Prostate Cancer
The Man, The Gland, The Dilemma
By Melinda Beck : WSJ : March 31, 2009
You've been getting annual blood tests to check for prostate cancer. But two big studies in the New England Journal of Medicine just found that screening for PSA -- prostate specific antigen -- doesn't save many lives. Should you keep checking it?
Your biopsy was negative for prostate cancer but your PSA keeps rising. Should you stop worrying -- or have another biopsy?
You've been diagnosed with early-stage prostate cancer. It's probably harmless, but it could turn lethal. Should you just watch it or treat it aggressively and run the risk of impotence or incontinence?
Prostate cancer poses some of the most vexing questions in medicine, and one out of every six men in the U.S. will confront them at some point in their lives. Today's Health Journal is the first of a two-part series that aims to provide some guidance. This article looks at new diagnostic techniques that may help to resolve some of these quandaries. Next week we'll examine the perplexing array of treatment options and weigh the pros and cons of each.
Should You Be Screened?
For all the uproar they created, the recent NEJM studies settled little in the long-running debate over whether prostate-cancer screening is worthwhile.
PSA testing revolutionized detection of the disease in the late 1980s. Before that, doctors relied on a digital-rectal exam, or DRE, and by the time tumors could be felt, some were fairly large. Now, about 90% of prostate cancers are found at an early and highly curable stage.
But PSA screening can flag tumors almost too early, leading to considerable unnecessary surgery or radiation. Most prostate cancers are so small and slow-growing that they don't need treatment. Of the 185,000 U.S. men diagnosed with the disease each year, an estimated 85% would likely die of something else long before their cancer caused problems.
On the other hand, some prostate cancers are aggressive, each year killing some 28,000 men in the U.S. -- and 288,000 worldwide -- who weren't treated in time. It's the second most deadly cancer in men, after lung cancer.
As of now, it's difficult to tell which patients have which kind of tumors in the early stages. Experts say many more men could safely opt for "watchful waiting" -- monitoring their cancers to see if they grow. But thousands of men each year opt to have their prostates removed surgically or treated with radiation to be on the safe side, and many live with urinary or erectile problems in the bargain.
"Right now we are treating people for anxiety, not cancer," says Faina Shtern, CEO of the AdMeTech Foundation, a nonprofit group that is lobbying Congress to increase federal funding for research into prostate imaging. "We do not know if they will benefit from treatment, but we know they will have complications," Dr. Shtern says.
Weighing all those factors, a U.S. government panel last year recommended that doctors stop screening men age 75 and over for prostate cancer, since the risk of treating it likely outweighed the benefits.
The recent NEJM studies seemed to extend that reasoning to younger men as well. One study of 77,000 North American men showed that regular PSA screening didn't save a significant number of lives over 10 years. A study of 182,000 European men showed a 20% reduction in deaths among those screened regularly. But in that study, 48 men had to be treated for every life saved.
Still, many cancer organizations issued statements defending PSA testing -- in the absence of something better -- and urging men to discuss it with their doctors.
Most doctors believe that men with a family history of prostate cancer should have annual PSA testing, along with African-American men, for whom the death rate from prostate cancer is twice as high as for whites. For others, "you probably don't have to get it tested every year," says Al Barqawi, a urologist at the University of Colorado Health Sciences Center. "If there's a change, then do it more often."
"Blind" Biopsies
A PSA level is cause for concern if it's higher than usual for the man's age or rising rapidly. If so, the next step is usually a biopsy. That's typically done in a urologist's office with an ultrasound probe and a spring-loaded needle gun inserted into the rectum, taking six to 12 samples at random.
The ultrasound can't see well into the prostate, so urologists are effectively sampling blindly. More than 1.2 million American men have such transrectal ultrasound, or TRUS, biopsies each year due to a suspicious PSA level. Less than 15% come back positive for cancer. But TRUS biopsies miss about 20% of cancers, so a negative biopsy isn't completely reassuring.
That's the situation Richard Edelman, president and chief executive of the Edelman public-relations firm, faced in 2007. His PSA had doubled over two years to four nanograms/milliliter, considered elevated for his age of 54. He also had three close relatives with prostate cancer. A standard TRUS biopsy was negative, but a few months later, his PSA had jumped to 7.5 ng/ml.
His doctor suspected a urinary-tract infection, one of several benign conditions that can increase the PSA level, and prescribed an antibiotic. But Mr. Edelman's PSA remained elevated, as did his anxiety.
To get more information, Mr. Edelman enrolled in a clinical trial at the National Cancer Institute, where doctors are hoping to improve tumor detection by scanning prostates with magnetic-resonance imaging. The MRI scans are then used to target biopsies at suspicious-looking areas. Mr. Edelman had a second biopsy, guided by MRI, which found cancer in two of 21 samples. "The value of the MRI was huge," he says.
Imaging of the prostate has lagged far behind imaging for breast cancer in women -- largely because the prostate is deep inside the pelvis and harder to access. "It's medieval and barbaric what we do to men without better imaging," says AdMeTech's Dr. Shtern, who helped advance the use of MRIs for breast cancer at the NCI in the 1990s. She notes that NCI today spends twice as much on research into breast cancer than prostate cancer research, even though prostate cancer is twice as prevalent. Mr. Edelman's firm is helping her group's efforts; as are some equipment manufacturers.
Researchers at NCI and several major medical centers are currently using several kinds of advanced MRIs to scan the prostate for abnormalities that could signal cancer. MRIs with contrast agents can highlight areas of new blood-vessel growth. Other techniques include MR spectroscopy, which looks for telltale chemical changes, and diffusion-weighted MRIs, which measure changes in water flow around cells. Clinical trials are underway to assess whether biopsies guided by such images are better than standard TRUS biopsies at finding cancers.
"None of these tests will absolutely differentiate benign from malignant. They're pointers to areas that should be further biopsied or followed," says Peter Choyke, the NCI's chief of molecular imaging.
