New Ways of Using “Old” Technology

BY MARK SCHOLZ, MD

My old professor from USC, Dr. John Daniels, once told me that most “new inventions” are usually the result of “old invention” being repurposed in a new way.  His own company was an example.  Dr. Daniels developed a process for extracting collagen from cow hides (before Botox came along, collagen was injected into wrinkles for cosmetic reasons). Collagen was FDA approved for injection into wrinkles, but Dr. Daniels readapted it for treating cancer.  He performed studies that injected collagen into the blood vessel feeding liver tumors to block the blood supply.

A couple weeks ago at the PCRI’s midyear update, Dr. Margolis spoke about the possibility of readapting multiparametric MRI (MP-MRI) for cancer screening in men with high PSA as an alternative to random biopsy. For those of you who don’t know, MP-MRI has already gained widespread acceptance as a backup plan for finding prostate cancers in men with high PSA levels when an initial 12-core random biopsy fails to detect cancer.

Any logical person would think that, “If the MRI is more accurate, less invasive and less expensive, why not simply do the MRI first, before the biopsy?”  Then, if the MRI is clear a biopsy can be avoided altogether. (And when the MRI does show a suspicious spot, only one or two cores are needed to biopsy it.)

However, the medical community, which has been doing random biopsy for the last 25 years, patiently awaits the results of studies to evaluate the accuracy of random biopsy and MP-MRI in head to head trials.  Unfortunately, these studies will take many years to complete.  And in the meantime, should we keep doing random biopsies in a million men every year?

We are all well aware of how quickly the development of new medical technology is accelerating.  So in this blog, my goal is to point out that as all these new treatments are becoming available, it creates new uncertainties about how to use them in the most optimal fashion.

Newly-approved, more powerful hormone treatments like Zytiga and Xtandi are a good case in point. Studies clearly validate their superiority over traditional hormone shots and pills in men with advanced disease.  But doctors are reluctant to prescribe such procedures for men with earlier-stage disease, even when the cancer is unequivocally high risk. Once again they cite, “The absence of clinical studies to support this new and expanded role.”  

One question always seems to arise when proposing to use a new treatment in an expanded role. The question is “Maybe we should reserve the new treatment in case the traditional treatment fails.  After all, don’t we need a backup plan?”  The problem, at least as far as treating relapsed cancer is concerned, is that most cancer “backup plans” can’t bring about a cure. The best chance for curing cancer is always with the first treatment.  And it’s not like this question hasn’t been already looked into.  Numerous studies have addressed the question of sequencing treatments versus using the same treatments simultaneously in combination.  Almost every time the cure rates are improved by using the treatments in a combination, “up-front” approach rather than trying one treatment and waiting to see if it fails before starting the second treatment.

So in summary, this is a new era of hope and discovery. I’m sure none of us are complaining about having a whole bunch of new and effective treatments available.  However, with this privilege come new responsibilities. But doctors and patients will need more flexibility in their thinking. In this era of rapid technological progress the standard preconceived notion that every treatment recommendation must be backed up by a scientific study will need to be reconsidered.   

African-Americans and Prostate Cancer

BY RALPH BLUM

The hard fact is that the death rate from undiagnosed prostate cancer for African-Americans is currently more than twice that for Caucasian men. Although scientists do not yet fully understand why this is so, it is widely believed that genetic differences, lifestyle, reluctance to undergo digital-rectal testing, and nutritional habits all play a role in these statistics. Which is why all African-Americans are urged to begin tests at an earlier age (40) regardless of their health history.

While African-American men are already at an increased risk for prostate cancer, that risk goes up even further if there is a family history of the disease. African-American men, with an immediate family member who had prostate cancer before age 65, have a one-in-three chance of developing the disease. With two family members involved, that risk rises to over 80%. This is why prostate cancer screening at a younger age is vital because by the time that symptoms appear, the cancer is more likely to be at an advanced stage.

The differences in prostate cancer diagnosis and treatment seem to account for a significant portion of the gap in death rates between blacks and whites.  First, black men are less likely than whites to have adequate insurance. Uninsured men have lower rates of screening and are less likely to see a health care professional. These men are more likely to be diagnosed with advanced disease –cancer that has spread outside of the prostate gland. It is worth noting that studies of blacks and whites in the military, where men have equal access to health care services, have shown that this equal access eliminates of most of the death rate gap.

So what can African-American men and their health care professionals do right now?  The advice is the same for black men as for all other men. Focus on early diagnosis through PSA screening.  The controversies about PSA screening are mostly related to over diagnosis of low-grade disease.  Many of these low-grade cancers don’t even need to be treated. They can be safely watched. And that fear can largely be address by evaluating an abnormal PSA finding with a MRI scan rather than a 12-core random biopsy.  Given the extremely high rates of prostate cancer in African-American men, getting a PSA test represents a simple but potentially life-saving act.

Scare Tactics about the “Symptoms” of Prostate Cancer

MARK SCHOLZ, MD

In this week’s blog I was supposed to finish out the “Helpful Medications” theme started at my last blog. Specifically I need to make a case for using statin drugs and metformin, a generic diabetes drug, to help suppress prostate cancer.  However, that blog has been temporarily postponed in place of the following:

When Ralph and I wrote Invasion of the Prostate Snatchers we knew our highest priority was to calm people down so they could begin to think rationally.  Obviously the word “cancer” freaks everyone out. People get so scared that all rational thought ceases.  They immediately jump into the arms of the nearest doctor who is willing to offer a quick fix.  With prostate cancer that just happens to be a surgeon.

