Archive - Initial Treatments After Diagnosis of Prostate Cancer

In my opinion, atrial fibrillation is not necessarily a contraindication to surgery, as I have operated on many such patients in consultation with their cardiologists. Also, I am unconvinced that proton beam radiation therapy offers any significant advantage over standard 3-dimensional conformal radiation or intensity modulated radiation therapy (IMRT).

In my opinion, your question cannot be answered with certainty. 5-alpha-reductase inhibitors (Proscar, Avodart, Jalyn, etc.) are widely used to treat men with benign prostate enlargement, and we know that some treated men may harbor undetected prostate cancer. However, several large studies have shown that men who have taken these drugs for several years have a significantly higher likelihood of being diagnosed with a very aggressive Gleason 8, 9 or 10 prostate cancer (see previous QUEST articles). Therefore, in my practice, I do not encourage the use of these drugs, and I inform my patients of this possible risk.

Yes, it is more difficult to remove a large prostate gland. It is particularly difficult to perform nerve-sparing surgery. It can be done, but it takes more skill and experience to do it successfully.

It is difficult to say with certainty whether this type of nerve graft works.

Radiation and hormonal therapy are certainly available, but the side effects of radiation may be greater because the tissues already have some damage to the blood supply from cryoablation.

There are small nerve fibers that pass through the inside of the prostate gland. These nerves secrete a growth factor that attracts prostate cancer cells. Accordingly, in the great majority of prostate cancers, the cancer cells are seen to be lined up surrounding nerve fibers. This is called “perineural invasion.” Perineural invasion is so common as to almost be a diagnostic feature of prostate cancer. Its clinical significance is that when it is found in a needle biopsy specimen, there is a greater chance that the tumor will be found to have spread outside the prostate gland. If the tumor has spread outside the prostate, there is a higher chance for tumor recurrence. However, if the tumor has not spread outside the prostate gland, there is little or no prognostic significance to perineural invasion.

You should seek a site that has state-of-the-art equipment. Minimum requirements (in my opinion) would be a high-energy linear accelerator that can deliver at least 15 million electron volt photons and give 3-dimensional conformal radiotherapy. I do not believe that intensity modulated radiation therapy (IMRT) or proton beam radiation therapy offer a significant advantage for treating prostate cancer. With regard to the skill and caring attitude of doctors and staff, this is more difficult to evaluate. The best way would be to review their credentials and ask to talk to other patients who have been treated there. Also, ask physicians who work in their region their opinion.

Proton beam therapy is available only at Loma Linda University in Los Angeles and the Massachusetts General Hospital in Boston. It is essentially a (more expensive) type of 3-dimensional conformal radiotherapy. I am told that it is aggressively marketed in southern California. I do not believe that it offers any material advantage in the treatment of prostate cancer over standard 3-dimensional conformal therapy with photons or over intensity-modulated 3-dimensional radiotherapy (another more expensive form of radiotherapy). In my opinion, proton beam radiotherapy is not free of complications. Moreover, I do not believe that the results of radiotherapy are as good as with surgery in young patients with organ-confined prostate cancer. My views on radiotherapy as the primary treatment for prostate cancer are presented in more detail on my website, under the National Media link, article #4 and in the video on the treatment of early prostate cancer on the home page of this website.

One of the problems about using hormonal therapy before surgery is that it can cause dramatic changes in and around the prostate gland (scarring around the prostate gland) in some cases. This sometimes makes it more difficult to perform nerve-sparing surgery. Proscar is a very mild form of hormonal therapy. When it was being developed, it was tested in patients with advanced prostate cancer. It was too mild when used alone to be an effective cancer treatment. However, in most cases the PSA levels declined for several months. This may be all that is necessary in patients who have a short delay before prostate surgery. However, there are other options that could be used, such as Lupron or Casodex (for example), but these stronger forms of hormonal therapy may cause more difficulty in performing nerve-sparing surgery.

Theoretically, because nerve-sparing surgery preserves the soft tissues around the prostate, there is a higher risk for cancer recurrence. It is not feasible at the time of surgery to check all of the margins in real time to determine with complete certainty whether the nerves can be preserved. The judgement about whether or not to spare the nerves involves consideration of the preoperative biopsy results, the findings on rectal examination and scans, and the PSA level. It also is strongly influenced by how easily and cleanly the prostate can be freed from the neurovascular bundles at the time of the operation.

It is possible, but less likely, that the cancer has spread outside the prostate if perineural invasion is not seen on biopsy. If all other parameters look favorable, it is reasonable to perform nerve-sparing surgery in the absence of perineural invasion.

It is effective, but not more so than standard external beam radiotherapy using 3-dimensional conformal treatment, which can be obtained in nearly every city. Proton beam therapy is only available in Boston and California.