MRIs often identify abnormalities that aren't cancerous. They also add $1,000 or more to the cost of a biopsy, which itself runs about $2,000. But Dr. Shtern argues that scanning before performing a biopsy could save money in the long run if it helps to reduce the $2 billion spent annually on standard biopsies that don't find cancer.
"It sounds good, but the burden of proof is on us to show that this makes a difference in detecting cancers," says Peter Pinto, director of the fellowship program at NCI's urologic oncology branch.
Has it Spread?
Once a biopsy confirms cancer, many major medical centers now use MRIs to help determine whether it has spread beyond the prostate and invaded the nearby nerves and blood vessels involved in sexual function and urination. That information can be crucial if a patient is considering surgery, radiation or watchful waiting.
More often, doctors are playing probabilities to determine whether early-stage cancers have spread beyond the prostate. Some use mathematical formulas based on a combination of PSA levels, a DRE and what's known as a Gleason score, a measure of a cancer's aggressiveness based on the pattern of abnormal cells seen on the biopsy.
Health columnist Melinda Beck discusses a new 3-D mapping biopsy procedure used to search for prostate cancer that is being performed at the University of Colorado Health Sciences Center.
And doctors often disagree about what that information signifies. In Mr. Edelman's case, one counseled watchful waiting since his Gleason score was a moderate six. Another doctor suspected Mr. Edelman's cancer had already spread, based on his PSA, and urged radiation and hormone therapy. At Memorial Sloan-Kettering Cancer Center in New York, Mr. Edelman had a second MRI that revealed that his cancer was still confined to the prostate, but was on both sides of the gland and had grown since the first MRI scan.
He opted for a radical prostatectomy last fall -- and he thinks he caught the cancer just in time. "I'm told I have more than a 95% chance of being around for a long time," he says. His last PSA was down to zero.
Doctors who use MRIs caution they aren't always definitive and can't see very small cancers, but even that can be useful. "If I don't see anything on an MRI, it helps reassure me you probably don't have a large, life-threatening cancer." says Peter Scardino, chief of urology at Memorial Sloan-Kettering.
"We are all like the blind men feeling the elephant," Dr. Scardino adds. "I don't rely just on the DRE, the PSA, the biopsy results or the MRI. But if we put all that information together, we can get a pretty good idea of what's going on."
Playing 'Battleship'
Rather than rely on imaging, a small but growing group of urologists prefer to bombard the prostate with more extensive biopsies. A "3D-mapping biopsy" takes 50 or more samples, five millimeters apart, throughout the gland. The needles are inserted through a grid that allows doctors to pinpoint the size, shape and location of any cancers. Practitioners liken it to playing the game Battleship with the prostate. Unlike a standard biopsy done through the rectum, a mapping biopsy is performed through the skin behind the scrotum with the patient under anesthesia.
The cost of a 3D-mapping biopsy is $5,000 to $6,000, due to the extensive pathology needed. They're far too costly and cumbersome for routine screening. But the technique can provide valuable information for making treatment decisions, and is increasingly covered by insurance and Medicare.
In the last three years, Dr. Barqawi at the University of Colorado has performed two hundred 3D-mapping biopsies on patients after they had had TRUS biopsies. Of them, 96 learned that their cancers were more extensive than the first biopsy showed. But 33 patients were reassured that their cancers were small and could just be watched.
Dr. Barqawi says 60 of the patients getting mapping biopsies learned that their tumors were so localized that they opted for new treatments known as targeted focal therapies. With these, doctors are able to destroy just the tumor with cryosurgery or specialized ultrasound and leave the rest of the prostate alone.
"Knowledge is power and that's especially true when managing patients diagnosed with early-stage disease to avoid un-needed surgeries," Dr. Barqawi says.
Molecular Markers
Scientists are also making headway in finding new molecular markers that may be able to signify not just the presence of cancer, but what its lethal potential is.
Researchers at the University of Michigan have identified a molecular waste product of tumors, called sarcosine, that is elevated in the urine of men with advanced prostate cancers. Researchers at Memorial Sloan-Kettering and elsewhere are studying circulating tumor cells -- bits of cancer cells that break off and enter the blood stream -- that may be able to indicate whether cancer has the potential to metastasize.
Some patients have more than one kind of prostate cancer, and scientists are developing PET scans and radioactive dyes that may one day be able to make different kinds of tumors light up like colored Christmas lights -- yellow for benign, red for really lethal.
"We've got potentially game-changing biomarkers that could get us out of the dilemma we are in with PSA," says oncologist Jonathan Simons, president of the Prostate Cancer Foundation, which funds some of that research. With the recent NEJM studies, he says, "We've been reminded again of how much work we need to do."
By Melinda Beck : WSJ : March 31, 2009
You've been getting annual blood tests to check for prostate cancer. But two big studies in the New England Journal of Medicine just found that screening for PSA -- prostate specific antigen -- doesn't save many lives. Should you keep checking it?
Your biopsy was negative for prostate cancer but your PSA keeps rising. Should you stop worrying -- or have another biopsy?
You've been diagnosed with early-stage prostate cancer. It's probably harmless, but it could turn lethal. Should you just watch it or treat it aggressively and run the risk of impotence or incontinence?
Prostate cancer poses some of the most vexing questions in medicine, and one out of every six men in the U.S. will confront them at some point in their lives. Today's Health Journal is the first of a two-part series that aims to provide some guidance. This article looks at new diagnostic techniques that may help to resolve some of these quandaries. Next week we'll examine the perplexing array of treatment options and weigh the pros and cons of each.
Should You Be Screened?
For all the uproar they created, the recent NEJM studies settled little in the long-running debate over whether prostate-cancer screening is worthwhile.
