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Report to the Nation on Prostate Cancer: A Guide for Men and Their Families  Being diagnosed with prostate cancer can be a life-altering experience. It requires making some very difficult decisions about treatments that can affect not only the life of the man diagnosed, but also the lives of his family members in significant ways for many years to come.
More than 218,000 men in the United States will be diagnosed with prostate cancer this year, and each and every one of them will need to make very personal and individualized decisions about treatment options and diet and lifestyle changes. But most importantly, each and every one of them will have to find a strong, knowledgeable team of physicians, nurses and other healthcare providers to help guide him through the process at each step of the way.
This book is about 100 pages, half dedicated to treating early prostate cancer and the other half discussing treatment of hormonal therapy and late stages of prostate cancer. It has a downloadable version of the book or you can request a free copy through the website of the prostate cancer foundation.
Prostate Cancer: Surgery Best Option?
Men who choose surgery for early prostate cancer are more likely to be alive 10 years later than men who opt for other treatments, a Swiss study shows.
"If you look not only at this study but at the studies we brought out in the last three or four years, in terms of survival for 10 or even 15 years, there is a distinct advantage in patients who underwent surgery for localized prostate cancer," Tewari tells WebMD. "This has implications for patients comparing different treatment options."
UroToday - Outcomes of Cryotherapy for Prostate Cancer
 The mean follow-up was 20 months. A total of 4% of patients who were continent pre-procedure were incontinent after therapy. A total of 39% of patients reported being potent pre-treatment and all men were impotent immediately after cryotherapy. The probability for a man potent prior to treatment to regain his ability to have intercourse with or without PDE-5 inhibitor assistance at 1, 2, and 4 years was 29%, 49%, and 51%, respectively. Nearly 80% of men achieved a PSA nadir of less than 0.4ng/mlwith a 4-year biochemical freedom from disease rate of 80%. In those experiencing disease failures, the mean time to failure was 4.2 months. Of 168 patients who underwent a prostate biopsy, 10% had CaP at a mean of 10 months after treatment.
Continue reading "Results of a large cryosurgery trial" »
UroToday - EAU 2007 - Minimally Invasive and Other Treatment Strategies in Localized Prostate Cancer
The authors conclude that this treatment modality is appropriate for patients with localized CaP who are not candidates for surgery. The oncological outcomes appear inferior to rates reported for radiotherapy and surgery.
2 abstracts were summarized from the EAU's meeting: The HIFU one showed relatievly safe results, but cancer cures that were less than radiation or surgery. This is the first generation device they were using and I expect the results to improve.
I think HIFU will be FDA approved in the US in the next 2-3 years.
The cryosurgical study was for radiation failures and gave the following results and side effects:
The 5-year biochemical recurrence free survival was 73% for low-risk patient, 45% for intermediate-risk men and 11% for high-risk patients. The reported complications included incontinence (13%), erectile dysfunction (86%), LUTS (16%), prolonged perineal pain (4%), urinary retention (2%) and rectovesical fistula (1%).
My prostate cancer counseling sheet. This is meant to give an idea of
the major forms of prostate cancer therapy and are the main one I focus on at a
consultation for newly diagnosed prostate cancer. This should only be used
under the supervision of a urologist.
A printable form can be
found online.
This was my first venture into google documents and my original experience was extremely positive. My counselling sheet changes periodically based on new treatments or side effects that I want to add. This will be extremely easy to edit without the need for an editor on the computer and can be done anywhere. I will likely place most of my instruction sheets on google documents. It also makes an easy to print out document for patients and has an internal PDF creator built into the online google editor.
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Age |
Gleason |
Amount of cancer
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Size of Prostate (urinary
symptoms) |
PSA |
Bone Scan |
CT Scan: |
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Overview: Reviewed options of
watchful waiting, radiation (brachytherapy, external beam, combination
brachytherapy and external beam), cryotherapy, hormonal therapy and
surgery.
Watchful waiting.
Usually inadvisable in an otherwise healthy man with a greater than 10
year life expectancy. Prostate cancer that is found early and has a low
Gleason (2-6) may grow slowly and may be monitored rather than treated.
Advantages- No
side effects from therapy.
Disadvantages-
Cancer eventually may spread and be incurable.
Hormonal therapy.
Prostate cells need testosterone to maintain themselves. Removing a man’s
testosterone may slow down the growth of prostate cancer cells. Usually
inappropriate for long term therapy of localized disease. There is
evidence that the cancer can spread even during long term hormonal
therapy. Hormonal therapy is not curative. Hormonal therapy may be
given prior to radiation.
