Prostate cancer is a unique medical problem, and a difficult one for the lay person to fully understand. It is the most commonly diagnosed non-skin cancer. Although, prostate cancer is something to be treated seriously, many prostate cancers grow quite slowly, and spread or metastasize very late in its course. The difficulty lies in determining which prostate cancers are likely to be deadly and thus must be treated aggressively and which can be dealt with more conservatively. Below is an attempt to explain this, and how we begin to help our patients try to understand this complex disease.
Cancer is an uncontrolled growth of cells in an organ or in the blood. When enough of these cells are present, this is called a tumor. Unlike cells in a benign tumor, malignant cells have the ability to spread throughout the body. This is called metastasis, and it is usually this metastasis that can be deadly. The challenge with all cancers is to catch them early before they have spread. If treated at that stage, they are really not much different than benign tumors. The way we look for prostate cancer early is with the PSA test and the rectal exam. If either of these is abnormal, we perform a prostate biopsy whereby small pieces of prostate tissue are collected and a doctor called a Pathologist determines microscopically if cancer is present.
If cancer is present, a Pathologist will grade the cancer. Currently, we use the team at George Washington, with all of our biopsies reviewed by several Pathologists who all must agree on the diagnosis and grade. With prostate cancer, this grading is called a Gleason grade or score. Gleason score is the most important determinant with prostate cancer that predicts survival, prognosis, the likelihood of being cured, the likelihood of "getting it all" with surgery, and the urgency of treatment or even if treatment is necessary at all. Patients diagnosed with prostate cancer must know their score, and what that score means. Patients do not need to know how the score is derived. The Gleason score ranges from 2-10, but today cancer is usually only seen within scores 5-10. The scores can be grouped as 5-6, 7 (3+4 as one group, and 4+3 as another), and 8-10. Thus, this system can really be simplified as being groups 1,2,3 or 4. This is how most other cancers are graded. Patients in group 1, or score 5 and 6, do not progress to death from prostate cancer over 50% of the time over 20 years of life. All scores above this will almost uniformly progress if given enough time. We also will look at how much cancer was found on the biopsy to get an idea of whether the cancer is growing and therefore likely to progress with time.
For patients in group 1 or score 5 or 6, it is reasonable to just "watch and wait" and not treat the cancer. This is particularly true for patients with less than a fifteen year life expectancy or with little cancer found on the biopsy. In such patients who do have a 15 year life expectancy, watchful waiting must be performed by performing period repeat biopsies with treatment performed if the cancer seems to be growing. Watchful waiting for higher Gleason scores is generally reserved for patients with a short life expectancy or where treatment would be exceedingly risky.
We also use the PSA level as a factor to determine whether a patient has been caught early. Here again, groups can be formed. Patients in the first group are those with PSA <10, then PSA <20, then >20. The risk of spread goes up with the PSA level, and thus the cure rate is lower as the PSA rises. Rectal exam is also used here, with the preferable situation being a normal rectal exam.
If watchful waiting is not appropriate, the patient must first determine what type of treatment is appropriate. The standard treatments for prostate cancer are surgery and radiation. Cryotherapy is emerging as a possible new frontier, but its lack of long term data and high rates of impotence at this point cause it not to be our first choice for early prostate cancer. We do advocate its use in the setting of radiation failure or in the setting of low-volume, low Gleason score cancer in a patient with pre-existing erectile function such as the diabetic patient. We believe that at this point focal cryotherapy should not be used as a first line treatment for organ confined prostate cancer. Radiation generally comes in two forms – implanted radioactive seeds and external beam radiotherapy. We at USW, perform many seed implantations, and send many patients for external beam radiotherapy. We feel that the literature has shown that generally seeds are inferior to surgery in curing prostate cancer for all Gleason scores higher than six, as well in patients with a lot of Gleason 6 cancer found on their biopsy. These days, radiation therapists seem to have hope that newer generation external beam machines (IMRT, etc.) carry with them higher cure rates, but long term data is lacking. Therefore, patients with higher Gleason scores are generally offered seeds and external beam therapy, or external beam alone, with the addition of hormonal therapy for at least six months. The side effects of radiation are generally those related to radiation to normal tissue such as the bladder and rectum. Radiation therapy, particularly combination therapy, causes at least if not more impotence than well performed robotic prostatectomy in the long term. Radiation causes far less incontinence, but this is countered by far more problems with irritative voiding symptoms and urgent defecation and rectal bleeding. Very rare complications include fistula formation. We will very commonly send patients to our radiation oncology consultants to discuss radiation further.
At USW, we primarily offer robotically assisted laparoscopic radical prostatectomy. Dr. Engel on rare occasions, does offer open radical retropubic prostatectomy. Dr. Engel feels as if he can perform radical prostatectomy with a far higher level of reproducibility and exactness than with the open approach. This leads to a far more meticulous preservation of the erectile nerves and a far more delicate and watertight reconstruction of the bladder and urethra. In our high volume center at GW, our data seems to be showing that this exactness and reproducibility is lowering rates of total incontinence, shortening the time to continence, halfing the time in the hospital, halfing the time with the catheter, and leading to near full recovery within two weeks. As well, the transfusion rate in our series is less than 1%.
If you have been diagnosed recently with prostate cancer, Drs. Engel, or Losee (bracytherapy) would be happy to have a consultation with you in our office. We perform over 400 such visits per year. We would be happy to try to help you understand your problem more completely and offer the highest quality, world class care possible. When coming for your consultation, please bring all pathology, radiology, and lab reports with you. As well, we encourage you to bring you spouse, family or significant other as usually these people are also integral to your education and decision process.