PSA testing revolutionized detection of the disease in the late 1980s. Before that, doctors relied on a digital-rectal exam, or DRE, and by the time tumors could be felt, some were fairly large. Now, about 90% of prostate cancers are found at an early and highly curable stage.
But PSA screening can flag tumors almost too early, leading to considerable unnecessary surgery or radiation. Most prostate cancers are so small and slow-growing that they don't need treatment. Of the 185,000 U.S. men diagnosed with the disease each year, an estimated 85% would likely die of something else long before their cancer caused problems.
On the other hand, some prostate cancers are aggressive, each year killing some 28,000 men in the U.S. -- and 288,000 worldwide -- who weren't treated in time. It's the second most deadly cancer in men, after lung cancer.
As of now, it's difficult to tell which patients have which kind of tumors in the early stages. Experts say many more men could safely opt for "watchful waiting" -- monitoring their cancers to see if they grow. But thousands of men each year opt to have their prostates removed surgically or treated with radiation to be on the safe side, and many live with urinary or erectile problems in the bargain.
"Right now we are treating people for anxiety, not cancer," says Faina Shtern, CEO of the AdMeTech Foundation, a nonprofit group that is lobbying Congress to increase federal funding for research into prostate imaging. "We do not know if they will benefit from treatment, but we know they will have complications," Dr. Shtern says.
Weighing all those factors, a U.S. government panel last year recommended that doctors stop screening men age 75 and over for prostate cancer, since the risk of treating it likely outweighed the benefits.
The recent NEJM studies seemed to extend that reasoning to younger men as well. One study of 77,000 North American men showed that regular PSA screening didn't save a significant number of lives over 10 years. A study of 182,000 European men showed a 20% reduction in deaths among those screened regularly. But in that study, 48 men had to be treated for every life saved.
Still, many cancer organizations issued statements defending PSA testing -- in the absence of something better -- and urging men to discuss it with their doctors.
Most doctors believe that men with a family history of prostate cancer should have annual PSA testing, along with African-American men, for whom the death rate from prostate cancer is twice as high as for whites. For others, "you probably don't have to get it tested every year," says Al Barqawi, a urologist at the University of Colorado Health Sciences Center. "If there's a change, then do it more often."
"Blind" Biopsies
A PSA level is cause for concern if it's higher than usual for the man's age or rising rapidly. If so, the next step is usually a biopsy. That's typically done in a urologist's office with an ultrasound probe and a spring-loaded needle gun inserted into the rectum, taking six to 12 samples at random.
The ultrasound can't see well into the prostate, so urologists are effectively sampling blindly. More than 1.2 million American men have such transrectal ultrasound, or TRUS, biopsies each year due to a suspicious PSA level. Less than 15% come back positive for cancer. But TRUS biopsies miss about 20% of cancers, so a negative biopsy isn't completely reassuring.
That's the situation Richard Edelman, president and chief executive of the Edelman public-relations firm, faced in 2007. His PSA had doubled over two years to four nanograms/milliliter, considered elevated for his age of 54. He also had three close relatives with prostate cancer. A standard TRUS biopsy was negative, but a few months later, his PSA had jumped to 7.5 ng/ml.
His doctor suspected a urinary-tract infection, one of several benign conditions that can increase the PSA level, and prescribed an antibiotic. But Mr. Edelman's PSA remained elevated, as did his anxiety.
To get more information, Mr. Edelman enrolled in a clinical trial at the National Cancer Institute, where doctors are hoping to improve tumor detection by scanning prostates with magnetic-resonance imaging. The MRI scans are then used to target biopsies at suspicious-looking areas. Mr. Edelman had a second biopsy, guided by MRI, which found cancer in two of 21 samples. "The value of the MRI was huge," he says.
Imaging of the prostate has lagged far behind imaging for breast cancer in women -- largely because the prostate is deep inside the pelvis and harder to access. "It's medieval and barbaric what we do to men without better imaging," says AdMeTech's Dr. Shtern, who helped advance the use of MRIs for breast cancer at the NCI in the 1990s. She notes that NCI today spends twice as much on research into breast cancer than prostate cancer research, even though prostate cancer is twice as prevalent. Mr. Edelman's firm is helping her group's efforts; as are some equipment manufacturers.
Researchers at NCI and several major medical centers are currently using several kinds of advanced MRIs to scan the prostate for abnormalities that could signal cancer. MRIs with contrast agents can highlight areas of new blood-vessel growth. Other techniques include MR spectroscopy, which looks for telltale chemical changes, and diffusion-weighted MRIs, which measure changes in water flow around cells. Clinical trials are underway to assess whether biopsies guided by such images are better than standard TRUS biopsies at finding cancers.
"None of these tests will absolutely differentiate benign from malignant. They're pointers to areas that should be further biopsied or followed," says Peter Choyke, the NCI's chief of molecular imaging.
MRIs often identify abnormalities that aren't cancerous. They also add $1,000 or more to the cost of a biopsy, which itself runs about $2,000. But Dr. Shtern argues that scanning before performing a biopsy could save money in the long run if it helps to reduce the $2 billion spent annually on standard biopsies that don't find cancer.
"It sounds good, but the burden of proof is on us to show that this makes a difference in detecting cancers," says Peter Pinto, director of the fellowship program at NCI's urologic oncology branch.
Has it Spread?
Once a biopsy confirms cancer, many major medical centers now use MRIs to help determine whether it has spread beyond the prostate and invaded the nearby nerves and blood vessels involved in sexual function and urination. That information can be crucial if a patient is considering surgery, radiation or watchful waiting.
More often, doctors are playing probabilities to determine whether early-stage cancers have spread beyond the prostate. Some use mathematical formulas based on a combination of PSA levels, a DRE and what's known as a Gleason score, a measure of a cancer's aggressiveness based on the pattern of abnormal cells seen on the biopsy.
Health columnist Melinda Beck discusses a new 3-D mapping biopsy procedure used to search for prostate cancer that is being performed at the University of Colorado Health Sciences Center.
