Prostate cancer is a unique but common medical problem, and a very difficult one for the lay person to fully comprehend. The greatest challenge to the patient first diving into the topic, especially on the internet, is what Dr. Jason Engel calls the great paradox. On the one hand, prostate cancer is now often presented as always slow growing, not particularly dangerous or harmful, and that eventually every man gets prostate cancer. On the other hand, the fact remains that prostate cancer can be as aggressive and deadly as any other cancer, as it is the number two cause of cancer mortality in men in the United States today. So which one is true?
The answer is that both are true in a sense. The treatment of prostate cancer and PSA screening in general has come under fire recently. Data from the US Preventative Task Force, released over five years ago but only more recently presented to the lay press, suggested that PSA screening in America was more harmful than good, even to the degree that guidelines for screening were changed and some primary care physicians stopped PSA screening altogether. This was a dangerous message, and only part of the story. For the first 20 years of widespread PSA screening, PSA was used as a true screening test, one where if a man’s PSA was above a certain level (4 ng/dl) a man underwent a biopsy. This lent itself to extreme over-testing, and extreme over-treatment in America. It is estimated that almost half of all cancers treated in the 1990’s through 2005 or so were very minimal and low grade. These cancers would now be deemed insignificant and perhaps not treated at all. PSA testing was finding cancer, but not cancer that really always needed to be treated. Thus, PSA was in some ways actually hurtful to American society more than helpful.
Most Urologists now do not use PSA as a single point screening test. PSA is now properly used as a trend test, especially with the doctors at USW. If used this way, PSA moves from perhaps the worst performing screening test in contemporary medicine to possibly the best of all screening tests available today.
The part that was not told to the lay press however is that most Urologists now do not use PSA as a single point screening test. PSA is now properly used as a trend test, especially with the doctors at USW. If used this way, PSA moves from perhaps the worst performing screening test in contemporary medicine to possibly the best of all screening tests available today. The most commonly used philosophy employed now is one where the goal of screening for prostate cancer is to find only aggressive cases, the ones responsible for the deaths in America. We call these significant cancers. Thus the old adage that all men will eventually get prostate cancer may be true if one includes low grade cancers that are not harmful as well as cancer grades that are now not even called cancer. We don’t look for those anymore. So, the first step in understanding prostate cancer is to first understand these points about PSA screening, which leads to the concept of significant versus insignificant prostate cancer.
In fact, to try to avoid finding insignificant prostate cancer, Dr. Engel generally will not offer a biopsy until at least two, or perhaps even three successive rises of the PSA are seen in a patient. These days, there is much interest in non-invasive tests such as 3-D Ultrasound, MRI and others to see if these technologies can be sensitive and specific enough to supplant an actual biopsy to look for prostate cancer. Dr. Engel has not found these tests to be particularly helpful in his practice yet, and feels that the philosophy of demanding successive rises of the PSA before biopsy is far more specific for finding aggressive cancers and excluding insignificant ones. In the same light, Dr. Engel is generally not an advocate for MRI targeted biopsies, as he feels that if such precision is required to find a cancer, the likelihood is so high that this will lead to finding insignificant cancers that he does not do them.
What is (Prostate) Cancer?
After understanding first whether a biopsy is indicated by these standards, it is important for a patient to then understand what cancer is in general. 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 which also grow in an uncontrolled manner, malignant (cancer) cells have the ability to spread throughout the body. This process is called metastasis, and it is metastasis that can lead to death and thus should be seen as the real enemy. The challenge with all cancers is to catch them early before they have spread which is of course what PSA seeks to do. If treated at that early stage, cancers are really not much different than benign tumors. The term prostate cancer refers to this process starting in this organ. Patients will often see the term adenocarcinoma on their biopsy report. This just refers to the cell type that transformed into prostate cancer. In the case of prostate cancer, well over 95% of cases are this cell type.
Patients must then understand the details of their own prostate cancer. These include parameters such as how much cancer was present on their biopsy (number of needles), the percentage of each needle or core that contains cancer, the PSA pattern and velocity of rise (much more important than just the latest PSA), and the highest grade of cancer seen on the biopsy report (Gleason grade). One thing to note regarding PSA is that patients found before their PSA gets to 10 ng/dl are considered to have been caught early, with a far lower risk of metastasis. In terms of Gleason score, Dr. Engel tries to explain this as really four grades, just like most other cancers have. The lowest grade is a 6(3+3). All Gleason grades lower than this are no longer called cancer. There are two grades of seven, 3+4 and 4+3, in order of aggressiveness, and finally Gleason scores 8-10, the most aggressive. All of these factors must be combined and not used in isolation to be able to assign risk stratification. Dr. Engel often uses the term no risk, low risk, moderate risk and high risk.
