Health Chats
Prostate Cancer
Wednesday Sep 09, 2009, 12:00PM - 01:00PM (EST)
Andrew Stephenson, MDBlank
Director of the Center for Urologic Oncology
Cleveland Clinic
Glickman Urological and Kidney Institute, Cleveland, OH
With so many treatments available for prostate cancer, how do you choose the right one? Join Dr. Andrew Stephenson for a live chat and get answers from one of the nation’s top urology programs.<br><br> Urologists at the Cleveland Clinic Glickman Urological & Kidney Institute have been recognized nationally and internationally by their peers as leaders in the field of urology. In 2009, for the 10th consecutive year, our urology program was ranked No. 2 in the United States by U.S.News & World Report in its “America’s Best Hospitals” survey.<br><br> The Glickman Urological & Kidney Institute is one of 26 institutes at Cleveland Clinic that group multiple specialties together to provide collaborative, patient-centered care. This care model allows the institute to offer all treatment options for prostate cancer. With prostate treatment, it’s not only about options, it’s about experience. Our physicians pioneered medical advances including laparoscopic and robotic prostate surgery, while treating thousands of men annually. In 2008, our institute saw patients from all 50 states, in addition to many international patients.<br><br> Andrew Stephenson, MD, is Head of Urologic Oncology at Cleveland Clinic's Glickman Urological and Kidney Institute and a staff member of the Taussig Cancer Institute. His clinical and research focus is the treatment of patients with cancers of prostate, bladder and testis. He has published over 50 articles in peer-reviewed journals since 2002 on issues related to prostate, bladder and testicular cancer, many of which have received international mainstream media attention. He has been invited to speak at several major international oncology conferences on these subjects.<br><br> The focus of this Health Chat will be on prostate cancer and treatment options for the disease.<br><br> Prostate cancer is the most common cancer in men, and the second leading cause of cancer deaths among men in the U.S. Every year, about 185,000, new cases of prostate cancer will be diagnosed in the United States. About one in six men will be diagnosed with prostate cancer during his lifetime, but only one in 35 men will die of it. More than two million men alive in the United States have been diagnosed with prostate cancer. The risk factors for prostate cancer include: age, family history, race, diet, male hormones and a sedentary lifestyle. Age is the greatest risk factor with 75 percent of all prostate cancers being diagnosed in men older than 65. Regular screening is the key to catching prostate cancer in its early stages. Physicians tailor prostate cancer treatment plans to their patient’s needs, taking into account the type of cancer, the age of the individual, the degree to which the cancer has spread and the general health of the patient. <form name="signup_form2" method="post" action="/health_chats/register/16"><br/> <div class="actions float_fix"> <a onclick="return false;" id="signup_form2_submit" class="big_gr_btn" href="#"><img src="/RoR/images/blank.gif" class="btn_l_img pos_rel"/><span style="padding-top: 2px;" class="btn_r_txt pos_rel"><span class="btn_r_txt_w">Register</span></span></a> <span><input type="submit" value="signup_form_h_submit" name="commit" class="hidden_submit"/></span> <script> Event.observe(document.signup_form2, 'submit', function(e) { if (true) { $('signup_form2_submit').replace('<b>Submitting</b> <img src="/RoR/images/wait_arrows.gif">'); } else { Event.stop(e); } } ); Event.observe($('signup_form2_submit'), 'click', function(e) { if (true) { document.signup_form2.submit();$('signup_form2_submit').replace('<b>Submitting</b> <img src="/RoR/images/wait_arrows.gif">'); } }); </script> </div> </form> <br/>
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MedHelp:
Welcome to today's health chat on prostate cancer. The chat will begin shortly at 12 PM Eastern/9 AM Pacific. Please feel free to submit your questions now and we'll start answering them then.
MedHelp:
We are very pleased to welcome Dr. Andrew Stephenson today.  Thank you for being with us to answer prostate cancer questions!
Andrew Stephenson, MD:
It is my pleasure to be with you today.  Thank you for the invitation.  I am happy to answer all the participants questions.
boulette:
Hi, my father was diagnosed 18 months ago with prostate cancer (fairly low grade) and was told his gleason was a 6. His PSA was 11. Since then, his PSA has gone down to 8 but the last biopsy taken 3 weeks ago, showed that the cancer had spread to the other side of his prostate. He now has a gleason of 7. We are waiting for a scan to see if it has spread anywhere else. My question is, looking at the above do you think it likely that it will have spread to anywhere else? I would have thought that it wouldn't have as he was on a watch and wait procedure. Now he has to have Radiotherapy after the scan. Thanks for your time and advice. -Boulette
Andrew Stephenson, MD:
Several factors about your father's prostate cancer are very favorable - patients with PSA < 10 and Gleason 7 or less have a very high probability of having cancer confined to the prostate.  There are 3 appropriate treatment options for his cancer - surgery, radiation therpay and seeds (or brachytherapy).  All are likely to give him high probability of cure.  You can estimate with very high accuracy his outcome after treatment using nomograms that we have developed at Cleveland Clinic.  They are available on-line for free use by patients and physicians at www.nomograms.org.