And doctors often disagree about what that information signifies. In Mr. Edelman's case, one counseled watchful waiting since his Gleason score was a moderate six. Another doctor suspected Mr. Edelman's cancer had already spread, based on his PSA, and urged radiation and hormone therapy. At Memorial Sloan-Kettering Cancer Center in New York, Mr. Edelman had a second MRI that revealed that his cancer was still confined to the prostate, but was on both sides of the gland and had grown since the first MRI scan.
He opted for a radical prostatectomy last fall -- and he thinks he caught the cancer just in time. "I'm told I have more than a 95% chance of being around for a long time," he says. His last PSA was down to zero.
Doctors who use MRIs caution they aren't always definitive and can't see very small cancers, but even that can be useful. "If I don't see anything on an MRI, it helps reassure me you probably don't have a large, life-threatening cancer." says Peter Scardino, chief of urology at Memorial Sloan-Kettering.
"We are all like the blind men feeling the elephant," Dr. Scardino adds. "I don't rely just on the DRE, the PSA, the biopsy results or the MRI. But if we put all that information together, we can get a pretty good idea of what's going on."
Playing 'Battleship'
Rather than rely on imaging, a small but growing group of urologists prefer to bombard the prostate with more extensive biopsies. A "3D-mapping biopsy" takes 50 or more samples, five millimeters apart, throughout the gland. The needles are inserted through a grid that allows doctors to pinpoint the size, shape and location of any cancers. Practitioners liken it to playing the game Battleship with the prostate. Unlike a standard biopsy done through the rectum, a mapping biopsy is performed through the skin behind the scrotum with the patient under anesthesia.
The cost of a 3D-mapping biopsy is $5,000 to $6,000, due to the extensive pathology needed. They're far too costly and cumbersome for routine screening. But the technique can provide valuable information for making treatment decisions, and is increasingly covered by insurance and Medicare.
In the last three years, Dr. Barqawi at the University of Colorado has performed two hundred 3D-mapping biopsies on patients after they had had TRUS biopsies. Of them, 96 learned that their cancers were more extensive than the first biopsy showed. But 33 patients were reassured that their cancers were small and could just be watched.
Dr. Barqawi says 60 of the patients getting mapping biopsies learned that their tumors were so localized that they opted for new treatments known as targeted focal therapies. With these, doctors are able to destroy just the tumor with cryosurgery or specialized ultrasound and leave the rest of the prostate alone.
"Knowledge is power and that's especially true when managing patients diagnosed with early-stage disease to avoid un-needed surgeries," Dr. Barqawi says.
Molecular Markers
Scientists are also making headway in finding new molecular markers that may be able to signify not just the presence of cancer, but what its lethal potential is.
Researchers at the University of Michigan have identified a molecular waste product of tumors, called sarcosine, that is elevated in the urine of men with advanced prostate cancers. Researchers at Memorial Sloan-Kettering and elsewhere are studying circulating tumor cells -- bits of cancer cells that break off and enter the blood stream -- that may be able to indicate whether cancer has the potential to metastasize.
Some patients have more than one kind of prostate cancer, and scientists are developing PET scans and radioactive dyes that may one day be able to make different kinds of tumors light up like colored Christmas lights -- yellow for benign, red for really lethal.
"We've got potentially game-changing biomarkers that could get us out of the dilemma we are in with PSA," says oncologist Jonathan Simons, president of the Prostate Cancer Foundation, which funds some of that research. With the recent NEJM studies, he says, "We've been reminded again of how much work we need to do."
Prostate Cancer : Treatment Options
You've been diagnosed with prostate cancer and after the shock comes confusion.
By Melinda Beck : WSJ Article : April 2009
Should you treat it fast with surgery but face an immediate risk of sexual and urinary problems? Or should you opt for weeks of daily radiation treatments and side effects that set in more slowly? Should you also use hormone therapy that may shrink the cancer -- and your sex drive along with it? Or should you just monitor your cancer and hope you'll catch it if it starts to spread out of control?
Today's Health Journal is the second in a two-part series on the many dilemmas that prostate cancer poses. Last week's column looked at imaging and biopsy techniques that can help clarify the diagnosis. This week's column explores the bewildering array of treatment options. A related column -- on living with "watchful waiting" -- will appear in the Journal's Encore supplement on April 18.
Some 185,000 men will be diagnosed with prostate cancer this year in the U.S., and many will get conflicting advice. There's little consensus on how or even whether to treat prostate cancer, which can be slow-growing and harmless or aggressive and lethal.
When the New England Journal of Medicine recently asked readers how they would treat a hypothetical 63-year-old man with a low-grade cancer and a rising PSA (for prostate-specific antigen), the more than 3,720 physicians who responded split almost evenly among surgery, radiation therapy and monitoring the cancer to see if it grew.
With doctors so divided, how can patients know who to believe and what to do?
The first step is to find out as much information you can about your own cancer.
You've been given a Gleason score, based on the pattern of abnormal cells seen in the biopsy. A Gleason 6 or below is considered low-grade. Gleason 7 and above is more worrisome. But traditional biopsies that sample the prostate at random can miss cancers in about 20% of cases, and may miss the most advanced spots. Ask how many biopsy samples were taken -- and whether imaging is available as well. MRI scans or a color Doppler ultrasound, used at some major cancer centers, can provide more information about suspicious areas.
"Don't stop until you have clarity on the location, the extent and the aggressiveness," says Faina Shtern, a former official at the National Cancer Institute, who now heads the AdMeTech Foundation, which is lobbying for more federal funding for imaging research.
It's reassuring to know that with early-stage cancers that are still confined to the prostate, there is a 90% "cure" rate -- which means patients are free of cancer for at least five years -- no matter which treatment they choose. And many prostate cancers are so slow-growing they may not require treatment at all.