Disadvantages-
Hot flashes, osteoporosis, etc.
Radiation: High energy
x-rays are used to kill cancer cells.
Brachytherapy.
Procedure: Performed as
outpatient, under anesthesia. Places radioactive seeds into the prostate
to burnout the cancer from within.
Concerns: Seeds may migrate
during placement leading to over or under treatment of certain areas of
the prostate (and cancer). Therefore, as a sole modality, may be less
effective than external beam or combination radiation therapy.
Side effects: Radiation
cystitis and proctitis (probably will be worse than other forms of
radiation); erectile dysfunction (may be less so than external beam or
combination radiation therapy).
Advantages:
Short duration of therapy. Few side effects up front if the prostate is
small.
Disadvantages:
Least effective treatment,. Side effects can occur even years after
therapy and may be underappreciated by some radiation oncologists.
Bladder outlet obstruction can occur and be difficult to treat,
especially if the prostate is enlarges.
MAY NEED OTHER
FORMS OF THERAPY TO SHRINK THE PROSTATE.
External Beam:
Procedure: Cast is made of
the body. Radiation is applied to the prostate through many ports,
5d/week for 7-8 weeks. Each session lasts about 20 minutes.
Side effects: Radiation
cystitis, proctitis, and erectile dysfunction.
Advantages-
Cure rates similar to surgery at 10-15 years with hormones added
Disadvantages-
Daily therapy for 2 months causes a systemic effect. Side effects can
happen later. Radiation effect in long term is unknown- new study shows
a 70% higher rate of rectal cancer after XRT.
Combination External
Beam and Brachytherapy
Combination of above, but
external beam will only last about 5 weeks. Same Side effect profile and
cure rate as external beam alone.
Surgery:
Procedure involves removal of
the entire prostate and seminal vesicles. The goal of this procedure is
to completely remove the cancer while it is contained within the
prostate. Surgery is typically about 3 hours long, and is considered
major surgery. Average blood loss is 2 units, but may be higher.
Patients are usually asked to bank blood for themselves prior to surgery
(“autologous blood”). Average hospital stay is about 3 days. A catheter
remains in the bladder for about 1-2 weeks. Back to work is usually no
sooner than 1 month after surgery.
Small risks of injury to
rectum or ureters, blood vessels, nerves.
Side effects: Incontinence,
usually lasting a few months. Erectile dysfunction.
Advantages: We
can more accurately predict your prognosis. Best long term cure rates.
Least amount of bladder outlet obstruction.
Disadvantages:
Major surgery with blood loss and recovery.
Robotic Prostatectomy:
The Robotic Radical
Prostatectomy represents a quantum leap forward in prostate cancer
surgery. The da Vinci Surgical System enables urologic surgeons to
perform a radical prostatectomy with similar, or improved technique when
compared to the standard open
procedure, while maintaining all the advantages of minimally invasive
surgery.
The robot controls tiny
jointed instruments, which can move at the tip like the human hand.
Unlike conventional laparoscopy and its two dimensional image, the da
Vinci camera has two lenses that combine to provide the surgeon a true
3-D image with 10x magnification. Also, any position or movement of the
surgeon’s hands is enhanced with scaling and tremor reduction and is
mirrored in real time.
Advantages of the
minimally invasive procedure may include reduced pain, scarring, risk of
infection, and less operative blood loss. Additionally, these
benefits have translated into shorter hospital stays, faster
recovery times, and a quicker return to employment and recreational
activities.
The robotic radical
prostatectomy can be performed with minimal blood loss and patients are
no longer advised to donate blood for their operation. Patients
typically go home after one night and can return to work within one to
two weeks. The urinary catheter remains in place for approximately six
days and continence is achieved more quickly and completely than with
the other surgical techniques. Erectile function is regained more
quickly and with greater frequency.
Advantages:
Best therapy available with least amount of side effects overall in
experienced hands.
Disadvantages:
Blood loss is still possible, as are other side effects of surgery.
Surgery can be longer than open for inexperienced surgeons.
Requires a
general anesthetic.
Learning curve
is longer than open surgery.
Cryosurgery: Involves
the use of liquid nitrogen to freeze and destroy cancer cells. Its main
use currently is for the control of local disease if primary therapy is
unsuccessful. Long term results using current technology are still not
known.
HIFU:
Similar to cryosurgery except
we are heating up the prostate with a focused ultrasound probe instead of
icing the prostate.
Advantages:
Probably least amount of side effects overall.
Disadvantages: It
is currently experimental in the US and available in Canada and Europe.
