Basic Knowledge: Test for Prostate Cancer

BY MARK SCHOLZ, MD

While at Pete’s Coffee to write my bi-monthly blog I ran into another regular who occasionally hangs out at Pete’s. Vandana is a professor at Loyola University.  She is an expert in the psychology of learning.  While we were talking I started to bemoan my struggles to educate people about prostate cancer. One of the biggest bugaboos I face is how people overestimate their grasp of the prostate cancer situation. Once I verbalized my complaint, Vandana immediately proposed I create a basic test of prostate cancer knowledge so men could self-assess their level of knowledge.  Thanks Vandana!

 

1.    Which of the following is NOT a Prostate Cancer Staging System?

a.    D’Amico

b.    AJCC

c.    Whitmore-Jewett

d.    Gleason

 

2.    Seed implant radiation compared to surgery causes:

a.    More erectile dysfunction

b.    More incontinence

c.    More urinary symptoms

d.    Lower cure rates

 

3.    Men with Gleason Score:

a.    Less than 7 never metastasize

b.    Over 7 always metastasize

c.    Of  4 or less have undergone surgery

d.    Both a and c are correct 

 

4.    Which of the following is true about robotic surgery compared to standard surgery?

a.    Gives higher cure rates and lower rates of incontinence

b.    Results in quicker recovery after surgery

c.    Improves the chances for preserving erectile function

d.    Causes less shrinkage of the penis

 

5.    Hormonal therapy with Lupron improves survival when combined with:

a.    Radiation

b.    Surgery

c.    Alkaline water

d.    All of the above

 

6.    Which of the following is not true about PSA levels?

a.    Measures cancer cells in the blood

b.    Is affected by testosterone

c.    Rises after sex

d.    Rises with infections in the prostate

 

7.    Incontinence occurs in more than 5% of men who have:

a.    Surgery

b.    Radiation

c.    Hormone therapy

d.    All the above

 

8.    What is climacturia after surgery?

a.    The urge to urinate after climbing

b.    The ejaculation of urine

c.    Goes away with time

d.    Only occurs with unskilled surgeons

 

9.    Which of the specialty doctors listed are  Board Certified in Internal Medicine?

a.    Radiation therapists

b.    Urologists

c.    Medical oncologists

d.    Radiologists

 

10. Which of the specialty doctors listed are least-likely to see patients with early-stage prostate cancer?

a.    Radiation therapists

b.    Urologists

c.    Medical oncologists

d.    None of the above

 

11. The risk of dying within 30 days of having prostate surgery is:

a.    1 in 20

b.    1 in 200

c.    1 in 2000

d.    1 in 20,000

 

12. What does Medicare pay $28,000 for?

a.    Radical prostatectomy

b.    Intensity modulated radiation (IMRT)

c.    Proton therapy

d.    Seed implant radiation

 

13. Patients referred to radiation therapy doctors most frequently come from:

a.    Other patients

b.    Advertisements

c.    Urologists

d.    Medical oncologists

 

14. Biopsy misses high-grade disease in what percentage of men diagnosed with low grade disease?

a.    0%

b.    5%

c.    15%

d.    30%

 

15. Hormone therapy with Lupron does not cause:

a.    Baldness

b.    Weight gain

c.    Osteoporosis

d.    Dry Skin                                                                                                                              

 

Answers: 

1.    d. Gleason is a grading system not a staging system

2.    c. More urinary symptoms

3.    d. Gleason less than 6 on needle biopsy indicates an error in interpretation

4.    b. Robotic surgery is accomplished with smaller incisions resulting in quicker recovery

5.    a. Radiation is the only correct answer

6.    a. PSA is a protein  from cancer cells that rises proportionate to the number cancer cells

7.    a. Surgery is the only type of treatment associated with such a high risk of incontinence

8.    b. Ejaculation of urine occurs in 20% of men undergoing surgery at a center of excellence

9.    c. Medical oncologist are the only cancer doctors with basic internal medicine training

10. c. Fewer than 1% of medical oncologists in US consult on men with early-stage PC

11. b. Mortality risk of prostate surgery in the US is one in 200

12. b. IMRT is $28,000, Medicare pays far less for either surgery or seed implants

13. c. Urologists refer most of the prostate patients to radiation docs.  That’s why radiation docs never say a bad word about surgery

