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This won't be as sexy of an article as the one on erectile dysfunction, and it won't be as funny as the one on vasectomies, but it's probably more important than either one. Today I want to talk about the diagnosis and treatment of prostate cancer. I wrote a previous article on the importance of seeing your physician and undergoing regular PSA (Prostate-Specific Antigen) blood tests and prostate exams. This is very critical for men as they age so we can detect prostate cancer as early as possible. Prostate cancer is highly treatable and even highly curable when caught early, but it can also spread beyond the prostate if it is not found and treated.
I hope to provide you a general overview here, but please understand that recommendations vary based on many, many factors and are constantly changing. Urologists spend their entire careers learning to make this complex decision well, and a complete summary of all the pros and cons would require a scope far broader than this article can hope to address. With that said, let’s delve into some common questions related to the dreaded C-word.
Diagnosis and Biopsy
I hope you have been following my advice by scheduling your regular PSA and prostate exam testing, and hopefully, it's always come out normal. However, if your PSA has been elevated, or your exam has shown a nodule, there will be some decisions to make. Usually, the next step involves a biopsy of the prostate. We may discuss getting an MRI prior to your biopsy, which is an increasingly utilized approach. It allows us to target the biopsy better. If you had an MRI prior to your biopsy, we may perform a special type of biopsy called an MRI fusion biopsy. Overall, biopsy day will be a day you’ll want to forget, but you'll be just fine.
The biggest risk of any prostate biopsy is a serious infection and so you will be given strong antibiotics. This is a very important point: there is virtually no risk of erection problems or urinary problems after a prostate biopsy. This point is often misunderstood on the internet and indeed, is often misunderstood by some physicians.
Once the biopsy is complete, you will meet with your urologist to discuss the results. Obviously, we all hope the results are benign (non-cancerous) but, for ~ 175,000 American men each year, the results will show prostate cancer. The information you need to consider next, and the decisions you will face, are complex.
Types of Prostate Cancer
If cancer is found, there are two major questions to consider: (1) how aggressive is your form of prostate cancer, and (2) how much cancer was found. Nearly all prostate cancer is the same type, called adenocarcinoma, which arises from the glands of the prostate. But the aggressiveness of prostate cancer varies dramatically. Prostate cancer is graded according to a scale called Gleason Score, which I'll be the first to admit, is a strange scoring system. Gleason 6 prostate cancer is the least aggressive. Gleason 7 prostate cancer is medium aggressive. Gleason 8, 9, or 10 are all considered highly aggressive. The more aggressive your cancer is, the more likely it is to spread and to do so quickly.
You and your urologist will also consider how much cancer was found. You will discuss how many of the biopsies had cancer in them. Usually, ~ 12-16 biopsies are taken. The more positive biopsies—called "cores"—the more cancer you have. This is especially true if the cores are positive on both the left and the right side of the prostate. This suggests that you have cancer on both sides. Another factor to consider is the percentage of each individual core that is positive. Again, the higher the percentage, the more cancer is present. As you can see, there is a lot of nuance to the evaluation, and these numbers are only a piece of the puzzle.
There are some other tests that may be obtained prior to making a decision about your treatment options. These tests are not necessary for all patients and many patients do not require any of these to make good decisions. If there is aggressive cancer found, or a large amount, additional imaging tests may be obtained to see if the cancer remains confined to the prostate. These are usually a bone scan and a CT scan. If an MRI was not obtained prior, it may be considered at this point. There are some emerging tests, such as specialized PET scans, but these are not usually necessary at this point in decision making.
New Genetic Testing
One new technique that helps with decision making is genetic testing. Currently, there are many types and brands, and as of now, no test is clearly superior. These tests may provide some additional information about how aggressive your prostate cancer is, and in some cases, these tests are very useful to help make decisions when you, or your urologist, is "on the fence" about the best treatment option.
For many men, this is one of the most difficult decisions they will ever make. The treatment decisions for prostate cancer can have a major impact on your life going forward. Please realize that these decisions are highly nuanced and require a full discussion based on individual details.