Nystrom:
Is routine testing for PSA levels still adequate in reducing prostate cancer mortality?
Andrew Stephenson, MD:
PSA screening is very controversial - 1 study from the US showed no benefit in mortality reduction.  A study from Europe showed a 20% reduction in mortality.  I tend to refer to the European study as the American trial had several methodological flaws. Nonetheless, despite a 20% reduction in mortality in the European study, researchers estimate that 48 cancers need to be diagnosed to prevent 1 cancer death at 10 years.  I recommend screening to patients beginning at age 50 unless they have other risk factors (family history, African-American ethnicity).  However, I balance this early detection approach with active surveillance in patients with prostate cancer who have very favorable (low-risk) features.
Nystrom:
What is the optimal screening and treatment strategy for Prostate Cancer?
Andrew Stephenson, MD:
The screening trial from Europe was PSA at 3 year intervals and patients were biopsied when the PSA was > 2.5 or 3.0 ng/mL or an abnormal rectal examination.
eaglesJW:
My Dad has been told he has Stage 4 prostate cancer.  They are not giving him much hope.  Are there any clinical trials any where that might be able to help him?
Andrew Stephenson, MD:
About 50% of men with metastatic prostate cancer will survive 5 years or more. A key prognostic factor is the PSA level after he has been on androgen deprivation therapy (ADT) for 6 months.  If the PSA level at that time is less than 1 ng/mL (or < 0.2 ng/mL), the survival may be 7 years or longer.  There are several clinical trials investigation novel approaches for these patients.  A trial we have open at Cleveland Clinic is a randomized trial of ADT +/- chemotherapy (docetaxel or Taxotere).  This trial is open at several centers in the United States.
Brightlight06:
My doctor has recommended I have robotic surgery for my prostate cancer.  Is this safer than regular surgery?  I guess I'm asking what are the pros and cons for this type of surgery?  Not being a doctor, it's really hard to know which is best for me.  
Andrew Stephenson, MD:
This most important factor influencing the outcome of radical prostatectomy is the skill of the individual surgeon and his/her track record in achieving excellent outcomes with respect to cancer control, potency, and urinary continence.  This is more important than whether one has a robotic or open radical prostatectomy.  I do perform a large number of both procedures.  In my hands and in the hands of others who perform high quality open and robotic prostatectomy, there is no difference in the outcomes that matter most to patients (cancer control, potency, continence).  Robotic surgery appears to be associated with less bleeding but essentially no difference in postoperative pain, recovery or need for blood transfusion.
Andrew Stephenson, MD:
For those who are not familiar with robotic surgery, it involves making small incisions and inserting instruments and a video camera into the abdomen through these "keyhole" incicsions (instead of making a larger incision and looking into the pelvis with the naked eye).  The instruments are attached to a robot that the surgeon controls at a video console in teh operating room.  Technically, the robot is not performing the operation - the surgeon controls teh robot.  Hope that clarifies things for those who were interested in this procedure.
Carol 1:
What causes prostate cancer?  My brother-in-law said that he was told that too much testosterone can cause this cancer. Is that true?
Andrew Stephenson, MD:
There are many risk factors for prostate cancer.  Age, family history, ethnicity, and dietary factors appear to be the most important.  A low testosterone level may protect one from developing prostate cancer but a high T level may not necessarily increase one's risk. Interesting work from Cleveland Clinic suggests that a virus (called XMRV) may be the cause of prostate cancer in some men (similar to the HPV virus causing cervical cancer in women).  
Jack615:
Hi - thanks for answering my question.  I have been diagnosed with prostate cancer and have been told that it is "localized".  What does that mean and what are the options for treatment for this type of prostate cancer?
Andrew Stephenson, MD:
There are many treatment options for localized prostate cancer.  Active surveillance (or watchful waiting) may be appropriate for pateints with favorable features (usually low PSA, normal prostate exam, and a small quantity of Gleason 6 cancer on biopsy).  These patients require careful monitor with PSA and repeat biopsy every 2 years.  In terms of active treatments, surgery (called radical prostatectomy - which can be done open or with robot), external-beam radiation therapy, and brachytherapy (also called seeds) are accepted treatment approaches with long track records of success.  Each treatment may impact one's urinary, sexual and bowel function to varying degrees which should also factor into one's decision....based on his preferences.
ea_poe:
Thank you for your time doctor. There is a lot of different information out there about prevention, some of which conflicts. I'm a 36 year old, in your opinion what are the steps I should be taking to prevent prostate cancer and minimize my risks?