The worst cure
rates at the current time. |
When I first saw this patient, there was a note in
the chart from the front desk saying "patient does not read". I asked if
this was a deliberate decision from the patient, or whether they had meant
to say that the patient was illiterate and could not read.
Unfortunately, the latter is true. The patient is a retired janitor who is
somewhat "developmentally delayed" (I think that's the current correct
term), and has never been able to learn to read. He has no family and is
functional enough that he does not have a guardian or someone with power
of attorney.
This poses a difficult situation because I diagnosed him with prostate
cancer after doing a biopsy, and tried to explain to him all the options
available for treatment. Prostate cancer is a disease where there are
several treatments choices available (surgery - open or laparoscopic-,
external beam radiation, brachytherapy, cryotherapy, observation etc...),
and the urologist and the patient arrive to a decision together after much
discussion.
Well, there wasn't much of a discussion with this patient because he did
not truly understand all risks and benefits involved with each option. I
did send him to see the radiation oncologist who agreed with me that the
patient has limited comprehension about the options.
The patient is quite pleasant. He will follow all the instructions we give
him, and our staff has been working extra hard to call and remind him of
all his medical appointments (X-ray, labs, office visits etc...). But this
is a tricky situation. The patient obviously needs treatment, and I am in
the awkward position of deciding for him what the next step should be. |
This was an interesting dilemma a colleague of mine faces as she write son
her blog.
My response
This is a great post and will add it to my blog to see what my readers think.
I have to preface my answer with the disclosure that I am a urologist who does
4-6 robotic prostatectomies per week.
I always recommend a second opinion and often have patients ask me to decide for
them.
I had one patient who I biopsied who was very similar to yours, but fortunately
did not have cancer.
My suggestion to you would be to choose for him what you would do for your dad
if it was him.
If you think incontinence would be too much, then radiation has a major
advantage. If you feel that anesthesia is best to be avoided, then external beam
would be the way to go.
If he is young and needs surgery in your opinion, I would recommend that.
The society frowns upon paternalistic physicians (and probably rightfully so),
but this is a good example of paternalism working well.
Good luck.
I received a phone call yesterday from a young man that was newly diagnosed with prostate cancer from the southeast.
He was interested in robotic surgery and had several questions.
He told me he found a local urologist who performs robotic surgery and asked me what kind of questions he could ask. He was turned off by his primary urologist who he felt, was not interested in speaking about robotics.
Among the questions he asked me was "Can I ask the robotic surgeon how many of these operations he has done?"
That got me to thinking about what are proper questions to ask and what are proper things a physician should do?
The specifics of my thoughts will be for prostate cancer, but the generalities can be diagnosed for many cancer, surgical, and other medial problems.
I personally perform about 6-10 consultations per week for newly diagnosed urologic cancer (mostly prostate, but also bladder and kidney, and less often adrenal and testis.)
What I usually tell patients is that they should feel free to ask anything. They can also interrupt me if they need to without worry while I am speaking.
I think the number of a certain procedure that someone performs is fair. I think how old they are is also fair. Board certification, how long they have been in private practice, and any question is OK to ask.
I recommend patients come in with their families and to take notes. Several patients have had recorders, which I personally do not like very much, but do let patients record our consultation if they choose.
I am open to discussing any therapy for their ailment. For example, for my newly diagnosed prostate cancer patients, we discuss watchful waiting, hormonal therapy, surgery (concentrating on open and robotic (touch on laparoscopic non-robotic); radiation (XRT, seeds, combination, and now cyberknife as a local hospital is advertising it); cryosurgery and HIFU (which is currently not approved by the FDA in the US).
I have had one experience I did not appreciate. I was helping my partner with a patient of his who had a few questions for me. The patient stood up and stepped into my personal space (about 6 inches from my face) and asked me a direct question while staring at me. He explained later he wanted to look into my eyes to see if he believed my answer, regarding whether I could perform his complicated surgery. I did answer questions for about 5 minutes after that.
Other than that, I do not recall being bothered by any question, and if I feel it is irrelevant, may choose not to answer a question, but am not insulted by it.
I also do not have a problem referring patients to different institutions or for different therapies than I can not provide. Our group has not performed an open prostatectomy in over 2 years, so if someone wants an open operation, I refer them to a few excellent open surgeons in our area.
My goal is to make the patient and his family feel as comfortable as possible and choose the therapy or surgeon that they feel most comfortable with. That being said I do, as most physicians do, recommend the therapy that I do best: robotic surgery for prostate cancer. I provide a secure email and ask patients to call or email me if they have any followup questions.
