptomatic bone metastases.
Hormone therapy (“androgen deprivation therapy”) can be used in place of surgery or radiation, and it can also be combined with RT in some cases. The idea of hormone therapy is to block testosterone, which fuels prostate cancer cells. This can be done with medications such as Lupron and/or newer medications such as abiraterone (Zytiga) or enzalutamide (Xtandi).
Many men respond quite well to hormonal treatment sometimes for many years, although it is considered palliative and not a cure.
Immunotherapy works by stimulating your own immune system to help fight the prostate cancer and has gradually been emerging as a viable treatment option for prostate cancer. Immunotherapy can include Sipuleucel-T (Provenge), which is a procedure where a patient's own immune cells are separated and collected from the blood (“leukapheresis”) and then taken to the laboratory where they are chemically stimulated to recognize and target prostate-cancer cells. These “activated” immune cells are then re-administered to the patient.
Another immunotherapy option is pembrolizumab (Keytruda), which targets PD-1, a checkpoint inhibitor protein on T-lymphocytes that normally keeps them in check and prevents them from attacking normal cells in the body. By blocking PD-1, Keytruda unblocks the immune response against prostate cancer cells. “Checkpoint inhibitor” drugs can be effective in patients whose cells have specific genetic mutations, such as a high level of microsatellite instability (MSI-H), or in one of the mismatch repair (MMR) genes.
Chemotherapy treatment options are usually reserved for metastatic disease, when prostate cancer has spread to bones and other organs. Taxane chemotherapy (docetaxel or carbazitaxe) is used most, but platinum chemotherapy is available, as well as controlled clinical trials with investigational agents.
Monitoring
After treatment, monitoring of prostate cancer is most often done by measuring the PSA. If the PSA stays down, that's a good sign. Imaging studies are also important, especially in the metastatic setting.
Complications of Treatment
Surgery (RP) and radiation therapy (RT) may have side effects that include urinary incontinence and erectile dysfunction because of damage to the bladder and to the local nerves and blood vessels. There is also an increased risk of developing bladder or rectal cancer following RT, sometimes many years later.
Hormonal therapy can cause cognitive dysfunction, hot flashes, osteoporosis, increased risk of cardiovascular disorders, fatigue, and muscle weakness.
Immunotherapy can cause fatigue, cough, nausea, itching, skin rash, decreased appetite, constipation, joint pain (including rheumatoid arthritis), and diarrhea.
Chemotherapy can cause nausea, vomiting, neuropathy, fatigue, and other side effects. With chemotherapy and radiation therapy, damage to do bone marrow may occur, with the development of myelodysplastic syndrome (MDS), aplastic anemia, and leukemia.
Disability Benefits Related to Prostate Cancer
Many men can live a normal life after treatment for prostate cancer and may be cured by RP, RT, or salvage RT. However, in some men, prostate cancer can recur and spread. When it spreads, prostate cancer frequently metastasizes to bone, causing severe bone pain. The pelvic bones and the spine are commonly affected. If treatment with chemotherapy is required, it can have many disabling side effects of its own.