In general, it is believed that prostate cancer that arises in the peripheral zone is more aggressive than that which arises in the transition or central zones. The apex includes the transition and pheripheral zones.

In my opinion, IMRT is not necessary to treat prostate cancer. I believe that the same treatment objectives can be accomplished with 3-dimensional conformal radiotherapy. See other Q&As that address this subject on this website.

There are several Q&As on my website about nerve grafting and about the meaning of perineural invasion. I would recommend that you read them if you have not already done so. If I were in your position, I would not elect to have the nerve graft because I am not convinced that this procedure works. However, the rationale given by your urologist and surgeon are sound, i.e., with perineural invasion on the biopsy, there is a higher risk (though not a certainty) of extracapsular extension, so the safest approach might be to resect the nerve on that side. However, with your relatively low Gleason grade and PSA, the tumor may be contained within the prostate and it might be possible to spare both nerves.

The surgeon can get a good estimate, but it is not perfect. Microscopic extracapsular extension cannot be detected.

It does not necessarily mean that cancer cells have been left behind, but some might have been. Actually, most patients who have positive margins and an undetectable postoperative PSA continue to have undetectable PSA levels even without radiation therapy. But there is approximately a 30% chance that the PSA will rise without radiotherapy. It becomes a matter of weighing the potential side effects of radiation versus the potential benefits of giving the radiotherapy early when there are the fewest possible cancer cells to treat. This is a dilemma discussed in detail on this website. I usually recommend postponing the radiotherapy until 3 to 4 months after the surgery until everything has healed and continence has returned. It is also probably true that not much would be lost if you carefully monitored the PSA and then, if it started to rise, received radiation therapy at once.

It does appear that you have a favorable situation, but a PSA of 6.9 is pretty high for a 45 year old man and a Gleason score of 3+3 is in the category of moderately aggressive cancer. I do not think it is possible to accurately assess the risk of cancer spreading if you delay surgery for one year, but I would think it is significant. Therefore, I usually advise patients to have treatment as soon as they can conveniently get it scheduled with the doctor of their choice.

There is no good evidence that neoadjuvant hormonal therapy improves the outcomes of surgery (it has been shown to be beneficial in high-risk patients treated with external beam radiotherapy). It can make it more difficult to perform nerve-sparing surgery. I do not think patients with relatively low risk tumors (Gleason grade less than 7, PSA less than 10, low volume involvement of the biopsy cores) need to take neoadjuvant therapy if surgery is delayed for a few months. Obviously, it is best to have the surgery performed as soon as feasible, but early detection through PSA testing probably give 5 to 13 years lead time. This means that without PSA testing, the cancer might not have been detected until 5 to 13 years later. So, a few months delay would seldom affect the ultimate outcome of treatment. Specifically, in your case, I do not think neoadjuvant hormonal therapy is necessary.

I have no personal experience in performing robotic laparoscopic radical prostatectomy. My comments on this procedure would be that I place it in the same category as other forms of laparoscopic radical prostatectomy in terms of the results that can be consistently obtained, i.e., it is uncertain at this time whether they are equivalent to those that can be obtained by a surgeon who specializes in open nerve-sparing radical prostatectomy. Please see articles from Quest on this topic which are posted on this website.

It is important to realize that hormonal therapy can be effective for many years in patients with advanced prostate cancer. Chemotherapy is also effective in many patients, but has more severe side effects. Also, a variety of new experimental treatments are in various stages of development.I believe that the best course at this time would be to go with the hormonal therapy in order to “buy time.” In the futures, it may be necessary to have chemotherapy,as well. The hope is that soon, newer, more targeted forms of therapy will become available. Of course, nobody can predict what treatment or when, but that’s the hope you and he need to hold on to. Stay on top of his treatment, take good care of his (and your) health, and plan to hang in there until something better is available.

Because of your age and the features of your tumor, I believe that radical prostatectomy is your best option, but that is not to say that it is your only safe option. I would not advise waiting 6 months to be treated. The complications you fear can best be avoided by chosing a surgeon with considerable experience in radical prostatectomy.

There is a 5-10% risk of having some permanent injury to the bladder following adjuvant radiotherapy. This usually means intermittent bleeding from the bladder or an irritable bladder syndrome. On the other hand, radiotherapy reduces the risk of having a recurrence of the prostate cancer in your bladder.

This would be the typical recommendation for patients with prostate cancer that is believed to have spread outside the prostate gland. However, several studies have demonstrated that the results of radical prostatectomy are favorable with Gleason grade 8 prostate cancer if the cancer is still contained within the prostate gland. Thus, if the doctors truly believe that the cancer is organ confined, radical prostatectomy also would be an option.