No Risk & Low Risk Prostate Cancer
In Dr. Engel’s vernacular, no risk and low risk patients usually are within the Gleason score 6 group, and are either older patients, or are patients where no suspicious PSA rise has been seen and/or little cancer was found on the biopsy. Active surveillance can often be done for these patients. It is important to understand that active surveillance is recognition that the parameters do not provide enough convincing evidence that one’s prostate cancer is significant, so more data is needed before opting for treatment. In Dr. Engel’s hands, that data comes in the form of regular PSA testing and rectal exams, and at least one more biopsy usually done six months from the first biopsy. More biopsies are done if the PSA continues to rise. As said above, Dr. Engel does not generally find MRI to be useful here, but does sometimes order them in certain circumstances or if the patient is more comfortable with one.
For patients where there is enough evidence to know that one’s prostate cancer will progress, treatment of some sort is indicated. This is where the hard part can start for some patients. There are options, and in some case too many options for the patient to sort out. There is marketing, and it is often hard for a patient to discern between education and marketing. There are very few head to head studies to choose a clear winner. Below are some general ideas and concepts. Here we have tried to make each treatment option available to be further reviewed by clicking on that option, so please do so to do learn more.
In general, one will not find unanimous consensus, even within each risk stratification, but there are some general rules. All patients are looking for the option with the highest cure rate and fewest side effects, and there are some circumstances where as of today there seems to be a clear winner, at least to Dr. Engel. Realize that what you see here therefore largely represent his opinions and not fact. Also, there simply is no substitute to consulting with an expert like Dr. Engel, Dr. Losee or another experienced Urologist or Radiation Oncologist to determine ones individual risk stratification and to determine what treatment is right for you.
High Risk Prostate Cancer
For high risk patients, Dr. Engel feels strongly that the treatment that most approximates the ideal of highest cure rate and fewest side effects is surgery.
For high risk patients, Dr. Engel feels strongly that the treatment that most approximates the ideal of highest cure rate and fewest side effects is surgery. A high dose radiation regimen is an alternative. This consists of a lengthy course of external beam radiation plus other modalities such as six months to two years of hormone therapy or a second radiation modality such as Cyber Knife or brachytherapy (seed implantation). But, few studies have shown radiation to offer the cure rate that surgery does. Hormone therapy masks whether a patient is cured or not, and arguably a combination regimen has more overall impact on one’s life than does surgery. Dr. Engel has published an often quoted study on the success of robotic surgery alone in the high risk setting (see Bibliography in his profile), and it is this research that cemented the strong leaning that he has towards surgery for these patients. Patients are encouraged to seek a radiation opinion, but usually choose robotic prostatectomy in these high risk situations.
Moderate Risk Prostate Cancer
For patients with moderate risk prostate cancer, and some low risk patients that are just above the threshold where active surveillance makes sense, there is often no “right answer”. Every patient learns differently, and some things resonate more than others. Dr. Engel calls the process of becoming comfortable with a particular treatment the “journey” of prostate cancer. What is done at USW is to encourage this process, and hopefully allow the patient on his own, with some counseling, to develop a gut leaning towards or away from certain treatments. This feeling is what should be followed in most cases, as long as it is not based on misunderstandings which are usually corrected during our office consultations.
Radiation Therapy for Prostate Cancer
Radiation therapy can be a good choice as long as one understands the side effects of radiation, both short term and long term, and the lack of closure that sometimes occurs with it. Cyber Knife radiation is a particularly appealing choice at first glance, but Dr. Engel reserves recommending this only to older patients, those with co-morbidities and those with low risk cancer due to its lack of long term cure rate data. As Cyber Knife and other modalities such as proton therapy are hyper-focused, side effects are lower. However, there is every expectation that long term data will show cure rates in higher Gleason scores also to be lower as the rectum and bladder must not be treated at all which disallows treatment all the way to the edges of the prostate at times.
Brachytherapy for Prostate Cancer
Brachytherapy, or prostate “seeding”, is declining in popularity but is still performed, particularly by Dr. Losee. This also is reserved at USW generally to less aggressive prostate cancer as long term cure rates for higher Gleason Scores is unimpressive. Dr. Engel finds the side effect profile to be acceptable for seeds, but less so than Cyber Knife, which has largely replaced brachytherapy in his practice.
Cryotherapy for Prostate Cancer
Dr. Engel performs cryotherapy for prostate cancer, and in some cases feels it is the perfect fit. Such patients might include an older patient with significant prostate cancer, a patient not a good candidate for radiation due to urinary difficulties, or one whose pathology report and parameters don’t seem to warrant highly aggressive management.
Dr. Engel performs cryotherapy in a surgery center setting as an outpatient, with little pain, and urinary obstruction from benign enlargement usually improves over a few months’ time. The cure rate is similar to radiation, but probably not as good as surgery. But, unlike radiation, cryotherapy can be repeated years later if cancer does recur. Dr. Engel makes sure all of his patients review this option, as well as surgery and radiation, when learning about prostate cancer and its treatments.
