BY MARK SCHOLZ, MD
Everyone is
excited about the latest craze in medical technology—genetic analysis of tumor
cells, which I’ll call GAT for short. The scientific progress that has been
made with GAT in my opinion is the second most
exciting area of advancement in medical technology today (see further below for
more about the first most exciting area). GAT technology is already being
commercialized for use in the medical marketplace in products like Prolaris
and Oncotype. This technology is able to
predict the aggressiveness of prostate cancers, enabling us to differentiate
between the men who need immediate treatment and those who can postpone
treatment safely.
The predictive power of GAT is certainly exciting, but there is already an
effective form of genetic testing available that has been around for more
than 40 years, the Gleason scoring system. The Gleason system relies on the
visual appearance of cells under the microscope to draw conclusions about their
inner genetic makeup. In the medical world, using the visual appearance of the
cancer cells is called phenotypic
analysis. GAT is genotypic
analysis. Drawing conclusions about underlying genetic makeup by simple
visual assessment is a pervasive in human experience. In courtship, we
rely on phenotypic analysis of the underlying genetic make-up of potential
spouses to form an opinion about their suitability as potential mates.
Perusal of the genetic pool of immediate family members provides further
insight.
So how can Gleason score draw conclusions about the underlying genetic
potential for tumor aggressiveness simply by looking at the appearance of cells
under a microscope? The answer is to do a comparison of the visual
appearance of cancer cells with the appearance of normal prostate cells. Normal
cells in the prostate perform varied functions but still work together as a
team. Specifically, healthy cells form into definable structures called
glands. In these glands some cells manufacture prostatic fluid, a complex
liquid comprising the ejaculate for the sperm to swim in. Other cells
organize to form ducts, a piping system to drain the fluid from the outer
periphery of the gland and channel it into the middle of the prostate so that a
large quantity of fluid can be expelled through the urethra at just the right
moment. All of these different cells work as a team and coexist in the
prostate functioning together in a structured glandular arrangement.
When a
trained pathologist looks at tumor cells under the microscope he grades them by
the degree of cellular disorder. He is asking himself the question, “How
much do these cells retain the normal glandular characteristics of the prostate
gland?” If a cross section of the tumor looks like an unbroken sheet of
uniform cells, the cancer is high-grade; the cells have lost their ability to
cooperate with each other and form glands. The cancer cells have been honed
down into little race cars with only one mission, to aggressively pursue its
own replicative destiny. When tumors have this appearance they are graded as a
Gleason 9 or 10. On the other hand, if the appearance of the tumor shows
residual glandular components, it is less aggressive, perhaps a Gleason 7.
Gleason 6 “cancer,” the type the one that never spreads, looks almost like
normal prostate gland tissue.
Predicting
future tumor behavior is obviously very important. How fast will it grow?
Is it likely to spread? How well can it be expected to respond to treatment? As
a result of decades of experience, doctors have learned to use the Gleason
scoring system to accurately predict the long-term outcome in individual
patients. The new GAT tests represent an important additional refinement,
further enhancing our ability to predict the future behavior of an individual
cancer. GAT holds one even bigger promise. In the future we believe GAT
testing will be a powerful aid in the selection of targeted therapy, i.e.,
picking cancer treatments with anticancer activity tailored to individual tumor
types. This hope, however, will have to be postponed until our limited
armamentarium of effective treatments is further expanded.
Now, what is
it that I consider to be the most exciting
area of medical progress? Since I am an impatient type of guy, someone who is
looking for quick results, I find immunotherapy more exciting than GAT. To
fully exploit the potential of GAT we will need to invent new pills for each of
the myriad of genetically different tumor types. Immunotherapy on the other
hand comes with its own “built-in” GAT system that enables it to target the
unique genetic signature of individual cancer cells. The immune system is so
smart, all we have to do is “flip the switch on” and starts cranking out
genetically targeted anticancer therapy. Recent developments in the field of
immunology are truly mind-boggling and hold promise for a big revolution in
cancer therapy within the next 5-10 years. I’ll try to address some of
these recent advances in an upcoming blog.
Showing posts with label gleason. Show all posts
Showing posts with label gleason. Show all posts
Tuesday, January 12, 2016
Tuesday, December 29, 2015
Predicting Prostate Cancer’s Future Behavior
BY MARK SCHOLZ, MD
Developing an accurate prognosis, i.e., predicting how a man’s cancer is likely to behave in the future, is the first and most important step toward optimal care. Future predictions are often looked at with some suspicion. With prostate cancer, however, our power to anticipate future cancer behavior is quite accurate unless there is a lack of thoroughness in gathering information.