The results of the Prostate Cancer Prevention Trial suggest, in my opinion, that long-term administration of Proscar can mask the presence of prostate cancer and allow its more aggressive elements to emerge in men who initially have PSA levels <3 and normal findings on digital rectal examination. I no longer recommend that men take Proscar on a long-term bais. The effect of short-term administration of Proscar in men with established prostate cancer who are waiting for surgery is uncertain. Certainly, it is possible that in this setting, Proscar could retard only the less aggressive cancer cells while the more aggressive ones continued to grow and spread unchecked.

In my opinion, the prior kidney surgery by itself should not prevent you from having a radical prostatectomy, all other matters being satisfoctory for surgery. Sometimes, considerably more tumor is found in the radical prostatectomy specimen. In my opinion, it would be safest to treat the prostate cancer with an effective treatment like radical prostatectomy.

In my opinion, no. Brachytherapy is not usually recommended after the prostate has been resected transurethrally because it might not hold the seeds properly. Also, I believe that radical prostatectomy is more effective treatment. Your situation seems very favorable for a cure.

He does stand a good chance for an excellent response to treatment and years of remaining good quality life. The radiotherapy and hormonal therapy have side effects that are discussed elsewhere on this website, but hopefully these will not be a major problem in his case.

In my opinion, there is no simple answer; however, in similar cases I have recommended surgery as the preferred curative option. Although it is sometimes difficult, it has been feasible in every case I have encountered so far. A non-curative option would be hormonal therapy.

I do not recommend it to my patients and would not opt for it myself if I had prostate cancer.

The complications of surgery after failed radiation therapy are up to 10-fold more likely, and they are more serious and more difficult to treat when they occur. I wrote an editorial in the Journal of Urology several years ago about this. However, there are some centers that have pursued salvage surgery. Sometimes it requires removal of the bladder as well. I would suggest that you search for “salvage radical prostatectomy” on PubMed.

I routinely order a bone scan and abdominal/pelvic CT scan to obtain a good base-line evaluation of the patient; however, these tests are not mandatory if the PSA is low and the Gleason grade is not high. Most surgeons would forgo them. In my opinion, successful nerve-sparing is more likely to achieved with an open procedure, but it depends upon the preference of the surgeon. Please see other Q&As concerning laparoscopic radical prostatectomy.

I do not know of there being a different risk of cell shedding between surgical approaches. However, I do believe the risk of inadvertently leaving some tissue behind, especially in the region of the bladder neck, might be higher with the laparoscopic approach.

Proton beam radiotherapy is effective but only a few facilities in the United States have the equipment.I think the same results could be achieved with 3-dimensional conformal therapy and a high-energy linear accelerator, which is available in almost every city of any size.

The role of the second doctor varies, but usually he or she assists the first doctor, who actually performs the surgery. If you have any questions about the role of the second doctor, you should directly ask the first doctor.

If it is believed that the cancer has spread beyond the pelvic area, primary hormonal therapy is the preferred treatment. It might be helpful to see an oncologist to verify the wisdom of the treatment choice.

In my opinion, you should have treatment. If you are otherwise healthy, I believe that a radical prostatectomy would offer the best chance for cure.

I am not an advocate of brachytherapy and, therefore, cannot speak from personal experience. But most physicians who are experienced in brachytherapy feel that it is difficult to achieve an adequate distribution of radiation with a large prostate gland, and, if the prostate does not shrink, will recommend a different form of treatment.

In my opinion, the robotic prostatectomy (often called the DaVinci prostatectomy) is not as effective as the traditional open prostatectomy for simultaneously accomplishing complete removal of cancer and preserving potency.
One of the reasons is that the robot lacks the “human touch” and it is not possible to appreciate how the prostate gland feels and how readily it separates from the nerves and other surrounding tissues.

The robot does not handle the prostate gland as gently as the human hand, and not infrequently the robot punctures the capsule of the prostate, leading to positive surgical margins.

Another limitation is that with the robotic prostatectomy, the prostate is removed by burning it out with electrocautery or a so-called harmonic scalpel that cuts by heat, and if the heat is too near the nerves, it irreversibly damages them. Also, if the burning is too close to the prostate gland, it risks cutting into the prostate, resulting in positive surgical margins and possibly leaving cancer behind.

Advocates of robotic surgery say that there is less bleeding and greater magnification with robotic surgery. However, excellent magnification and visualization can be provided with open surgery, and with an experienced surgeon, few patients require blood transfusions from another person.

With robotic surgery, it is more difficult to suture and apply hemostatic clips and it is more difficult to perform a lymph node dissection.

