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Urology (Expert Forum)
Deciding on treatment
Answered by
Kevin Pho, MD - Internal Medicine
Kevin Pho, MD
Boston - MA
Questions in the Urology forum are answered by Dr. Stephen Liroff, affiliated with the Henry Ford Hospital. Topics covered include benign prostate disease, penis curvature, cystisis, kidney stones, pediatric urology, prostate, sexual dysfunction, urinary tract infections (UTI), and urological cancers.
Deciding on treatment
by Phillyboy, Dec 16, 2003 12:00AM
I need help with a man's most difficult decision: what form of treatment to choose for prostate cancer. My details are as follows. Age: 69, Health: very good, no chronic conditions, not overweight or a smoker. Most recent PSA = 2.9, % free PSA = 12%. 12-needle biopsy staged at 7 (3+4) by 1 pathologist, and at 6 by a second. 5 positive areas, all on one side, no positive areas on other side. There is a palpable area on the one side with cancerous cells. The worst parts of my prostate are the 2 lowest areas. My dilemma, not unique I know, is that after reading several books and looking at many internet sources, I am torn between choosing the surgical treatment (a nerve-sparing retropubic radical prostetectomy) and a very focussed conformal radiation treatment + seeds to be followed by hormonal treatment for 4 months to 2 yrs. Both of these treatments would be performed by very skilled and very experienced specialists at excellent hospitals. Each specialist recommends his modality of treatment, but says the other is a reasonable choice too!
I think I am a generally good risk for surgery, and can take the time for recovery. Of course I am attracted by the lesser down-time that radiation treatments involve. I know that you can't tell me what to do, but can you tell me what to consider as the benefits, risks and long-term considerations in making this decision? Is there something in my particualar case In terms of the best and current data, what are the differences in side-effects of the treatments for a patient like me? What are the long-term recurrence and survival data? What should I consider in weighing the pros and cons? I would greatly appreciate all the suggestions you can provide to help me with this excruciatingly difficult decision.
I think I am a generally good risk for surgery, and can take the time for recovery. Of course I am attracted by the lesser down-time that radiation treatments involve. I know that you can't tell me what to do, but can you tell me what to consider as the benefits, risks and long-term considerations in making this decision? Is there something in my particualar case In terms of the best and current data, what are the differences in side-effects of the treatments for a patient like me? What are the long-term recurrence and survival data? What should I consider in weighing the pros and cons? I would greatly appreciate all the suggestions you can provide to help me with this excruciatingly difficult decision.
Doctor's Answer
by Kevin Pho, MD, Dec 18, 2003 12:00AM
, Dec 18, 2003 12:00AM
To answer this question, I am going to paste an article from UptoDate, which provides answers to the questions you are asking.
Patient information: Treatment for early prostate cancer
Eric A Klein, MD
Cleveland Clinic Foundation and Taussig Cancer Center
Prostate cancer is a malignancy of the prostate gland, an organ that forms a ring around the urethra (the tube that carries urine from the bladder to the outside of the body) near its connection to the bladder. Prostate cancer is the most common cancer affecting men. Every year, approximately 189,000 men are diagnosed with prostate cancer in the United States, and 30,200 die from this disease. Over the last decade, the increasing use of prostate cancer screening by measurement of blood levels of prostate-specific antigen (PSA) has led to more cases being diagnosed at an early stage, when the cancer is still restricted to the prostate gland, and highly curable.
There are three standard approaches to treating early prostate cancer: surgical removal of the prostate gland, radiation therapy with or without hormone therapy, and "watchful waiting," a term that describes the decision to delay definitive treatment while carefully monitoring the patient for evidence of progression or growth of the cancer. Hormone therapy has traditionally been reserved for men with advanced or metastatic prostate cancer, although new applications of hormonal therapy as a supplement to watchful waiting, surgery, or radiation show some promise.
The ultimate choice of treatment is dependent upon several factors.
The likelihood that the prostate cancer is confined to the prostate gland and therefore, potentially curable
A man's age and overall health, including any other medical conditions
The outcomes and potential side effects associated with the different forms of treatment
Here we will discuss the pretreatment evaluation of men with early prostate cancer, and describe the available treatment options, outcomes from therapy, and treatment-related side effects.
PRETREATMENT EVALUATION — Prior to selecting the best treatment option, it is critically important that the extent of the prostate cancer be correctly determined. Although the true local extent of involvement can only be determined by surgical removal, several pretreatment factors can be used to predict whether a prostate cancer is likely to be confined to the prostate gland itself (termed organ-confined disease) or spread beyond the prostate gland, and therefore, more advanced. The most important pretreatment factors that determine outcome are the clinical stage, the level of the serum PSA, and the degree of aggressiveness of the tumor, referred to as the Gleason grade.
Prostate cancer stage — Physicians use a common notation to describe the extent, or stage of a cancer. The tumor-node-metastasis (TNM) system is the most common method used to stage prostate cancer (show table 1). Within the TNM system, T1 tumors are microscopic, and cannot be felt by the physician on rectal examination; T2 tumors can be felt with a rectal examination, but appear to be confined to the prostate gland; T3 tumors have grown beyond the prostate into the capsule of connective tissue that surrounds the gland, or into the seminal vesicles (glands near the prostate that secrete fluid into the reproductive tract); T4 tumors have grown locally beyond the prostate, and involve nearby tissues. The finding of a T3 or T4 tumor suggests a more advanced tumor that is not likely to be cured, even with aggressive surgery. It should be noted that the stage that is assigned by a rectal examination is termed a clinical or "c" stage, while a man who has undergone surgical removal of the prostate with microscopic evaluation will be assigned a pathologic, or "p" stage.