I also suggest second opinions as I believe it helps a patient have more than one opinion on their problem. I often give out the name of a radiation oncologist who I trust, but sometimes a medical oncologist if that would be beneficial.
I also give out the names of 2 robotic surgeons that I would go to if someone in my family had prostate cancer if asked.
I give patients the option of speaking to 2 patients of mine that are similar to them in age and preoperative medical condition. This allows them to speak to someone who had what I expect to be a similar experience. Having a 73 year old man speak to a 53 year old man will not help very much, but he should speak to someone who is in his 70s.
I would welcome input from other physicians and patients about their feelings on this topic, as I am sure my views are not the only views.
Key Highlights:
3,159 men studied
15 years long-term follow-up data
Primary data end point - Death, not PSA Recurrence
Weighted & Adjusted Outcomes in all Cohorts
Patients Treated with Radical Prostatectomy or Radiotherapy shown to live longer than patients in the Watchful Waiting Category
Overall Survival Rate is in favor of Radical Prostatectomy vs. Radiotherapy vs. Watchful Waiting (65%, 50%, 35% respectfully)
** The increased survival duration was 8.6 years for Radical Prostatectomy vs. 4.6 years for Radiotherapy (An 87% difference in favor of Radical Prostatectomy)
Continue reading "Article comparing surgery v. radiation v. watchful waiting" »
Robotic Prostate Surgery - What Men Need To Know
I came across this article on the web and can answer this for my practice:
"If you are considering robotic prostate surgery over traditional open surgery, you should make the following questions part of your doctor-screening process:
* How long have you been performing prostate surgery in general?"
I have been in private practice since July of 2003 and trained at Indiana University for urology for 6 years. The bulk of my prostate surgery started in 1999 as a urology resident.
"* How long have you been using the da Vinci robot?"
My first operation with the 4-arm standard was in December of 2004 and with the daVinci S, March of 2006.
"* How many of these surgeries do you perform each year?"
I performed 60 robotic prostatectomies in 2005 (80 total robotic operations) and should perform about 140 in 2006 (175 total operations). I keep a monthly update on this blog.
"* What is your overall success rate with robotic surgery?"
I keep statistics on my personal website, roboticcancer.com
"* Are there any unique considerations to robotic surgery as compared to open surgery?"
There are a few, but the only real negative once you have learned and understand the technology well is the loss of feedback. This is counteracted by a 10 times magnification of the anatomy at about 2-3 inches away as opposed to in open surgery, where we can magnify the anatomy 2.5 times with loupes at about a foot away. I believe this gives a picture that is about 20 times better for robotic than open.
Fortunately I have developed techniques that has allowed robotic surgery even in patients with previous surgeries, very large prostate up to 200 grams so far, and in obese patients (up to a BMI of 43 so far).
An important paper was recently published in JAMA that concluded that men between 65 and 80 may do better with surgery or radiation than with watchful waiting.
The authors did a good job with this observational study. They looked at all men with prostate cancer and compared those who had treatment with radiation or surgery and compared them to men who did not receive therapy for at least 6 months after diagnosis.
They found that there was a 30% lower mortality in the men that had therapy. The authors made an effort to compare the men with regard to other medical conditions and pointed out that without a randomized trial, there may be a selection bias since most urologists counsel men with good 10 year life expectancies to undergo therapy and men with poor life expectancies to have watchful waiting.
This is one study that I can use to help guide patients, but not an absolute decision maker in my opinion.
I reviewed my patients to see how many men I did robotic prostatectomies on. Over my first 200 robotic prostatectomies I operated on 19 men that were 70 or older:
5 were 70
11 were 71-74
1 was 76,78, and 80
I typically counsel them based on their health, the aggressiveness of their cancer and tell these men they will likely be equally cured with surgery or radiation.
12 of the 19 went home in 1 day, 6 in 2 days, and 1 in 3 days. The only medical problem I had was one patient who was re-hospitalized with a pulmonary embolus (blood clot in lung) a few days after going home and did well on blood thinners.
I do feel that these men often have significant BPH symptoms that is greatly helped by surgery. They do seem to have more incontinence in the short run, but they have done well. 9 of the prostates were big (larger than 50 grams), 5 were very big (greater than 75 gms), and 1 was huge (123 grams).
As for continence, 8 of the 15 that I have data on had 1 pad or less incontinence at 1 month, and 8 of 11 had 1 pad or less incontinence at 3 months, and 7 of 7 were in 1 pad or less at 6 months.