There are a number of broad categories of treatment options we will consider, but please remember, there are many more treatment options (and combination of options) that I can discuss here. Please do not think that just because I did not discuss an option in this short article, that is ineffective or ill-advised. There are many good options for you to evaluate with a trusted physician. In our practice, each patient receives a customized treatment plan depending on the nature of the cancer as well as the patient’s unique symptoms and overall health.
For men with a less aggressive type of prostate cancer, or for those who have some other more threatening medical issues, active surveillance is an option. This does not treat your prostate cancer but does monitor it closely for signs of progression. This option will require frequent PSA tests and will often require at least one repeat biopsy. If there is evidence of cancer progression, you may have to cease the active surveillance protocol and pursue another treatment option. Make no mistake though, for the correct patient, active surveillance can be a safe option that spares you from some of the side effects of prostate cancer treatment.
Side Effects of Treatment
Almost any path of prostate cancer treatment has side effects. Because of the prostate’s prime location, there are two main side effects associated with prostate cancer treatment. One is incontinence. Because the muscles that control urination are located close to the prostate and are sometimes unavoidably injured during treatment, the result is some urine leakage. For most men, this issue is temporary, but not for all. The other problem is that the nerves that control erections are located on the surface of the prostate and cannot be seen with the naked eye. When it is safe, we attempt to save these nerves, but they are often "shocked" and erection issues are common after treatment. Again, these are usually temporary, but it’s common for men to need some "help" in this department in the future. There are many ways we can help with common erection issues.
There are now many types of radiation used to treat prostate cancer. Generally, this is considered a less aggressive treatment approach than surgery, but it may also have fewer, or more mild, side effects. Please remember though, that is merely a broad generalization. Conventional radiation uses photons to kill prostate cancer. It is often delivered five days a week for 8 to 9 weeks of treatment. There are many other types of radiation in use, including radioactive seeds (called Brachytherapy), CyberKnife, Proton beams, and modifications of the original type of radiation called IMRT or EBRT. When discussing treatment options, I often have my patients speak with a radiation oncologist to get a full-spectrum picture of what the positives and negatives are as it relates to their specific cancer diagnosis.
One of the downsides to radiation therapy is that, usually, if it fails to cure your prostate cancer, surgery is not an option as a back-up plan. This is because the radiation causes inflammation and scar tissue that would make subsequent surgery dangerous. The two major side effects from prostate cancer treatment discussed above can occur with radiation but are usually less problematic than with surgery.
There are emerging techniques with the goal of being able to target a specific tumor in the prostate without damaging the rest of the prostate. The hope is that we could treat your cancer without subjecting the patient to significant side effects. Currently, the most common types of ablation are Cryo (freezing the prostate) and HIFU (High Intensity Focused Ultrasound). While these may emerge as the standards for prostate cancer, most urologists will currently only consider these in select cases at this time, since they are still emerging as a technology.
Surgical Removal of the Prostate
Surgical removal of prostate cancer has long been and remains the gold standard treatment.
It has advanced significantly over recent years with the addition of the DaVinci robot and now >90% of prostate surgery in this country is done with this technique. "Robotic" surgery is a total misnomer though, as the machine did nothing by itself; every movement is controlled by the skilled surgeon behind the controls. This means that the malignant tissue can be removed with higher proficiency than non-robotic surgical methods. There are many differences between surgeons, so please remember these generalizations stated here apply to my surgical techniques.
Surgery is done in the hospital and usually requires six small incisions, most of them smaller than your fingernail. You typically stay one night in the hospital. Once the prostate is removed during surgery, your surgeon will sew the urethra and bladder back together, for this reason, you will need a catheter for at least a few days after surgery.
I hope this helped provide a useful overview of prostate cancer and its treatment options. Please remember, once again, that prostate cancer is one of the most complex diseases to treat. Please keep in mind that no two situations are ever the same. If we at Midtown Urology can help guide you, or a family member, through these difficult decisions, we’d be glad to help.
This Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition.
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