Endorectal coil MRI — A new x-ray method called endorectal coil MRI uses magnetic resonance imaging to assess the prostate and its surrounding tissues. Although this technique is not yet widely available, it appears to be particularly helpful in evaluating the possibility of extension outside of the prostate capsule or into the seminal vesicles in men who are considering surgery.
Serum PSA level — The vast majority of men with prostate cancer have elevated levels of PSA in the blood. The level of PSA at the time a prostate cancer is diagnosed provides important information as to the likelihood of finding organ-confined disease. As PSA levels increase, the likelihood of disease spread to tissues beyond the prostate gland rises. Men with a PSA concentration less than 10 ng/mL have a 70 to 80 percent chance of having organ-confined disease, compared to 50 percent for those with PSA levels 10 to 50 ng/L, and only 25 percent with higher PSA levels [1]. Because of this, men with PSA levels above 10 ng/mL are usually recommended to undergo a CT scan of the abdomen and pelvis, and a bone scan prior to treatment in order to detect any spread of tumor to the pelvic and abdominal lymph nodes, or bones.
The pretreatment PSA level can also predict the likelihood of a cancer recurrence after treatment. Men with a lower PSA concentration are more likely to be cancer-free five years after treatment than those with a higher pretreatment PSA level.
Biopsy grade — A prostate biopsy, in which a small amount of tissue is removed from the prostate and examined under a microscope, is typically performed when prostate
Patient information: Treatment for early prostate cancer
Eric A Klein, MD
Cleveland Clinic Foundation and Taussig Cancer Center
Prostate cancer is a malignancy of the prostate gland, an organ that forms a ring around the urethra (the tube that carries urine from the bladder to the outside of the body) near its connection to the bladder. Prostate cancer is the most common cancer affecting men. Every year, approximately 189,000 men are diagnosed with prostate cancer in the United States, and 30,200 die from this disease. Over the last decade, the increasing use of prostate cancer screening by measurement of blood levels of prostate-specific antigen (PSA) has led to more cases being diagnosed at an early stage, when the cancer is still restricted to the prostate gland, and highly curable.
There are three standard approaches to treating early prostate cancer: surgical removal of the prostate gland, radiation therapy with or without hormone therapy, and "watchful waiting," a term that describes the decision to delay definitive treatment while carefully monitoring the patient for evidence of progression or growth of the cancer. Hormone therapy has traditionally been reserved for men with advanced or metastatic prostate cancer, although new applications of hormonal therapy as a supplement to watchful waiting, surgery, or radiation show some promise.
The ultimate choice of treatment is dependent upon several factors.
The likelihood that the prostate cancer is confined to the prostate gland and therefore, potentially curable
A man's age and overall health, including any other medical conditions
The outcomes and potential side effects associated with the different forms of treatment
Here we will discuss the pretreatment evaluation of men with early prostate cancer, and describe the available treatment options, outcomes from therapy, and treatment-related side effects.
PRETREATMENT EVALUATION — Prior to selecting the best treatment option, it is critically important that the extent of the prostate cancer be correctly determined. Although the true local extent of involvement can only be determined by surgical removal, several pretreatment factors can be used to predict whether a prostate cancer is likely to be confined to the prostate gland itself (termed organ-confined disease) or spread beyond the prostate gland, and therefore, more advanced. The most important pretreatment factors that determine outcome are the clinical stage, the level of the serum PSA, and the degree of aggressiveness of the tumor, referred to as the Gleason grade.
Prostate cancer stage — Physicians use a common notation to describe the extent, or stage of a cancer. The tumor-node-metastasis (TNM) system is the most common method used to stage prostate cancer (show table 1). Within the TNM system, T1 tumors are microscopic, and cannot be felt by the physician on rectal examination; T2 tumors can be felt with a rectal examination, but appear to be confined to the prostate gland; T3 tumors have grown beyond the prostate into the capsule of connective tissue that surrounds the gland, or into the seminal vesicles (glands near the prostate that secrete fluid into the reproductive tract); T4 tumors have grown locally beyond the prostate, and involve nearby tissues. The finding of a T3 or T4 tumor suggests a more advanced tumor that is not likely to be cured, even with aggressive surgery. It should be noted that the stage that is assigned by a rectal examination is termed a clinical or "c" stage, while a man who has undergone surgical removal of the prostate with microscopic evaluation will be assigned a pathologic, or "p" stage.
Endorectal coil MRI — A new x-ray method called endorectal coil MRI uses magnetic resonance imaging to assess the prostate and its surrounding tissues. Although this technique is not yet widely available, it appears to be particularly helpful in evaluating the possibility of extension outside of the prostate capsule or into the seminal vesicles in men who are considering surgery.
Serum PSA level — The vast majority of men with prostate cancer have elevated levels of PSA in the blood. The level of PSA at the time a prostate cancer is diagnosed provides important information as to the likelihood of finding organ-confined disease. As PSA levels increase, the likelihood of disease spread to tissues beyond the prostate gland rises. Men with a PSA concentration less than 10 ng/mL have a 70 to 80 percent chance of having organ-confined disease, compared to 50 percent for those with PSA levels 10 to 50 ng/L, and only 25 percent with higher PSA levels [1]. Because of this, men with PSA levels above 10 ng/mL are usually recommended to undergo a CT scan of the abdomen and pelvis, and a bone scan prior to treatment in order to detect any spread of tumor to the pelvic and abdominal lymph nodes, or bones.
The pretreatment PSA level can also predict the likelihood of a cancer recurrence after treatment. Men with a lower PSA concentration are more likely to be cancer-free five years after treatment than those with a higher pretreatment PSA level.
Biopsy grade — A prostate biopsy, in which a small amount of tissue is removed from the prostate and examined under a microscope, is typically performed when prostate