BY MARK SCHOLZ, MD
assume that the differences in the way prostate cancer behaves—one man develops
symptoms and another doesn’t—is because they are seeing different stages of the same illness. What’s overlooked, often with disastrous
consequences, is that these differences are also due to the fact that distinct varieties of prostate cancer exist.
optimal therapy depends on matching an appropriate treatment with both the
correct stage and the correct type of prostate cancer.
Since blue is the color for prostate cancer, as pink is the color for
breast cancer, the PCRI has subdivided prostate cancer into five major Shades of Blue. These shades incorporate both the stage and the type of disease. The five shades are SKY, TEAL, AZURE, INDIGO and
first three shades, SKY, TEAL and AZURE, represent men who have had no previous
surgery or radiation. TEAL is what medical professionals call “Intermediate-Risk.” Men in the TEAL
shade have identical characteristics to SKY—PSA under 10, Gleason under 7 and a
small nodule (or no nodule) on digital rectal examination. However, in
addition, men in TEAL have one of the following: PSA between 10 and 20, or, Gleason of 7, or digital rectal exam
with a “biggish” nodule confined to one side of the gland.
men in TEAL have a small but real chance of cancer spread, staging scans of the
bone and body are needed. In addition, a
multiparametric MRI or a Color Doppler Ultrasound should be done to check for
spread around the gland just outside the capsule. If extra-capsular disease is
seen, the shade changes from TEAL to AZURE.
Treatment for TEAL
list of treatment options for TEAL is long.
While occasionally men are candidates for active surveillance— particularly
those who are older—one of the following treatments is usually administered:
Robotic surgery, open surgery, intensity modulated radiation, temporary
high-dose seed radiation, permanent seed radiation, a combination of seed
radiation and IMRT, proton therapy, Cyberknife, focal therapy or testosterone
inactivating pharmaceuticals (TIP).
Sometimes a short course of TIP is combined with radiation.
therapy “focuses” treatment on the cancer itself rather than the whole
gland. Typical tools used for focal
therapy are cryotherapy, HIFU or laser. In general, skillfully administered
focal therapy is thought to be associated with a lower risk for side effects
and only slightly higher risk of future cancer relapse. However, focal therapy
is very new and there are relatively few studies accurately describing
option is to use TIP. TIP causes the cancer to shrivel up. Typically TIP is continued for six to twelve
months after which men are placed on active surveillance.
general principle is that treatment success depends just as much on the skill
of the administering doctor as it does on the type of treatment selected.
general principle is that cure rates with most of the different treatments are
so close that for comparison purposes, they should be considered identical. Of
course, the truth of this principle is predicated on the assumption that all
treatments are administered by equally skilled experts.
Side Effects of Treatment
prostate gland is so close to other critical organs it becomes very difficult
to target the gland without damaging surrounding structures. The most common
side effects, therefore, are persistent difficulties with sexual, urinary or
rectal function. For example, after
radiation in an average 65-year-old, about 75% of men will recover back to
their normal pretreatment level of urinary function. About 50% will recover
back to their normal pretreatment level of sexual function. After surgery,
about 50% of men have urinary function that is restored but only 20% describe
their sexual function as recovering back to baseline.
about the incidence of side effects after focal treatment are less than certain
because this technology is so new. Overall, assuming that the treating
physicians are skillful, one would expect somewhat better potency rates and
somewhat lower cure rates compared to standard surgery or radiation.
TIP with others options is even more difficult.
Cure rates are certainly much lower. However, the good news is that permanent side effects are rare. The three most troublesome side effects
during therapy are low libido, weight gain and fatigue. Weight gain and fatigue
are partially counteracted with diligent diet and exercise. Low libido only
resolves after TIP is stopped. Other common side effects such as hot flashes,
calcium loss from the bones, mood swings, breast growth and erectile
dysfunction can be prevented with medication.
the TEAL Shade of Blue, compared to men in the other shades, face the biggest challenge—making
a therapeutic choice. First, there are
so many options. Second, none of the options are attractive. The “best” choice is only relatively better than the others; it’s
never something you want to do. Making
the best choice for yourself requires good comparison shopping skills, and that
requires extensive homework. There are no shortcuts. Third, the biggest
differences between the options are not related to the cure rates, it’s the
concern about permanent side effects that needs the most attention.
my recommendation for selecting treatment is to create a list of all the
reasonable choices and study them closely, especially in term of the potential
long-term side effects. The “worst”
choices should be eliminated one by one. The last option left on the list will
probably be the best treatment for you.