But every man's cancer is different, as is his general health, family history, life situation and mindset. Make sure you understand your own priorities. Some men want the cancer out as fast as possible; others want to avoid surgery at all costs. Some want the best chance for a long-term cure; some care as much or more about avoiding incontinence or erectile dysfunction.
Here's a look at the options:
Surgery
Men diagnosed with prostate cancer in their 40s and 50s are often steered toward surgery (called a radical prostatectomy), since it's thought to offer the best chance for long-term survival. What's more, removing the prostate and examining it in a lab is the only way to know for sure how much cancer was there and how likely it is to return.
Prostate Cancer: Weighing the options
"I present the choice very simply: either you are damaging the prostate or removing it," says Randy Fagin, who performs robot-assisted surgeries in Austin, Texas. "If you damage it and leave it there, what if the cancer comes back? If you have surgery, it's gone."
Surgeries using the daVinci Robotic System now account for over 50% of prostatectomies. The surgeon sits at a console about six feet from the patient and, while watching on a video screen, manipulates miniature, flexible tools that perform the surgery through small incisions. It's minimally invasive, which reduces pain, recovery time and blood loss. Most patients go home the next day. (See related video)
"If you have a well-trained robotic surgeon, there's absolutely no reason to filet patients open and go through all the mess we used to have," says David Samadi, chief of robotic and minimally invasive surgery at Mount Sinai Medical Center in New York City who has performed over 1,800 robotic prostatectomies.
Doctors who practice traditional "open" surgeries say there are no reliable studies showing that robotic surgery has higher cure rates or fewer side effects than conventional surgery.
Both camps agree that having a highly experienced surgeon is far more important than the method he or she uses. How can patients find one? Jan Manarite, a counselor of the Prostate Cancer Research Institute, a nonprofit patient education group, suggests joining a local support group and asking for recommendations. "Some surgeons will also give you a list of their patients to talk to -- that's a sign of honesty and transparency," she says.
Removing the prostate does carry a high risk of side effects, since many delicate nerves and blood vessels involved in urination and ejaculation run through the gland. Depending on where and how big the cancer is, surgeons may be able to use "nerve-sparing" procedures that preserve much of those functions. Most men need a urinary catheter for a week or two after surgery. Some need to wear absorbent pads for a few weeks, but most are fully continent within a year.
Sexual function after surgery depends largely on the age of the patient, his potency before surgery and the skill of the surgeon. "Whatever you start out with, even in the hands of an artist, you will probably come away with a little bit less," Ms. Manarite says.
Radiation
Men over 70, those with other health problems or those whose cancer has spread beyond the prostate are usually counseled to have radiation. External-beam radiation therapy, or EBRT, requires no incisions, no hospitalization and no anesthesia. But it can be inconvenient: Patients generally undergo 40 or more treatments over six to eight weeks. High-energy beams damage the ability of cancer cells to replicate. The entire prostate slowly withers as well.
Radiation has fewer immediate side effects than surgery, but urinary discomfort and loss of sexual potency often set in gradually.
The goal of all EBRT is to maximize the radiation hitting the prostate and minimize its impact on surrounding tissue. The field took a big leap in recent years with intensity-modulated radiation therapy, which allows doctors to sculpt the radiation beam to fit the contours of the individual patient's prostate.
One variation, TomoTherapy, takes a new CT scan at the start of each treatment and adjusts the beam accordingly. CyberKnife condenses the standard number of radiation sessions from 40 down to just a handful, at higher doses, so treatment is often completed in a single week. (See related video)
Traditional radiation oncologists argue that there is no evidence to prove that such innovations offer better outcomes.
The lack of evidence has been a particular issue for proton-beam therapy, which fires super-accelerated atomic particles, rather than X-rays, at prostate and other cancers. Proponents say proton-beam therapy causes fewer side effects because protons can be made to peak at the target area and then stop, minimizing collateral damage on the way out of the body.
But proton accelerators cost $125 million to $225 million each and are the size of two football fields. There are currently only five in the U.S., with several others in the works. The therapy costs patients -- in most cases, Medicare -- about four times what traditional radiation costs. Critics say there is no conclusive evidence that the added cost is justified.
In another form of radiation called bracytherapy, doctors insert 70 to 80 tiny radioactive pellets into the prostate that gradually dissolve and destroy cancer cells internally. Many patients like the convenience: It requires just one minimally invasive procedure that lasts about an hour.
One downside is that patients are advised to avoid prolonged contact with pregnant women and children to minimize a slight risk of radiation exposure to them. In high-dose bracytherapy, a radioactive source is placed in the prostate only temporarily, with no risk to others. Studies have shown that bracytherapy carries a higher risk of urinary problems than other therapies.
'Male Lumpectomy'
About 20% of prostate cancer patients have very small localized tumors. One new option for them is focal ablation, in which doctors destroy the individual tumor while leaving the rest of the gland intact, much like a lumpectomy for breast cancer.
Of several ablation techniques, cryotherapy has been in use the longest. Doctors insert metal prongs into the prostate to surround the tumor and freeze it with liquid nitrogen. In a study presented last month at the Society for Interventional Radiology, Gary M. Onik, director of the Center for Safer Prostate Cancer Therapy in Orlando, Fla., reported that of 120 men who had focal cryoablation over 12 years, 93% of men had no evidence of cancer recurrence, and 85% retained sexual function. (See related video)
Another focal technique used in Europe, Canada and Mexico is high-frequency ultrasound, or HIFU, which involves heating localized prostate tumors rather than freezing them.
A key to focal therapy is knowing the precise size, shape and location of tumors. It's frequently used with three-dimensional mapping biopsies that can supply that data after taking 50 or more samples.
Critics argue that prostate tumors that are small and localized enough for focal therapy could be safely watched instead. Dr. Onik says that's just the point: Focal cryosurgery offers a middle ground between watchful waiting and more aggressive therapies. "Let's ablate the cancers we know about, and then do watchful waiting," he says. Meanwhile, the minimally invasive procedure can be repeated if the cancers recur.