The Size of the Tumor
Tumor size is a universally important prognostic sign for almost all types of cancer including prostate cancer. The method for incorporating tumor size into the Anthony D’Amico’s staging system relies on the degree of PSA elevation, the tumor grade and on how the prostate "feels" with the finger of a trained practitioner. These indicators are useful but don’t incorporate information from modern imaging. Imaging provides accurate information about tumor size and the presence or absence of extracapsular extension. These are very powerful prognostic predictors and it would be foolish to disregard their importance. As things stand presently these indicators are often used to divide the low, intermediate and high risk categories into "favorable" and "unfavorable" subcategories, each with a different spectrum of recommended treatment options.
Knowing Past Treatments Tells Something about Future Prognosis
Historically, since the total number of available treatments is relatively limited, practitioners have used a sequential "trial and error" treatment methodology that administers the standard treatment options in a fairly predictable sequence. For example, it is not uncommon for men to start with surgery or radiation. When a relapse occurs, standard hormone therapy (Lupron) is often started and given intermittently or continuously. Hormone therapy usually controls the disease for an average of 10 years. When Lupron stops working, immunotherapy with Provenge is usually follows. After Provenge, more potent hormone therapy with Xtandi or Zytiga is started. If these two agents prove ineffective, chemotherapy with Taxotere or radiation with Xofigo would be considered next.
The whole point of presenting the treatment sequence described in the previous paragraph is to convey the idea that the number of previous treatments communicates important information about that patients’ future prognosis. Having "failed" Lupron, for example, bespeaks of a much more worrisome prognosis compared to the situation where Lupron continues to be effective.
Response to Lupron, The Mother of All Metrics
The quality of the "response" to Lupron is actually one of the most powerful prognostic metrics available. The degree of PSA decline after Lupron is incredibly important. How low the PSA drops after starting Lupron is called the "PSA nadir." The specific PSA threshold used to determine a "good response" is less than 0.1. Believe it or not, there is a huge difference in prognosis between a man on Lupron for six months who has a PSA of 0.1 versus a man whose PSA levels off at 1.0.
An Established History is also a Prognostic Indicator
Another somewhat obvious prognostic indicator that is often overlooked and almost never discussed in textbooks has to do with the prognosis of men who have been diagnosed years ago -- over time it is apparent that things are turning out much better than what might have been expected based on their initial indicators. For example, take the case of a man who started off with a panoply of bad indicators—tumor is in the lymph nodes and Gleason 10—but after aggressive treatment remains in remission for 5 years. The fact that things have gone well for five years counts bigtime in his favor going forward. Remember, the original prognostic predictors of a Gleason 10 were just that, predictors. No predictor is 100% accurate. Five years of established history is a stronger predictor than the original Gleason score. The fact that things have gone well for five years, strongly indicates that the future is for that individual is bright. Such individuals have "beaten the odds."
The Location of the Tumor in the Body
Another extremely important indicator of prognosis, something that even laypeople anticipate by simple common sense, is the location of the cancer in the body. Location says volumes about how things are likely to progress in the future. For example, consider the following sequence of progressively more serious cancer sites:
•Contained within the prostate
•Extended into the seminal vesicle
•Spread to the lymph nodes
•Bone metastases
•Liver metastasis
Each of these locations is very important for determining prognosis.
This short blog is just an introduction to some of the "profiling" methods utilized in generating an accurate prognosis. Space limitations preclude discussion here about other known prognostic factors such as the size of the prostate gland (discussed in a previous blog), genetic tests and PSA doubling time. The D’Amico risk categories constitute the backbone of useful prognostic information. However, the additional prognostic information beyond the D’Amico risk categories that are discussed in this blog, provide additional useful information necessary for determining an accurate prognosis. An accurate prognosis is the starting point for accurate selection of treatment.
Developing an accurate prognosis, i.e., predicting how a man’s cancer is likely to behave in the future, is the first and most important step toward optimal care. Future predictions are often looked at with some suspicion. With prostate cancer, however, our power to anticipate future cancer behavior is quite accurate unless there is a lack of thoroughness in gathering information.
The Size of the Tumor
Tumor size is a universally important prognostic sign for almost all types of cancer including prostate cancer. The method for incorporating tumor size into the Anthony D’Amico’s staging system relies on the degree of PSA elevation, the tumor grade and on how the prostate "feels" with the finger of a trained practitioner. These indicators are useful but don’t incorporate information from modern imaging. Imaging provides accurate information about tumor size and the presence or absence of extracapsular extension. These are very powerful prognostic predictors and it would be foolish to disregard their importance. As things stand presently these indicators are often used to divide the low, intermediate and high risk categories into "favorable" and "unfavorable" subcategories, each with a different spectrum of recommended treatment options.
