Cancer of the prostate — a small, walnut-sized gland that helps to produce semen in the male reproductive system — is the second leading cause of cancer death among men, and the American Cancer Society estimates that more than 186,000 new cases will be diagnosed in 2008. Nevertheless, there is controversy about who should be screened and treated. The prevalent recommendation is a PSA blood test and digital rectal screening for every man over 50. But a growing number of opponents argue that general widespread screening — especially for men over 70 — leads to unnecessary biopsies and treatments of cancers that would not cause harm if left alone.
[sidebar]If your PSA is abnormal for your age (a PSA of 4 would be fine for a 75-year-old but not for a man of 40),what typically follows is a biopsy to determine the aggressiveness of the tumor. A positive diagnosis only leads to further questions: Should you undertake watchful waiting or definitive treatment? To sort out the confusion, you might find it helpful to consult with a medical oncologist who specializes in prostate cancer. Our suggestions are from Dr. Gary Hudy at Fox Chase and Dr. Naomi Haas at Penn.
Here are some of the options you’ll be discussing:
Surgery: The choices for nerve-sparing radical prostectomy to remove the prostate are either standard open surgery or robotic surgery. Dr. Alan Wein, chief of urology at Penn, prefers the classic approach. “Otherwise,” he says, “the surgeon can’t change what he’s doing based on feel because there is no feel.” His other objection is that data on robotics is only four to six years old: “We won’t know the full efficacy until the data is eight to ten years old.”
Nevertheless, the trend is heavily toward robotics because it cuts the hospital stay in half (two days to one), there is less blood loss, and the smaller incision hastens recovery time by two and a half weeks. Presbyterian urologic surgeon Dr. David Lee particularly likes that his field of vision is magnified 10 times and he can see the prostate on his monitor in 3D. A note of caution comes from Cooper Hospital urologist Dr. Raul Parra, who does six to eight robotic surgeries weekly: “Experience is crucial. There is a learning curve of a least 150 to 200 procedures, and a solid grounding in open surgery is a prerequisite on the rare chance the robot fails.”
Radiation therapy: Rather than remove the prostate gland, radiation aims to eradicate only the cancerous areas in a series of daily treatments over several weeks. “Radiation equals the best nerve-sparing surgery for encapsulated tumors,” says Dr. Eric Horwitz, acting chairman of radiation oncology at Fox Chase, “but it’s better for bigger cancers that have broken through the skin of the gland.” There are several new procedures designed to do this. They include:
Intensity Modulated Radiation Therapy (IMRT): This option uses computerized 3D images of the patient’s prostate and surrounding organs to control and direct the x-ray beam. Because of the precision, higher doses of radiation can be used with less risk of side effects. Fox Chase was the first in the area to have this machine, and in 2007 they got the latest model, called the Calypso Beam. Dr. Horowitz calls this “a GPS for the prostate. It tracks real-time movement during radiation to assure the exactness of the beam.”
Proton Beam Therapy: Penn will be one of the few places in the country to offer this when its machine arrives in early 2009. This very new concept bombards the tumor with protons instead of x-rays.
Brachytherapy: Better known as radioactive seed implants (pictured above), this places rice-size seeds into the prostate, where they emit radiation to the tumor over a period of about 10 months until they lose their power. The technique has been around for a long time, but improved ultrasound imaging technology assures more accurate seed placement. It’s most effective for early stage cancer.
HIFU: Jefferson is currently participating in a clinical trial to examine this minimally invasive way to treat early-stage prostate cancer. A probe shoots an intense ultrasound beam to the prostate to destroy the cancer. “Normally this is a one-time ‘Star Wars’ treatment, but it can be repeated,” says Jefferson urologist Dr. Leonard Gomella, who thinks this technology is very promising. While it’s considered experimental in the U.S., it’s popular in Europe and Canada.