Watchful Waiting
At least 50% of men diagnosed with prostate cancer in the U.S. have a low-grade form of the disease that experts say doesn't need immediate treatment and may never. But less than 10% opt to put treatment off and just monitor their cancer. That's in part because it can be psychologically difficult to live with untreated cancer, and in part because the medical system is geared toward active treatment.
"Some patients tell me that their doctors never mentioned this as an option," says oncologist Jeri Kim, the principal investigator of a watchful waiting trial at M.D. Anderson's Multidisciplinary Prostate Cancer Clinic in Houston. It's one of a few academic centers where patients consult doctors from all the rival disciplines to arrive at the best option.
The big risk with watchful waiting is that a cancer will spread from a highly curable early stage to a more advanced stage, growing outside the prostate, that is far more difficult to treat. Some tumors that have been stable for years can suddenly start to spread.
That's why Dr. Kim and others stress that patients and doctors alike need to do active monitoring, with PSA tests every three to six months, digital rectal exams annually, and repeat biopsies if the PSA starts to rise. "You can't have a patient who will disappear on you. If the guy moves to Florida and five or six years from now his PSA hits 90, then it's over," Dr. Samadi says.
A handful of doctors in the U.S. -- and many more in Europe -- use color Doppler ultrasound imaging to monitor prostate cancer patients. Real-time ultrasound imaging can be done painlessly in a doctor's office. Areas of increased blood flow that signify cancer show up in color. "The ultrasound differentiates not just cancer, but which cancers are lethal," says Robert L. Bard, a radiologist in New York City, who has been monitoring about 3,000 prostate-cancer patients.
Other doctors who use Doppler ultrasound caution that nothing is 100% accurate -- but it can provide more reassurance for patients monitoring their cancer. A biopsy targeted at suspicious areas can help verify whether a tumor is changing.
Diet and Exercise
Besides being conscientious about followup exams, patients can help their own cause by maintaining a healthy diet and lifestyle. "Active surveillance also means you are going to change your life and do things that can slow the cancer down," says Charles Myers, former chief of clinical pharmacology at the National Cancer Institute and a prostate-cancer survivor himself who now treats patients in Charlottesville, Va.
Dr. Myers says it's critical to maintain an adequate level of vitamin D, which can help keep cancers in check. Many older people are deficient. Studies have also shown that a Mediterranean diet -- with plenty of fish, olive oil and vegetables -- can slow cancer growth, along with vitamin E, selenium, lycopene, omega 3 fatty acids and green tea polyphenol, as well as avoiding animal fat.
Getting exercise and minimizing stress can go a long way as well. Stress hormones epinephrine and norepinephrine help prostate-cancer cells grow and impair the immune system.
"I'm proud of what I'm doing," says Ronald Zaza, who was diagnosed with prostate cancer in 1996, six weeks after having quadruple bypass surgery. He has since abandoned meat and chicken for vegetables and tofu, started running marathons and is monitoring his cancer once a year with a color Doppler ultrasound. So far, it's not showing any suspicious areas, and Mr. Zaza says, "I'm 71 and just ran a marathon. I feel like I'm 35."
Late-Stage Cancer
Not all prostate-cancer patients can control their cancer with diet and exercise. For those whose cancer has metastasized, a variety of hormone therapies that block testosterone can often stop the progression very successfully, at least for a while. The downside is a high risk of osteoporosis, hot flashes, depression, breast enlargement, diabetes, obesity and high blood pressure. Using hormone therapy intermittently can help reduce such side effects.
A number of new drug therapies are under investigation -- including drugs that block the androgen receptors on cancer cells. Results of a clinical trial on Avodart, a medication for enlarged prostates, as a treatment to slow cancer growth, are expected this spring. Doctors and patients also have high hopes for Provenge, which could offer the first immunotherapy agent approved to fight cancers.
In the past, chemotherapy drugs have not been as successful against prostate cancers as other cancers. But Taxotere is showing promise, particularly when combined with other drugs that fight blood-vessel growth in tumors.
Patients with advanced prostate cancer often find that medications can be effective in a variety of combinations, and when one stops working, it may be effective again in a few months. "Somewhere between cure and death is a middle road where you are keeping a cancer suppressed or under control," says Ms. Manarite, whose husband, Dominic, has had metastatic prostate cancer for nine years.
Some experts also urge men with prostate cancer -- at any stage -- to join clinical trials if possible. "That's how we made all the progress in breast and colon cancer," says Jonathan Simons, president of the Prostate Cancer Foundation, which funds clinical research. "We have some very important ideas to test that might lengthen your life."
You've been diagnosed with prostate cancer and after the shock comes confusion.
By Melinda Beck : WSJ Article : April 2009
Should you treat it fast with surgery but face an immediate risk of sexual and urinary problems? Or should you opt for weeks of daily radiation treatments and side effects that set in more slowly? Should you also use hormone therapy that may shrink the cancer -- and your sex drive along with it? Or should you just monitor your cancer and hope you'll catch it if it starts to spread out of control?
Today's Health Journal is the second in a two-part series on the many dilemmas that prostate cancer poses. Last week's column looked at imaging and biopsy techniques that can help clarify the diagnosis. This week's column explores the bewildering array of treatment options. A related column -- on living with "watchful waiting" -- will appear in the Journal's Encore supplement on April 18.
Some 185,000 men will be diagnosed with prostate cancer this year in the U.S., and many will get conflicting advice. There's little consensus on how or even whether to treat prostate cancer, which can be slow-growing and harmless or aggressive and lethal.
When the New England Journal of Medicine recently asked readers how they would treat a hypothetical 63-year-old man with a low-grade cancer and a rising PSA (for prostate-specific antigen), the more than 3,720 physicians who responded split almost evenly among surgery, radiation therapy and monitoring the cancer to see if it grew.
