Advances offer prostate cancer patients many options for a cure
“Every man dies, but no man needs to die from prostate cancer,” says Dr. William Catalona, a renowned urologist at Northwestern Medical Center.
To many men, receiving a diagnosis of prostate cancer might sound like a death sentence. However, as technology advances for earlier detection and multiple treatment options, most cases of prostate cancer are deemed curable, according to local urologic oncologists.
“Cancer of the prostate is still a deadly disease, but with a lot of emphasis and screening and PSA evaluation and most importantly, men finally being aware that they need to get checked, we have seen a shift in the diagnosis of prostate cancer to significantly earlier disease for most people,” says Dr. Byron Hodge, a urological oncologist at Lakeland Regional Cancer Center and Polk County Medical Association member. “So, what we’re seeing now is a lot less people who come in now with metastatic cancer of the bones, a lot less people who have disease in their lymph nodes, and a lot more people who are very careful.”
Hodge adds that in the mid 1980s, 80 percent of people who received their first diagnosis of prostate cancer were probably not curable. “And today, 80 percent of people I see are probably curable with a number of different modalities because we are seeing an earlier diagnosis,” he says.
These different modalities range from the radiation and surgery options that have been used historically to treat prostate cancer, to newer treatments like nuclear medicine, cryotherapy, and robotic surgery.
In addition to new treatment options, doctors also are excited about the new ways in which patients are being diagnosed with the disease, often allowing treatment options to be selected before the cancer progresses into an advanced stage.
In the past, patients could only depend on an examination followed by a biopsy to determine their likelihood of having prostate cancer. Today, however, men have a variety of options for determining their cancer risk.
“There are some new tests out now,” Hodge explains. “There’s Prostate Cancer Gene 3 (PCA3), which is a gene-based test carried out on a urine sample. That can tell if there are prostate cancer cells in the urine and that can lead to a biopsy.”
Dr. Faiyaaz Jhaveri, a urologist at Heart of Florida Hospital in Haines City, also spoke of another test through a company called Aureon.
“Aureon is a pathology group out of New York that does a specialized analysis of prostate biopsies that can sometimes show that the cancer is more aggressive and needs to be treated aggressively,” he says.
Additionally, LRCC has developed a test in conjunction with the center’s radiology and imaging specialists.
“Something we’ve developed here in Lakeland is called a Dynamic Contrast Enhanced (DCE) MRI of the prostate,” Hodge says. “It’s a way of imaging the prostate that’s about 90 percent accurate for determining the presence of cancer in the prostate. So, when patients may have a negative biopsy or suspicious lesion, this is a way to image it. It’s complicated physics, but the imaging is very accurate to see these lesions. These are patients with 3 and 4 millimeter tumors that you couldn’t see on anything else except the MRI.”
In regard to these new diagnosis options, when should a patient get checked?
“As urologists, we feel the average guy should get a digital rectal exam and a PSA scan by age 45,” Hodge says. “If you fall into a high risk group, probably age 40 is a reasonable time to do it. We have seen guys in their early- to mid-30s, but those are rare. If you have a situation where every guy in your family has had a prostate problem, then those men need to get checked sooner.”
Hodge notes that it is important for men to have both the PSA and digital rectal exam, because they complement one another.
“Occasionally we will see people with a lump in their prostate and a low PSA, and those guys have cancer,” he says. “So that’s important.”
After a man is diagnosed with prostate cancer, he has many options to discuss with his doctor.
“This is really an exciting time for physicians who treat prostate cancer,” says Dr. Michael Tomblyn, the chief of therapeutic radiopharmaceuticals and director of clinical research in the department of radiation oncology at Moffitt Cancer Center and Research Institute in Tampa. “Over the past few months, several new treatments have been approved by the FDA for patients who have unfortunately had their cancer come back and has spread to the bones.”
From the standpoint of radiation oncology and nuclear medicine, Tomblyn says physicians still use the injections of radioactive drugs, like Quadramet and Metastron, for these patients.
“These ‘liquid radiation’ treatments go directly to areas of bone disease and slowly deliver a continuous dose of radiation in the surrounding region which decreases the patient’s bone pain,” he says. “The injection is into a vein over about 30 seconds and is painless. These agents are very well-tolerated, with the primary side effect being a temporary decrease in blood counts, although minor compared to the effects of chemotherapy. Recently, a large international trial was completed looking at a newer form of injectable radiation (Alpharadin) in patients with metastatic prostate cancer, and the early analysis shows a significant improvement in how long patients lived compared to those who were given a placebo. This is the first time we have ever seen radiation improve survival in patients with prostate cancer that has spread to the bones.”
He adds that FDA approval for these drugs should come in about a year or so.
“These injectable radiation drugs are very good choices for people with cancer that has spread to multiple sites in the bones, no longer controlled by hormonal drugs, and with bone pain requiring pain relieving drugs,” Tomblyn says. “For patients who are relatively healthy and willing to try, it would be standard to first recommend chemotherapy before using these agents. However, for the many patients unwilling to try chemotherapy or once cancer has progressed after chemo, these agents should be considered primary choices for the relief of bone pain.”
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Surgery has long been an option for patients diagnosed with prostate cancer, but in recent years, the means of performing a prostatectomy has drastically changed.
“Traditionally, surgery for kidney masses or blockages required large incisions that were painful,” says Dr. Frances Martin, a urological oncologist at LRCC and a Polk County Medical Association member. “The hospital recovery period was much longer than it is today. Most surgeries to treat medical conditions of the kidney and ureter — including malignant cancers — may be performed with minimally invasive operative techniques. LRMC has two of the newest robotic surgery systems that allow patients to have advanced care and a quick recovery.”
One of the systems available is the da Vinci Robotic Surgery System.
“The da Vinci System is the first of its kind to be approved by the FDA for general laparoscopic surgery using robotic methods,” says Dr. Sijo Parekattil, a Winter Haven Hospital urologist and Polk County Medical Association member. “Men who undergo the laparoscopic technique have less blood loss, less need for pain medication, a shorter hospital stay, quicker return to regular meals and activities, early removal of urethral catheters, and a quicker recovery. In short, laparoscopy treats the prostate cancer as effectively as surgeries performing the open procedure, but with advantages as listed above.”
Additionally, performing the surgery with the da Vinci robotic system provides a more accurate, steady “hand” than even the most experienced surgeon could offer the patient.
“When the traditional method of surgery is performed, there’s always a risk of the surgeon’s hands shaking and causing damage to the delicate areas around the prostate,” says Dr. Mark Bandyk, a Lakeland Regional Cancer Center urologist who completed a urologic oncology fellowship at MD Anderson Cancer Center. He also is a Polk County Medical Association member.
However, despite its accuracy, the da Vinci arm does not take the place of a skilled surgeon, says Jhaveri, who will be performing surgeries using Heart of Florida Hospital’s new robotic models.
“The robotic arm is simply another tool used by skilled surgeons,” he says. “The surgeon isn’t at the bedside of the patient during the surgery, but he is operating the machine and guiding it through the surgery. It allows for very precise movements, without tremor and risk of tearing up veins and vesicles.”
Another option for prostate cancer treatment is cryotherapy, or the freezing of the tumors inside the prostate. This is a popular treatment option at Heart of Florida and Lakeland Regional Cancer Center. For more in-depth information about this treatment, please see the For Men Feature on page 7.
story by MEREDITH JEAN MORTON