Knowing Past Treatments Tells Something about Future Prognosis
Historically, since the total number of available treatments is relatively limited, practitioners have used a sequential "trial and error" treatment methodology that administers the standard treatment options in a fairly predictable sequence. For example, it is not uncommon for men to start with surgery or radiation. When a relapse occurs, standard hormone therapy (Lupron) is often started and given intermittently or continuously. Hormone therapy usually controls the disease for an average of 10 years. When Lupron stops working, immunotherapy with Provenge is usually follows. After Provenge, more potent hormone therapy with Xtandi or Zytiga is started. If these two agents prove ineffective, chemotherapy with Taxotere or radiation with Xofigo would be considered next.
The whole point of presenting the treatment sequence described in the previous paragraph is to convey the idea that the number of previous treatments communicates important information about that patients’ future prognosis. Having "failed" Lupron, for example, bespeaks of a much more worrisome prognosis compared to the situation where Lupron continues to be effective.
Response to Lupron, The Mother of All Metrics
The quality of the "response" to Lupron is actually one of the most powerful prognostic metrics available. The degree of PSA decline after Lupron is incredibly important. How low the PSA drops after starting Lupron is called the "PSA nadir." The specific PSA threshold used to determine a "good response" is less than 0.1. Believe it or not, there is a huge difference in prognosis between a man on Lupron for six months who has a PSA of 0.1 versus a man whose PSA levels off at 1.0.
An Established History is also a Prognostic Indicator
Another somewhat obvious prognostic indicator that is often overlooked and almost never discussed in textbooks has to do with the prognosis of men who have been diagnosed years ago -- over time it is apparent that things are turning out much better than what might have been expected based on their initial indicators. For example, take the case of a man who started off with a panoply of bad indicators—tumor is in the lymph nodes and Gleason 10—but after aggressive treatment remains in remission for 5 years. The fact that things have gone well for five years counts bigtime in his favor going forward. Remember, the original prognostic predictors of a Gleason 10 were just that, predictors. No predictor is 100% accurate. Five years of established history is a stronger predictor than the original Gleason score. The fact that things have gone well for five years, strongly indicates that the future is for that individual is bright. Such individuals have "beaten the odds."
The Location of the Tumor in the Body
Another extremely important indicator of prognosis, something that even laypeople anticipate by simple common sense, is the location of the cancer in the body. Location says volumes about how things are likely to progress in the future. For example, consider the following sequence of progressively more serious cancer sites:
•Contained within the prostate
•Extended into the seminal vesicle
•Spread to the lymph nodes
•Bone metastases
•Liver metastasis
Each of these locations is very important for determining prognosis.
This short blog is just an introduction to some of the "profiling" methods utilized in generating an accurate prognosis. Space limitations preclude discussion here about other known prognostic factors such as the size of the prostate gland (discussed in a previous blog), genetic tests and PSA doubling time. The D’Amico risk categories constitute the backbone of useful prognostic information. However, the additional prognostic information beyond the D’Amico risk categories that are discussed in this blog, provide additional useful information necessary for determining an accurate prognosis. An accurate prognosis is the starting point for accurate selection of treatment.
Tuesday, January 27, 2015
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
Tuesday, January 13, 2015
Prostate Cancer: Starting at the Very Beginning
BY MARK SCHOLZ, MD
Yesterday I sat down with a new patient, Sam, a charming man who, unfortunately, was just found to have a prostate nodule and a PSA of 50. When I asked Sam why he had not visited a doctor for over 10 years or undergone any PSA testing, he responded, “I have always enjoyed perfect health. Why see a doctor?” Sounds sort of like a stupid response, but judging by his healthy appearance, (looking more like a 70 year old than an 80 year old), one would have to say that until now his policy has been pretty successful.
However, if Sam was going to participate intelligently in further discussions about the selection of optimal treatment, his prostate cancer knowledge would need a major upgrade. Since my instruction had to begin at a very elementary level, I thought I would use this blog to share the main themes of our almost two-hour meeting together. Focusing on the basic first steps seems an appropriate theme for this, my first blog of the New Year.
Not All Cancers Are the Same
Many patients introduced into the cancer world fail to understand that lung cancer, breast cancer, brain cancer and prostate cancer are each a distinct illness, each with more differences than similarities. These different cancers are as different as kidney stone disease is different from pneumonia. Therefore, preconceived notions coming from personal experiences with one type of cancer occurring in family members or friends are frequently misleading.
