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What's New on the Prostate Cancer Front

Issue: October 2009

By: Edward Levin, M.D.

It used to be the cancer no one talked about…even though it’s the most common type of non-skin cancer in men in the United States. Now, it seems everywhere you turn you see something about prostate cancer in the media, and sometimes the messages are mixed.

For instance, prostate cancer screening—through a PSA test and rectal exam—has not officially been noted to decrease the risk of death, even though most large studies now seem to be leaning toward acknowledging that it clearly does. Prostate cancer mortality rates in countries that routinely screen for the disease are decreasing at about 3% a year, and actually increasing in places that haven’t yet adopted an aggressive screening program.

As studies are finalized that document prostate cancer treatment successes, we’ll be able to officially say that screening is a valuable way to catch the disease in an early enough stage so it can be treated and cured. Since prostate cancer has no symptoms, it rests on us as medical professionals to counsel male patients to get screened on an annual basis, usually starting at around age 45. Urologists tend to begin screening before the American Cancer Society-recommended ages of 50 for most men and 45 for those with family history or other risk factors.

Certainly no one cares for the rectal exam, but the momentary discomfort is worthwhile…given that without it, 10% of prostate cancers will be missed, and those that don’t show up in a PSA test are often the most aggressive. Studies are underway to determine the frequency at which screenings should be performed, based on initial PSA test and rectal exam results, general health and other considerations.

Here’s one more sobering thought that should make it more palatable for men to get screened: before the advent of the PSA test 20 years ago, most prostate cancer was diagnosed at the metastatic stage, and the average survival rate after diagnosis was about 18 months. Today, the cancer-specific survival for men who have been diagnosed and treated for organ-confined prostate cancer is, in most cases, the same as those who haven’t had the disease.

Treatment Options

There are pros and cons to all therapy options for treating prostate cancer—radiation therapy (external beam or brachytherapy); surgery (open prostatectomy and laparoscopic robotic removal of the prostate); and the newest technology, cryotherapy (freezing the prostate). Continence is usually preserved in all modalities and, with the exception of cryotherapy, sexual potency is usually maintained as well. Observation protocol—just watching the cancer to see what happens over time—is something I have personal reservations about, since science today doesn’t allow us to precisely predict which cancers will metastasize during the observation period, but it’s an option some elderly men might consider.

Brachytherapy, an outpatient procedure through which radiation seeds are implanted in the prostate, has been getting a lot of attention, but it’s not a new modality. I’ve been working with Dr. Steven Doggett, a radiation oncologist who specializes in prostate cancer, to treat patients very successfully with brachytherapy for almost 10 years at Sutter Fairfield Surgery Center.

Brachytherapy is being used with more frequency to treat prostate cancer for reasons that include the following:

· No incisions, minimal pain and blood loss

· Urinary incontinence rates less than 1% compared to 10% with surgery

· A 6-25% chance of sexual dysfunction following the procedure, compared to 50% with surgery

· Lower rates of bowel irritation compared to external beam radiation

· Convenience—one-time outpatient procedure and patients can go back to work within one week

· Lower cost compared to external beam radiation and surgery

Because of men’s fears about having sexual or voiding problems, we use ultrasound and fluoroscopy during the procedure as well as intra-operative MRI fusion to ensure we spare the urethra, rectum and nerves that facilitate erections. Unfortunately, since Mother Nature put the prostate between the bladder and urethra, the process can be quite delicate.

Earlier this month, research from two independent studies was released that supported brachytherapy as an option for early-stage prostate cancer patients that provides a superior disease-free survival rate. The figures from the studies by the Prostate Cancer Foundation of Chicago and the Taussig Cancer Center at Cleveland Clinic are nearly identical:

· The Chicago study involved low-risk, intermediate and high-risk prostate cancer patients treated over an 11-year period, finding that overall cure rates were 96%, 84% and 75%, respectively. The survival rate of those in the intermediate and high-risk groups who added external beam radiation to their treatment regime had results that far exceeded those who opted for surgery.

· The Cleveland Clinic study found brachytherapy to be superior to surgery in all cases. The five-year survival rates for low-risk, intermediate and high-risk patients were recorded as 95%, 89% and 71%, respectively.

Not all patients will be candidates for brachytherapy, based on their PSA results and pre-operative evaluation. It’s important to not have any preconceived notions about any specific treatment option, because what’s right for one person isn’t necessarily right for another. All prostate cancers aren’t the same, so the recommended treatment will be based on the patient’s fears, concerns, lifestyle and overall medical condition as well as the prediction of the cancer’s aggressiveness.

That being said, I always offer all available therapies to my patients and encourage them to meet with people who specialize in those I don’t do, and I help patients make informed decisions about the treatment option that fits their unique situation. I also try to ensure that people peddling “pie-in-the-sky” solutions that prey on patients’ fears don’t lead them astray. Although that seems to be more and more prevalent, the fact is that most patients, especially those whose cancer is organ-confined, will have good results using standard prostate cancer treatments.

Edward Levin, M.D., is a board-certified urologist with Solano Regional Medical Group and is on staff at Sutter Solano Medical Center. He practices through Sutter Regional Medical Foundation’s offices in Fairfield and Vacaville.

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