Treatment for Prostate Cancer

Risk Stratification

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.

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.