Surgical Treatment for Prostate Cancer
But the mainstay of treatment, and the one most often performed by Dr. Engel, is surgery. Although he has performed hundreds of open surgeries in the form of nerve sparing radical retropubic prostatectomy (RRP), still performed regularly by Dr. Losee, he now exclusively performs robotic prostatectomy and has now performed over 1500 such surgeries. He is considered a pioneer in the field of robotic surgery and was the first to perform such cases in the mid-Atlantic region through his development of the robotic surgery program at George Washington.
As a pioneer in the field since 2004, Dr. Engel was on the front lines of proving that robotic prostatectomy offered great advantages with practically no drawbacks to the previous approach, RRP. Although fading rapidly in popularity, RRP can still at times be presented to patients as an equivalent or even superior alternative to robotic prostatectomy. When patients are faced with this confusion, Dr. Engel will usually offer an explanation of the history of prostatectomy in general. There are different ways of performing prostatectomy. They represent a progression of technology over time, not equal alternatives as can sometimes be told to patients.
Originally, and before the development of ultrasound, Urologists only approached the prostate through the skin below the scrotum, called the perineum. Biopsies and surgeries were done this way. Thus, the original approach to prostatectomy was called a perineal prostatectomy. This approach is very rarely performed today, and has little utility as the exposure is limited, and most argue not at all ideal for sparing erectile nerves. A big leap forward came from the description of the erectile nerves, located between the rectum and prostate. Surgeries were then performed in the more invasive approach, RRP, with the idea that the tradeoff between invasiveness through an open lower abdominal incision and the potential of sparing these nerves was justified. This became the predominant approach for nearly 20 years despite very significant drawbacks. With the RRP, the surgeon is deep in the pelvis, using very long instruments, not able to fit his/her hands into the pelvis. It is a very bloody operation, and sometimes not gratifying to the surgeon as visualization can be very limited, and often much of the operation is done bluntly, with traction using a blind finger to dissect.
The technological leap that brought laparoscopy back to the forefront was the invention of robotic instruments for laparoscopy via a system called da Vinci. Here, the laparoscopic instruments now rotated like human wrists, offering all of the functions of a human hand in a very small instrument.
This left an opening for Urologists to be receptive to an approach that would be less bloody, more reproducible and less invasive. The first step forward was laparoscopic prostatectomy, popularized in Europe and a few centers in the United States. Whereas this did provide good visualization, was less bloody and was less invasive, the limitations of using standard laparoscopic instruments in many ways outweighed the benefits, and no real overall advantage was seen. Dr. Engel performed several of these successfully, but abandoned them and went back to the RRP. The technological leap that brought laparoscopy back to the forefront was the invention of robotic instruments for laparoscopy via a system called da Vinci. Here, the laparoscopic instruments now rotated like human wrists, offering all of the functions of a human hand in a very small instrument. Now, a surgeon could utilize all of the advantages of laparoscopy (tiny incisions, less blood loss, great visualization, shorter recovery) and not only not be disadvantaged by the instruments, but rather perform the operation much better than one could do with their actual hands which are too large to fully utilize in this operation.
When Dr. Engel first began performing robotic prostatectomy in 2004, 5% of prostatectomies were done this way. Now, well over 90% are done this way.
A far more detailed discussion of robotic prostatectomy can be found on the robotic surgery section of this site. When Dr. Engel first began performing robotic prostatectomy in 2004, 5% of prostatectomies were done this way. Now, well over 90% are done this way. Still, one may choose to have an RRP for certain reasons, and Dr. Engel supports this. Some patients will simply be more confident in an institution in general where RRP is performed, and this peace of mind outweighs the benefits offered by robotic surgery. Some patients value their relationship with their own Urologist who happens to perform RRP. This would be another excellent reason to choose RRP. But the fact remains that by now, it has been shown that in equivalently experienced hands, the robotic approach provides strikingly faster recovery, less blood loss, earlier continence, and often fewer complications than the open approach. It is not magic, and experience with either approach will always trump technology. Robotic surgery does not avoid the fact that all patients will go through a period of incontinence and all patients will struggle with their erections afterward. Dr. Engel feels strongly that robotic surgery will shave a few percentage points off of these side effects and will minimize them, but makes sure patients have proper expectations.
If you have been diagnosed recently with prostate cancer, Dr. Engel (robotic prostatectomy, cryotherapy) or Dr. Losee (brachytherapy or RRP) would be happy to have a consultation with you in our office. We will make sure we review your case with you, make sure you understand the problem first thoroughly, and will then go over all treatment options before zeroing in on the right one for you. When coming for your consultation, please bring all pathology, radiology, and lab reports with you. As well, we encourage you to bring your spouse, family or significant other as usually these people are also integral to your education and decision process.