Prostate Cancers are a Mixed Bag
It’s fairly easy to see why dissimilar cancer types, such as bladder cancer and skin cancer for example, behave differently; it may be harder to understand that prostate cancer itself comes in many different and distinct subtypes. Part of this varied behavior can be explained by the disease stage: No one is surprised by the fact that cancer diagnosed at an early stage has a different outlook compared to cancer diagnosed after it has metastasized.
However, beyond the issue of variable stage, when comparing two different prostate cancers of exactly the same stage, what we call “prostate cancer” can be extremely variable. Consider the following: In 2014, 70,000 men were diagnosed with a type of prostate cancer considered to be so harmless that experts universally agree it is best managed with active surveillance only. However, at the other extreme, also in 2014, a very different type of prostate cancer led directly to 28,000 deaths.
Prostate Cancer in the Bone is Not Bone Cancer
A common misconception that needs to be rectified is that cancer that originates in the bone, i.e bone cancer, is a totally different entity than prostate cancer that has spread to the bone. Primary bone cancer grows quickly, often spreads to the lungs and does not respond to hormones. Prostate cancer that spreads to the bone tends to grow much more slowly, only rarely spreads to the lung and usually regresses radically with hormone therapy. Prostate cancer in the bone and primary bone cancer are two separate and distinct illnesses that should not be confused with each other.
Doctors and Patients, the Human Factor
The human factor further complicates the selection of optimal treatment. Doctors who treat prostate cancer come from different schools of thought. Not only are urologists, who are surgeons, trained differently from radiation specialists, the true cancer specialists, the medical oncologists, are practically never involved with early-stage prostate cancer. Differences among patients—age, fitness, prostate size for example—can also radically influence treatment selection.
Sam’s Situation
With a PSA of 50, Sam is going to need a bone scan. He may have already developed metastases. His initial color Doppler ultrasound shows a rather vascular tumor (about an inch and a half long) with some early extra-capsular spread. A targeted biopsy, a single core of the tumor, is scheduled for next week and will let us know the Gleason score.
If the scans turn out to be clear, and if Sam was ten years younger, radiation and hormone therapy would give him the best chance for cure. But in an 80-year-old, the possible side effects that can result are more problematic. Also, we don’t know anything yet about the pace of his disease. Might it be feasible for Sam monitor to the situation for a while? Alternatively, radiation alone or mild hormonal therapy alone (with Casodex) could be considered. Sam and his wife left our meeting with a copy of Invasion of the Prostate Snatchers promising to read it in preparation for our next meeting.
Yesterday I sat down with a new patient, Sam, a charming man who, unfortunately, was just found to have a prostate nodule and a PSA of 50. When I asked Sam why he had not visited a doctor for over 10 years or undergone any PSA testing, he responded, “I have always enjoyed perfect health. Why see a doctor?” Sounds sort of like a stupid response, but judging by his healthy appearance, (looking more like a 70 year old than an 80 year old), one would have to say that until now his policy has been pretty successful.
However, if Sam was going to participate intelligently in further discussions about the selection of optimal treatment, his prostate cancer knowledge would need a major upgrade. Since my instruction had to begin at a very elementary level, I thought I would use this blog to share the main themes of our almost two-hour meeting together. Focusing on the basic first steps seems an appropriate theme for this, my first blog of the New Year.
Not All Cancers Are the Same
Many patients introduced into the cancer world fail to understand that lung cancer, breast cancer, brain cancer and prostate cancer are each a distinct illness, each with more differences than similarities. These different cancers are as different as kidney stone disease is different from pneumonia. Therefore, preconceived notions coming from personal experiences with one type of cancer occurring in family members or friends are frequently misleading.
Prostate Cancers are a Mixed Bag
It’s fairly easy to see why dissimilar cancer types, such as bladder cancer and skin cancer for example, behave differently; it may be harder to understand that prostate cancer itself comes in many different and distinct subtypes. Part of this varied behavior can be explained by the disease stage: No one is surprised by the fact that cancer diagnosed at an early stage has a different outlook compared to cancer diagnosed after it has metastasized.
However, beyond the issue of variable stage, when comparing two different prostate cancers of exactly the same stage, what we call “prostate cancer” can be extremely variable. Consider the following: In 2014, 70,000 men were diagnosed with a type of prostate cancer considered to be so harmless that experts universally agree it is best managed with active surveillance only. However, at the other extreme, also in 2014, a very different type of prostate cancer led directly to 28,000 deaths.