14. c. 15% of men with low grade disease have higher grade disease that the biopsy missed

15. a. Men with baldness treated with hormone therapy  often notice a return of their scalp hair

Pay-Off Versus Collateral Damage

BY RALPH BLUM

Life is full of risks, but if you are one of the legion of men with prostate cancer whose urologist is recommending a radical prostatectomy, make sure you have considered the following risks of collateral damage:

Incontinence: 
Urinary leakage is usually a temporary problem after a prostatectomy, but even the best urologists report that about 7% of their patients are left with permanent and constant urinary drainage.  Less skilled surgeons have much higher rates. After surgery, most men experience some minor leakage when they cough, lift, bend over, or laugh.

Another problem is the formation of scar tissue in the urethra, the passage from the bladder to the penis. The suture site where the severed urethra is reconnected can become constricted by scar tissue that blocks the flow of urine. This may be correctable with urethral dilation, a process forcing oversized, stainless steel probes up the penis to stretch out the ring of rock-hard tissue. Unfortunately, scar tissue is notoriously uncooperative, often refusing to stretch at all. In some cases the stretching fractures the brittle ring of tissue, resulting in permanent incontinence. If that happens, another operation is required to implant an artificial sphincter.

Impotence:
Without nerve-sparing surgery permanent erectile dysfunction is virtually inevitable. With nerve-sparing surgery, the best surgeons hope to be able to save the nerve bundles (located very close to the back of the prostate on both sides) that control erections. If both sides of the nerve bundles can be saved, potency is around 40% to 75% in patients under 70 years old (depending on which expert you consult, and the patient characteristics). If only one side of the nerve bundles can be saved, potency drops to around 25% to 45%. However, until the doctor actually performs your surgery, he won’t know whether he can spare the nerve bundles.

Even men who recover their erections after surgery undergo a prolonged period of impotence, often lasting up to a year or more. During this time of enforced abstinence, as with any unused muscle, atrophy of the penis occurs. This means that of the men who end up recovering some degree of erectile function, only 5% report that their erections are as good as before surgery.  Additionally, despite claims from urologists who maintained for years that patients’ complaints of penis shrinkage were anatomically impossible, diligent researchers have finally collected the necessary measurements showing that shrinkage is common. The average amount is about one-half inch, although some men undergo considerably greater shrinkage.

Studies show that impotence can totally redefine a man’s self-esteem, his self-confidence and his relational satisfaction. In some cases Viagra can help with surgically induced impotence. However, penis vacuum devices, penis tourniquets, penis injections (yes, with needles) or the surgical implantation of a plastic rod into the penis is often required to restore function. In my case, lead me to the monastery!

Other Rare but Possible Risks from Surgery:

• Significant blood loss requiring transfusions
• Pain from surgery
• Blood clots in the legs
• Heart Attack
• Infection
• Temporary or permanent memory loss from anesthesia
• Miscellaneous surgery-related problems

 

So with these considerable risks, what is the pay-off for undergoing surgery? The major pay-off is, if you are lucky and have a successful nerve-sparing prostatectomy, it will cure the cancer and you will suffer minimal collateral damage. The only other advantage is you get a better idea of how serious your cancer is because the pathologist evaluates the prostate after its removal. If he finds that the cancer has spread even a little, you and your doctor can decide what to do next.

 

No one knows for sure which prostate cancer treatment gives a better chance for cure or a better quality of life. But if you decide to go with a prostatectomy, make sure that the surgeon you are considering is experienced and skilled in the procedure.

Surgery vs. Seeds vs. IMRT

BY MARK SCHOLZ, MD

 

Many men with Intermediate-Risk prostate cancer consider treatment with radiation or surgery. Treatment selection is influenced by age and preexisting status, especially as regards baseline sexual and urinary function. These days “surgery” usually means robotic surgery rather than the older, “open” procedure. Brachytherapy (radioactive seeds), and intensity modulated radiation (IMRT) are the most widely used types of radiation.

 

Cure Rates

All treatment options result in similar cure rates assuming the best physicians and technology are used. If any single treatment can be considered to have a slight advantage, it is brachytherapy. Seed implants deliver a somewhat higher dose of radiation, possibly with slightly better accuracy. All types of radiation have a slight cure-rate advantage over surgery because radiation treats a small margin around the gland. Surgery, especially when extra-capsular disease is present, may leave cancer behind, an unfortuante situation called “a positive margin.”