With doctors so divided, how can patients know who to believe and what to do?
The first step is to find out as much information you can about your own cancer.
You've been given a Gleason score, based on the pattern of abnormal cells seen in the biopsy. A Gleason 6 or below is considered low-grade. Gleason 7 and above is more worrisome. But traditional biopsies that sample the prostate at random can miss cancers in about 20% of cases, and may miss the most advanced spots. Ask how many biopsy samples were taken -- and whether imaging is available as well. MRI scans or a color Doppler ultrasound, used at some major cancer centers, can provide more information about suspicious areas.
"Don't stop until you have clarity on the location, the extent and the aggressiveness," says Faina Shtern, a former official at the National Cancer Institute, who now heads the AdMeTech Foundation, which is lobbying for more federal funding for imaging research.
It's reassuring to know that with early-stage cancers that are still confined to the prostate, there is a 90% "cure" rate -- which means patients are free of cancer for at least five years -- no matter which treatment they choose. And many prostate cancers are so slow-growing they may not require treatment at all.
But every man's cancer is different, as is his general health, family history, life situation and mindset. Make sure you understand your own priorities. Some men want the cancer out as fast as possible; others want to avoid surgery at all costs. Some want the best chance for a long-term cure; some care as much or more about avoiding incontinence or erectile dysfunction.
Here's a look at the options:
Surgery
Men diagnosed with prostate cancer in their 40s and 50s are often steered toward surgery (called a radical prostatectomy), since it's thought to offer the best chance for long-term survival. What's more, removing the prostate and examining it in a lab is the only way to know for sure how much cancer was there and how likely it is to return.
Prostate Cancer: Weighing the options
"I present the choice very simply: either you are damaging the prostate or removing it," says Randy Fagin, who performs robot-assisted surgeries in Austin, Texas. "If you damage it and leave it there, what if the cancer comes back? If you have surgery, it's gone."
Surgeries using the daVinci Robotic System now account for over 50% of prostatectomies. The surgeon sits at a console about six feet from the patient and, while watching on a video screen, manipulates miniature, flexible tools that perform the surgery through small incisions. It's minimally invasive, which reduces pain, recovery time and blood loss. Most patients go home the next day. (See related video)
"If you have a well-trained robotic surgeon, there's absolutely no reason to filet patients open and go through all the mess we used to have," says David Samadi, chief of robotic and minimally invasive surgery at Mount Sinai Medical Center in New York City who has performed over 1,800 robotic prostatectomies.
Doctors who practice traditional "open" surgeries say there are no reliable studies showing that robotic surgery has higher cure rates or fewer side effects than conventional surgery.
Both camps agree that having a highly experienced surgeon is far more important than the method he or she uses. How can patients find one? Jan Manarite, a counselor of the Prostate Cancer Research Institute, a nonprofit patient education group, suggests joining a local support group and asking for recommendations. "Some surgeons will also give you a list of their patients to talk to -- that's a sign of honesty and transparency," she says.
Removing the prostate does carry a high risk of side effects, since many delicate nerves and blood vessels involved in urination and ejaculation run through the gland. Depending on where and how big the cancer is, surgeons may be able to use "nerve-sparing" procedures that preserve much of those functions. Most men need a urinary catheter for a week or two after surgery. Some need to wear absorbent pads for a few weeks, but most are fully continent within a year.
Sexual function after surgery depends largely on the age of the patient, his potency before surgery and the skill of the surgeon. "Whatever you start out with, even in the hands of an artist, you will probably come away with a little bit less," Ms. Manarite says.
Radiation
Men over 70, those with other health problems or those whose cancer has spread beyond the prostate are usually counseled to have radiation. External-beam radiation therapy, or EBRT, requires no incisions, no hospitalization and no anesthesia. But it can be inconvenient: Patients generally undergo 40 or more treatments over six to eight weeks. High-energy beams damage the ability of cancer cells to replicate. The entire prostate slowly withers as well.
Radiation has fewer immediate side effects than surgery, but urinary discomfort and loss of sexual potency often set in gradually.
The goal of all EBRT is to maximize the radiation hitting the prostate and minimize its impact on surrounding tissue. The field took a big leap in recent years with intensity-modulated radiation therapy, which allows doctors to sculpt the radiation beam to fit the contours of the individual patient's prostate.
One variation, TomoTherapy, takes a new CT scan at the start of each treatment and adjusts the beam accordingly. CyberKnife condenses the standard number of radiation sessions from 40 down to just a handful, at higher doses, so treatment is often completed in a single week. (See related video)
Traditional radiation oncologists argue that there is no evidence to prove that such innovations offer better outcomes.
The lack of evidence has been a particular issue for proton-beam therapy, which fires super-accelerated atomic particles, rather than X-rays, at prostate and other cancers. Proponents say proton-beam therapy causes fewer side effects because protons can be made to peak at the target area and then stop, minimizing collateral damage on the way out of the body.
But proton accelerators cost $125 million to $225 million each and are the size of two football fields. There are currently only five in the U.S., with several others in the works. The therapy costs patients -- in most cases, Medicare -- about four times what traditional radiation costs. Critics say there is no conclusive evidence that the added cost is justified.
In another form of radiation called bracytherapy, doctors insert 70 to 80 tiny radioactive pellets into the prostate that gradually dissolve and destroy cancer cells internally. Many patients like the convenience: It requires just one minimally invasive procedure that lasts about an hour.
One downside is that patients are advised to avoid prolonged contact with pregnant women and children to minimize a slight risk of radiation exposure to them. In high-dose bracytherapy, a radioactive source is placed in the prostate only temporarily, with no risk to others. Studies have shown that bracytherapy carries a higher risk of urinary problems than other therapies.