Andrew Stephenson, MD:
There is a lot of exciting progress being made on developing prevention strategies for prostate cancer.  A class of drugs called 5-alpha reductase inhibitors (finasteride and dutasteride) appear to reduce a man's risk by up to 25%.  Given your young age, I would not recommend starting these drugs at this time.  They are usually considered in men age 50 or older.  There is some increasing evidence that a PSA level at age 35-45 may be highly predictive of a man's lifetime risk of prsotate cancer (if the PSA is > 1 ng/mL, these men should be considred for screening before age 50).  If the PSA is < 1 ng/mL, they probably do not need to be screened with PSA until age 50.  In general, a heart-healthy diet (low fat, high fiber, low carbohydrate) may be the best way to reduce your risk of prostate cancer at your age (it's also good for the rest of you too!).
Don188:
Hello. I had a robotic laparoscopic prostatectomy in April. I had significant incontinence after the procedure but had begun to see some improvement to where I could get by on about 2.5 pads per day. At about the 4 1/2 month point this suddenly changed (literally overnight) to where I required 7 to 8 pads per day (as bad or worse than it's ever been). Is this common or a sign of a problem? (I also have noticable lower back pain.) Thank you.
Andrew Stephenson, MD:
You should see your urologist.   Sounds like you may have a urethral stricture or something else going on.
cbugen:
Are there any current alternatives to ADT for rising PSA after RP and salvage radiation? My husband is 63, 3 years post RP and 2.5 post radiation. His PSA has gone from 0.1 to 1.7 in three years. He had Gleason 9, no positive margins, no seminal vessicle invasion and was rated T3A. He feels great, has gone completely vegan, is a competitive swimmer and enjoys a healthy sex life. All the Dr.s seem to be pushing ADT and other interventions. Nothing we read seems to show any very promising results and the quality of life impact seems to be great. We monitor the PSA regularly do bone scans, etc. How long can we watch and wait?
Andrew Stephenson, MD:
If the PSA is rising slowly, I am inclined to observe these patients closely.  there is really no alternative yet to androgen deprivation therapy (ADT).  The problem wiht ADT is that there are considerable short- and long-term side-effects.  Given his low PSA, I would not be inclined to start ADT as there is little evidence to suggest that starting it now would be more beneficial compared to starting it at a later point in time.  As long as his PSA is < 10 ng/mL, I  am less inclined to start ADT.  When it is started, there is reasonable evidence to intermittent (start and stop) ADT is just as beneficial as continuous ADT - with the added benefit of improved quality of life and less cost.  This is a reasonable approach for patients with rising PSA only with no evidence of metastatic disease.  However, patients with metastatic prostate cancer (e.g. positive bone scan) should be managed wiht continuous ADT.
BK2005:
Thank you so much for answering our questions!  My father is 83 years old and was recently diagnosed with prostate cancer. His doctor has suggested "watchful waiting".  Would it be wise for us to get a 2nd opinion?  Part of me is screaming " What are we waiting for? Get the cancer out of him!"  
Andrew Stephenson, MD:
It is always worthwhile to get a second opinion.  My usual approach is to repeat the biopsy to make sure we are not underestimating the threat pose to a man by his cancer (e.g. more cancer on biopsy, or higher grade disease on biopsy).  If the repeat biopsy confirms favorable disease, WW or active surveillance is reasonable.  I follow these patients with PSA every 6 months with repeat biopsy every 2 years.
starman6600:
I am 68 y/o w/m and have BPH. Are there any advances from the original Green Light Laser in the past 2 years?
Andrew Stephenson, MD:
Green light laser is atreatment for BPH, not prostate cancer.
boulette:
Thank you. We live in the UK so his options were either radiotherapy or removal. But they advised against the removal due to his age. Do you think he is too old to have it removed? He is 77 but very very fit and young looking.
Andrew Stephenson, MD:
I don't use age to determine one's suitability for radical prostatectomy - I base it more on overall health and life expectancy.  That being said, we usually recommend external-beam radiotherpay or seeds over surgery in elderly patients because the periperative risks are higher with surgery than with the other 2 procedures.  Depending on the cancer features of your family member, active surveillance may be a reasonable approach (particuarly if his cancer features are favorable) as the threat this cancer poses to his longevity or quality of life may be minimal (certainly within the next 10 to 15 years).  
ChitChatNine:
About 7 yrs ago, a good friend of mine had prostate cancer that moved into his urethra where it was diagnosed as originating from the prostate and moving upwards.  He had continuously gotten bad urinary tract infections and finally they did some sort of highly specialized test at Thomas Jefferson University Hospital and found the cancer -- this was after repeated normal CT Scans.  After extensive surgery (both kidneys intact) & chemotherapy, it's been 7yrs and he's in full remission.  
What is the benchmark for becoming "cancer free" with Prostate Cancer?  Is it 10yrs?
Andrew Stephenson, MD:
Spread of prostate cancer to the urethra is very rare.  I suspect your friend had urethral cancer (or perhaps urothelial cancer of the prostatic urethra).  If he's 7 years out and cancer-free, he's in great shape.  For prostate cancer, 10 years is the benchmark most physicians use.  For urethral cancer, 5 years would be a very reasonable timepoint to estimate "cure".  
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