Scare tactics are effective from a business point of view since in business “time is money.” Frightened people act quickly and decisively, thus saving everyone time.  The psychology of fear is also quite commonly used in advertising.  You have heard these mottos and mantras many times before: “Time is Running Out,” or, “Space is Limited.”  No one wants to miss a one-time opportunity.

The threat of losing a one-time chance for cure naturally drives newly-diagnosed prostate cancer patients to act quickly. And there is after all a certain type of logic to people unfamiliar with prostate cancer.  With almost any other type of cancer a delay in treatment will reduce cure rates. Surprisingly with prostate cancer this is only rarely the case. However, the idea of a “harmless cancer” is certainly foreign to us all. It will take some time for newly-diagnosed patients to absorb this unexpected fact.

That’s why it is critically important to encourage men to take time to gather their senses and calm down.  Given some space to reflect they will learn that with prostate cancer they need to weigh the potential for treatment-related side effects against the tiny amount of increased survival surgery or radiation offers in men with low-risk disease.

As noted above, the fears and confusion incurred by a recent prostate cancer diagnosis have a certain type of logic. But what is totally illogical is the proliferation of articles I keep coming across on the internet that purportedly describe the “Symptoms of Prostate Cancer.”  Invariably these articles present a long list of symptoms such as urinary frequency, nighttime urination, slow urination, and blood in the urine as possible indications of prostate cancer.

These articles are completely false! EARLY PROSTATE CANCER ALMOST NEVER HAS SYMPTOMS.  This is why the PSA blood test has been so revolutionary.  PSA can detect prostate cancer before symptoms of advanced disease occur. The most common symptom of prostate cancer—bone pain—only occurs after the disease has spread to the bones. Prostate-related symptoms, when they are present, signal another diagnosis such as prostatitis or prostate enlargement. These prostate problems have nothing to do with prostate cancer. Symptoms such as these may need evaluation and treatment but there is no reason to scare people with the suggestion of cancer.

Competition on the internet has become so fierce that just about any scare tactic is considered acceptable, up to and including bald-faced lying.  But let’s put this falsehood to rest.  The myth that early-stage prostate cancer causes urinary or sexually related symptoms is an exploitative tactic that can lead to all kinds of harm, creating anxiety and fear that results in unnecessary diagnostic testing such as random needle biopsies that lead to the over-diagnosis of low-risk prostate cancer.

Robot, Robot, Burning Bright …

RALPH BLUM

If you have read some of my previous blogs you probably will be aware that I am not an advocate of radical prostatectomies in any shape, way or form. But since the robot-assisted laparoscopic prostatectomy (RALP) is the flavor of the month with both prostate cancer patients and their urologists, it seems pertinent to zero in on some of the information you need to know if you are considering this procedure.

 

There is something alluring about the idea a surgeon sitting at an attached console and manipulating a robot’s mechanical arms to perform this highly complex and intricate operation. But if you are under the impression that it is the robot making those small incisions in your abdomen to perform the operation, think again. It is the skill of the surgeon that will preserve (or not) your sexual function by avoiding damaging the miniscule nerves that run along each side of the prostate and control erections.  It is the surgeon’s experience that will (or not) protect the sphincter that allows you to retain urinary control. And it is the surgeon’s expertise that will ensure a positive, long-term outcome.

 

RALP has advantages over other forms of radical prostatectomy in terms of pain, blood loss, and recovery time. No small thing. But keep in mind that any complex surgery comes with risks: the small risk of heart-attack, stroke, blood clots in the legs that could travel to the lungs, reactions to anesthesia, and infection of the incision sites. And because there are many blood vessels near the prostate gland, there is also the risk of prolific bleeding, in which case blood transfusions might be necessary—which carry their own risk. But your risk level depends primarily on your overall health, your age, and the skill of your surgical team.

 

Having said that, I realize how tempting it is to go for closure. But is surgery—robotic- assisted or otherwise--really closure? Statistics show that is debatable.  And in terms of the side-effects that most men are concerned about (urinary incontinence and impotence)  there is little difference between robotic-assisted surgery and laparoscopic surgery performed without the robot. Bottom line, the most important factor with either procedure is the surgeon’s experience and skill.

 

Opinions differ about how many robotic-assisted operations a surgeon needs to perform to become really proficient, but surgeons at community hospitals rarely have sufficient experience. And you do not want to be part of a surgeon’s steep learning curve. Dr. Vipul Patel, of the Global Robotics Institute in Celebration, Florida, appears to be leading the pack having performed some 8,000 robotic prostatectomies.

 

It’s apparently hard to resist the lure of a robot. But any kind of radical prostatectomy is both costly and risky, so don’t let your natural desire for closure blind you to the risks of such a challenging surgery—especially if you are 70 or over.  In fact if you have low-risk prostate cancer and are over 65, you have a 20% chance of dying of cancer in the next 20 years compared to a 60% chance of dying of something else. So buyer beware!