'Male Lumpectomy'
About 20% of prostate cancer patients have very small localized tumors. One new option for them is focal ablation, in which doctors destroy the individual tumor while leaving the rest of the gland intact, much like a lumpectomy for breast cancer.
Of several ablation techniques, cryotherapy has been in use the longest. Doctors insert metal prongs into the prostate to surround the tumor and freeze it with liquid nitrogen. In a study presented last month at the Society for Interventional Radiology, Gary M. Onik, director of the Center for Safer Prostate Cancer Therapy in Orlando, Fla., reported that of 120 men who had focal cryoablation over 12 years, 93% of men had no evidence of cancer recurrence, and 85% retained sexual function. (See related video)
Another focal technique used in Europe, Canada and Mexico is high-frequency ultrasound, or HIFU, which involves heating localized prostate tumors rather than freezing them.
A key to focal therapy is knowing the precise size, shape and location of tumors. It's frequently used with three-dimensional mapping biopsies that can supply that data after taking 50 or more samples.
Critics argue that prostate tumors that are small and localized enough for focal therapy could be safely watched instead. Dr. Onik says that's just the point: Focal cryosurgery offers a middle ground between watchful waiting and more aggressive therapies. "Let's ablate the cancers we know about, and then do watchful waiting," he says. Meanwhile, the minimally invasive procedure can be repeated if the cancers recur.
Watchful Waiting
At least 50% of men diagnosed with prostate cancer in the U.S. have a low-grade form of the disease that experts say doesn't need immediate treatment and may never. But less than 10% opt to put treatment off and just monitor their cancer. That's in part because it can be psychologically difficult to live with untreated cancer, and in part because the medical system is geared toward active treatment.
"Some patients tell me that their doctors never mentioned this as an option," says oncologist Jeri Kim, the principal investigator of a watchful waiting trial at M.D. Anderson's Multidisciplinary Prostate Cancer Clinic in Houston. It's one of a few academic centers where patients consult doctors from all the rival disciplines to arrive at the best option.
The big risk with watchful waiting is that a cancer will spread from a highly curable early stage to a more advanced stage, growing outside the prostate, that is far more difficult to treat. Some tumors that have been stable for years can suddenly start to spread.
That's why Dr. Kim and others stress that patients and doctors alike need to do active monitoring, with PSA tests every three to six months, digital rectal exams annually, and repeat biopsies if the PSA starts to rise. "You can't have a patient who will disappear on you. If the guy moves to Florida and five or six years from now his PSA hits 90, then it's over," Dr. Samadi says.
A handful of doctors in the U.S. -- and many more in Europe -- use color Doppler ultrasound imaging to monitor prostate cancer patients. Real-time ultrasound imaging can be done painlessly in a doctor's office. Areas of increased blood flow that signify cancer show up in color. "The ultrasound differentiates not just cancer, but which cancers are lethal," says Robert L. Bard, a radiologist in New York City, who has been monitoring about 3,000 prostate-cancer patients.
Other doctors who use Doppler ultrasound caution that nothing is 100% accurate -- but it can provide more reassurance for patients monitoring their cancer. A biopsy targeted at suspicious areas can help verify whether a tumor is changing.
Diet and Exercise
Besides being conscientious about followup exams, patients can help their own cause by maintaining a healthy diet and lifestyle. "Active surveillance also means you are going to change your life and do things that can slow the cancer down," says Charles Myers, former chief of clinical pharmacology at the National Cancer Institute and a prostate-cancer survivor himself who now treats patients in Charlottesville, Va.
Dr. Myers says it's critical to maintain an adequate level of vitamin D, which can help keep cancers in check. Many older people are deficient. Studies have also shown that a Mediterranean diet -- with plenty of fish, olive oil and vegetables -- can slow cancer growth, along with vitamin E, selenium, lycopene, omega 3 fatty acids and green tea polyphenol, as well as avoiding animal fat.
Getting exercise and minimizing stress can go a long way as well. Stress hormones epinephrine and norepinephrine help prostate-cancer cells grow and impair the immune system.
"I'm proud of what I'm doing," says Ronald Zaza, who was diagnosed with prostate cancer in 1996, six weeks after having quadruple bypass surgery. He has since abandoned meat and chicken for vegetables and tofu, started running marathons and is monitoring his cancer once a year with a color Doppler ultrasound. So far, it's not showing any suspicious areas, and Mr. Zaza says, "I'm 71 and just ran a marathon. I feel like I'm 35."
Late-Stage Cancer
Not all prostate-cancer patients can control their cancer with diet and exercise. For those whose cancer has metastasized, a variety of hormone therapies that block testosterone can often stop the progression very successfully, at least for a while. The downside is a high risk of osteoporosis, hot flashes, depression, breast enlargement, diabetes, obesity and high blood pressure. Using hormone therapy intermittently can help reduce such side effects.
A number of new drug therapies are under investigation -- including drugs that block the androgen receptors on cancer cells. Results of a clinical trial on Avodart, a medication for enlarged prostates, as a treatment to slow cancer growth, are expected this spring. Doctors and patients also have high hopes for Provenge, which could offer the first immunotherapy agent approved to fight cancers.
In the past, chemotherapy drugs have not been as successful against prostate cancers as other cancers. But Taxotere is showing promise, particularly when combined with other drugs that fight blood-vessel growth in tumors.
Patients with advanced prostate cancer often find that medications can be effective in a variety of combinations, and when one stops working, it may be effective again in a few months. "Somewhere between cure and death is a middle road where you are keeping a cancer suppressed or under control," says Ms. Manarite, whose husband, Dominic, has had metastatic prostate cancer for nine years.
Some experts also urge men with prostate cancer -- at any stage -- to join clinical trials if possible. "That's how we made all the progress in breast and colon cancer," says Jonathan Simons, president of the Prostate Cancer Foundation, which funds clinical research. "We have some very important ideas to test that might lengthen your life."