UroToday - Prostate Cancer Surgery Outcomes: Surgeon Dependent Factors
"Subgroup analysis showed superior recurrence free survival for patients treated by surgeons with greater than 1,000 operations compared to less than 50 operations. After 250 surgeries, the curves plateau."
This was a presentation by one of the worlds best prostate cancer surgeons, Dr. Peter Scardino.
Pertinent findings were that surgeon volume was a factor in outcomes, as was surgeon technique.
The number of cases that we do can not be changed, but technique can be improved. With robotics I think the learning curve can be somewhat quickened by reviewing surgeries on video. Ive found it helpful to review DVDs of robotic surgeries from such experts as Dr. Patel and Dr. Ahlering and review my own DVDs on cases that were difficult.
I also think it is important for surgeons to keep a database to see how they are doing and if anything can be fixed. In my robotic series, the outcomes have improved for the first 75 or so, but have been fairly stable since then over the last 100+. I think the most important reasons to have a relatively quick learning curve were my previous open prostate cancer experience of over 100 operations, as well as viewing expert video and my own video.
UroToday - What is the Best Approach for Screen-Detected Low Volume Cancers?
What is the Best Approach for Screen-Detected Low Volume Cancers?
BETHESDA, MD (SUO 7th Annual Meeting - December 1-2, 2006:NIH) - In a session moderated by Dr. Eric Klein, Cleveland Clinic, Dr. Laurence Klotz, University of Toronto presented the "The Case for Observation".
My patients know where I stand on this. I am certainly on the side of Drs. Blute (Mayo Clinic) and Montie (University of Michigan) favoring radical prostatectomy.
A colleague of mine asked on a blog comment:
"Do patients need to make there own decisions or should the urologist guide them to the best decision?"
That's a great question and every urologist, medical oncologist, and radiation doc would have his/her own opinion.
Continue reading "Prostate cancer- How does one decide on therapy?" »
The ultimate deadline Chicago Tribune: "The ultimate deadline
Faced with conflicting medical advice, newsman Robert Jordan took the road less traveled to treat his prostate cancer
By Robert Jordan
Special to the Tribune
Published June 18, 2006"
This story was given to me by a patient. Mr. Jordan has done excellent research and has hit on the important points that are overlooked by many patients and not stressed by all physicians.
1- Second opinions are a good thing. There are many opinions in choosing the best form of treatment for prostate cancer and a second opinion can help get multiple views.
2- In his decision making about choosing radiation, he writes: "Doctors there use tomotherapy, which targets radiation on the cancerous area. Patients can continue a nearly normal lifestyle during the course of the therapy, which is painless and non-invasive. It leaves most patients continent and potent, but subsequent scarring from the radiation, sometimes two to three years later, can cause problems in both those areas."
You are trading in short term side effects for long term effects with radiation.
3- He understands the importance of cautery free surgery: "I read up on the da Vinci procedure in medical journals and discovered papers discussing the advantages of not using cautery-a technique that stops blood vessels from bleeding with an electrical arc, which immediately coagulates the blood. Zapping a blood vessel so near a nerve couldn't be good for the nerve, I thought, so I looked for da Vinci surgeons who did not cauterize."
Even bipolar devices that do not spread electricity, will spread heat and I try to limit any cautery near the nerves including the prostate pedicles.
I think this article hits on most of the important points in choosing therapy for prostate cancer and is a must read for newly diagnosed patients.
UroToday - European Urology - Watching the Face of Janus- Active Surveillance as a Strategy to Reduce Overtreatment for Localised Prostate Cancer
A good abstract by Swedish urologists that addresses many of the issues for watchful waiting.
It points out that the best candidates have a small amount of gleason 6 cancer. Most men did well for several years with this option.
These people should have repeat biopsies at intervals and may have a negative psychological impact from choosing this therapy.
I always discuss watchful waiting as a possible therapy with newly diagnosed cancer.
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Medical care can be a gamble--and patients often don't understand the
odds. University of California researchers aim to change that, with an
interactive Web-based tool that they are calling the roulette wheel. This
color-coded visual model uses a computer algorithm to help patients and
their doctors assess the possible outcomes of different treatments. |
Source:
Time.com
Original paper:
The Roulette Wheel: An Aid to Informed Decision Making
I like this as a way to counsel prostate cancer patients. I think number percentages are hard to comprehend as most patients think the less likely things are unlikely to happen.
Seeing a wheel for possible outcomes may be a little easier to comprehend. For example, plug in my data for erection rates at 6 months and show them these are the possibilities.
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