 

Quality of Life

Since cure rates are equivalent, the main criteria for selecting treatment are side effects. Table 1 lists the risks faced by a 65-year-old with good erectile function and without preexisting prostate problems. Risks are adjusted up or down based on a man’s age and his sexual and urinary function prior to treatment.
 

Table 1 Long Term Side Effects

Impotence Incontinence Climacturia* Urethritis Stricture** Proctitis Surgery 50% 8% 15% - 5% - Seeds 30% 1% - 10% 2% 1% IMRT 30% 1% - 4% 2% 2% *Climacturia is the ejaculation of urine rather than sperm **Stricture is a urethral scar

Short Term Side Effects
Some of the long-term effects noted in Table 1 also occur short term. All men are impotent after surgery though 50% eventually recover some functionality. Urinary symptoms, termed “urethritis,” occur in two-thirds of men who undergo brachytherapy, usually lasting a couple months. Proctitis symptoms lasting one to two months occur in about half of the men who are treated with IMRT.

Treatment for Long Term Side Effects

Shrinkage and shortening of the penis due to surgery may be partially averted with early use of Viagra, Cialis or Levitra, and when necessary, the injection of prostaglandins. For treating impotence or incontinence, patient satisfaction is about 85% with a surgically implanted penile prosthesis and 60% with a surgically implanted artificial urinary sphincter. Chronic urethritis, a non-healing radiation burn of the urinary passage, manifests as pain, frequent urination, and a compelling urge to urinate right now. Proctitis side effects can be described similarly, but affecting the rectum. Palliative treatments for chronic urethritis and proctitis are only partially effective.

 

Further Aspects of Surgery and Radiation

 

Surgery: The surgical skill of urologists varies and is measured by how frequently cancer is left behind after the surgery, termed a positive margin. The best surgeons average a 10% rate. Studies show that many urologists, even at reputable centers, leave cancer behind up to 50% of the time. Prostate removal gives information about the size and grade of the cancer, helping to improve the accuracy of projections about future relapse. Surgery also simplifies PSA monitoring, since unlike radiation, there is no residual prostate gland producing PSA.

Seeds: Brachytherapy with permanent seeds is an outpatient procedure. Temporary, high-dose-rate (HDR) brachytherapy requires an overnight stay in the hospital. Men with preexisting urinary problems or glands over 60cc are more prone to develop urethritis from brachytherapy. A benign PSA rise after the implant, termed a “PSA Bump,” occurs in 30% of men and can engender considerable anxiety.

IMRT treatment requires two months to deliver. Radiation beaming through surrounding organs may increase the risk of bladder and rectal tumors, though the risk is clearly less than one percent. The biggest risk besides impotence is proctitis. In the future, the injection of hydrogel between the prostate and the rectal wall may eliminate this risk (Hydrogel is pending FDA approval).

Cyberknife and Proton Therapy: Cyberknife is like IMRT but treatment is over one to two weeks rather than two months. Proton therapy is also similar to IMRT except it fires heavier subatomic particles (proton vs. photon). Proctitis rates are reported to be slightly higher with either of these two modalities.

Combination Radiation with Seeds and IMRT: Men with High-Risk disease and even some with Intermediate-Risk are treated with a combination of Seeds and IMRT. The side effects of Seed/IMRT combinations are similar to those of seeds alone.

The Outdated Sequencing Argument
As stated at the outset, cure rates are high with both radiation and surgery. Arguments touting surgery as the “Gold Standard” were true ten years ago when suboptimal radiation resulted in lower cure rates. Regrettably, to this day, many surgeons are still claiming that sequencing surgery before radiation is advantageous. This outdated thinking prioritizes planning for relapse, forgetting about the need to focus on quality of life. The goal is to be cured with the first treatment and be spared the side effects of additional rounds of therapy.

Taking Time to Decide
Prostate cancer is slow moving condition. There is no need rush to a decision. Radiation or surgery cures men with Intermediate-Riskprostate cancer 70-90% of the time. Even if a relapse occurs, salvage therapy usually gives a normal life expectancy. Additional options, besides surgery and radiation, can also be considered for men in the Intermediate-Risk category including active surveillance, focal therapy and intermittent hormone blockade. However, these treatments are outside the medical mainstream and beyond the scope of this short blog.