Enthusiasts of the robotic procedure claim it is “less invasive” and has a quicker recovery time. But actually it is more invasive because the surgeon has to go through the peritoneal cavity to get to the prostate (a more invasive approach associated for greater risk for injury to the bowel, major blood vessels, and the ureters and a greater risk for later intestinal obstruction from adhesions). Usually 6 one-inch incisions are made for robotic surgery, while for open surgery, one 4 to 5 inch incision is made that does not enter into the peritoneal cavity. With the smaller incision now frequently used for open surgery, there is no material difference in the recovery time and return to normal activity…
The complications with robotic prostatectomy are more serious than with open prostatectomy and they lead to more postoperative emergency room visits, more re-hospitalizations, and more re-operations.

I believe that with the robotic or laparoscopic prostatectomy, the patient and the surgeon have to make more of a stark choice between removing all of the cancer or preserving the nerves to maintain potency. I believe that there is a greater likelihood of accomplishing both objects with the increased access provided by the open approach.

Most importantly, however, the robotic prostatectomy has no track record in terms of long-term cancer control. If small amounts of cancer are left behind, it may not become apparent for years.

Patients sometimes tell me that they know someone who underwent a robotic prostatectomy a few months ago and seems to be doing fine. However, the final outcome of the operation may not become apparent for up to 10 years. Thus, long-term cancer cure rates are needed before one can truly evaluate the effectiveness of the operation.
In sum, I do not believe the robotic prostatectomy is as safe a cancer operation as open radical prostatectomy, and I do not believe that nerve-sparing can be as readily or safely accomplished.

For patients, the most important outcomes of radical prostatectomy are: Is he cured of his cancer? Is he continent? Can he have erections sufficient for intercourse?

These questions have been well documented for open rostatectomy. The jury is still out with laparoscopic/robotic prostatectomy. The most important factor is the surgeon and not the technique.

Prostatic ductal cancers are uncommon but not rare. Often they produce very little PSA or none at all.
Ductal carcinomas generally are more aggressive than the more common prostate cancers that arise from the small glands in the prostate called prostatic acini (thus the typical prostate cancer is sometimes referred to more formally as an “acinar adenocarcinoma.”

The most effective treatment for ductal cancers is radical prostatectomy if the cancer is contained within the prostate gland.

The response to radiation therapy or hormonal therapy is not as good for ductal cancers as for acinar cancers.
The most effective chemotherapy drug used for acinar cancers is docetaxel (Taxotere) but little information is available on its effectiveness with ductal cancers.

Yes, it is possible. It is more inconvenient for the surgeon to remove the lymph nodes with a laparoscopic prostatectomy, but it can be done.

Radical prostatectomy is more difficult to perform in patients with a very enlarged prostate gland; however, this situation rarely precludes performing surgery. The normal prostate gland has a volume of 30 ml, and the largest prostate gland I have removed was 379 ml. Thus, an extremely large prostate gland can be removed safely by an experienced surgeon.

My practice is to wait for 6 weeks after the biopsy to allow any inflammation to resolve. Then the surgery should be performed as soon as it can be conveniently scheduled. Many patients who delay their surgery are found to have positive margins or extension of cancer outside the prostate and then need to have postoperative radiation. They often wonder whether if they had not delayed, the result would have been different.

If the cancer is confined to your prostate, surgical removal is more effective in curing it. If it is not, there is still a chance that it can be cured with a lower dose of postoperative radiation therapy. Radiation therapy alone has 3 downsides: (1) sometimes even the higher dose of radiation required to treat the whole prostate gland does not cure the cancer; (2) sometimes a new cancer can arise in the remaining prostate tissue, and (3) there is an increased risk of (radiation- induced) bladder cancer and colo-rectal cancer in patients who have been treated with radiotherapy for prostate cancer. You can safely have radiotherapy after surgery, but surgery after radiotherapy is associated with a 10-fold higher complication rate, including urinary incontinence, erectile dysfunction, and even the possibility of needing a temporary colostomy.

In my opinion, a nerve-sparing prostatectomy is the preferred treatment for you because of your relatively young age, the presence of Gleason pattern 4 cancer in the biopsy specimens, and your relatively high PSA (the median PSA for men in their 40s is 0.7). I perform open nerve- sparing prostatectomy because I believe (1) it offers the advantages of the surgeon having the ability to touch the tissues and appreciate how readily or not the prostate separates from the surrounding tissues, (2) the ability to avoid burning the prostate using heat or electrocautery as is commonly used in robotic surgery, and (3) better access to the surgical field. The amount of pain and recovery is essentially the same for both approaches, and, in my hands, the need for transfusions is the same as with robotic prostatectomy. I believe my outcomes are as good as any. Nevertheless, the most important factor is the experience and skill of the surgeon. Please visit my website, www.drcatalona.com, for more information and search “robotic prostatectomy.