Prostate Cancer in the Bone is Not Bone Cancer
A common misconception that needs to be rectified is that cancer that originates in the bone, i.e bone cancer, is a totally different entity than prostate cancer that has spread to the bone. Primary bone cancer grows quickly, often spreads to the lungs and does not respond to hormones. Prostate cancer that spreads to the bone tends to grow much more slowly, only rarely spreads to the lung and usually regresses radically with hormone therapy. Prostate cancer in the bone and primary bone cancer are two separate and distinct illnesses that should not be confused with each other.
Doctors and Patients, the Human Factor
The human factor further complicates the selection of optimal treatment. Doctors who treat prostate cancer come from different schools of thought. Not only are urologists, who are surgeons, trained differently from radiation specialists, the true cancer specialists, the medical oncologists, are practically never involved with early-stage prostate cancer. Differences among patients—age, fitness, prostate size for example—can also radically influence treatment selection.
Sam’s Situation
With a PSA of 50, Sam is going to need a bone scan. He may have already developed metastases. His initial color Doppler ultrasound shows a rather vascular tumor (about an inch and a half long) with some early extra-capsular spread. A targeted biopsy, a single core of the tumor, is scheduled for next week and will let us know the Gleason score.
If the scans turn out to be clear, and if Sam was ten years younger, radiation and hormone therapy would give him the best chance for cure. But in an 80-year-old, the possible side effects that can result are more problematic. Also, we don’t know anything yet about the pace of his disease. Might it be feasible for Sam monitor to the situation for a while? Alternatively, radiation alone or mild hormonal therapy alone (with Casodex) could be considered. Sam and his wife left our meeting with a copy of Invasion of the Prostate Snatchers promising to read it in preparation for our next meeting.
Tuesday, May 6, 2014
Selecting Prostate Cancer Treatment
BY MARK SCHOLZ, MD
"You mean you have never heard of diffusion-weighted imaging” Exclaimed a recently-diagnosed prostate cancer patient to his doctor. How could his doctor be unacquainted with this important aspect of modern prostate imaging? It’s shocking when a patient realizes he possesses more medical information than the “expert.”
No One Can Be an Expert in Everything
Actually, in this modern era, this situation is being encountered more and more frequently. It’s not so surprising when considering the explosive growth rate of new medical information. It’s humanly impossible for anyone to stay abreast of every new medical development. For example, even though urologists “specialize” in diseases of the urinary system, their area of responsibility demands expertise in a wide variety of unrelated but important areas such as urinary infections, prostate enlargement, prostate infections, sexual dysfunction and kidney stones. They also have to be expert at the surgical treatment of such problems as congenital defects, bladder cancer, testicular cancer and kidney cancer… just to name a few.
Prostate Cancer by Itself is Quite Complex
Prostate cancer alone is intricate enough to keep a specialist occupied full time. For example, simply staging prostate cancer is complicated. Prostate cancer staging uses a multimodality profiling system that estimates the likelihood of microscopic metastases outside the prostate using PSA, Gleason grade, and a percentage of cancer-containing biopsy cores. Now, new imaging techniques are providing further information about the size and location of the cancer within the prostate gland. And even more recently molecular profiling has become commercially available. Staging prostate cancer properly has become a continually developing art form.
Seeking Advice—Delivered from a Level Playing Field
Equally important is the need to seek out unbiased treatment advice. Unfortunately, the process of rendering advice about treatment options is usually very slanted. Urologists (who are surgeons) usually recommend surgery. Radiation therapists usually recommend radiation. This is not to imply that these physicians have less than the best intentions. Over time they just become convinced that what they do is the best option for their patients who are consulting them.
What You Don’t Know Can Hurt You
The number of treatments available for men with newly-diagnosed disease is rapidly expanding. For example, what was previously known simply as “radiation” now includes IMRT, Proton therapy, Cyberknife, two types of Brachytherapy as well as various combinations of these different radiation modalities. Hormone therapy options have now expanded beyond traditional Casodex and Lupron to include Zytiga and Xtandi. The management of the potential side effects of hormone therapy requires special training in diet physical fitness, bone integrity and sexual health to limit the risk of lingering damage after treatment is completed. These days, relapsed or advanced prostate cancer requires physicians who are conversant in genetic typing, modern PET scans, immunotherapy and injectable radiation.
Every Journey Begins with a Single Step
So newly diagnosed prostate cancer patients are faced with daunting situation. Clearly there is no simple answer to this tangle of complicated issues. However, the newly diagnosed cancer patient is far from helpless. He has two overriding responsibilities. First, he must learn as many facts as possible by getting thoroughly educated about the different treatments for his specific type of prostate cancer. Second, he must use discernment in the selection of which physicians to consult.
There is Time to Learn
With prostate cancer there is rarely a need to rush into making a treatment decision because it is usually slow growing. There is plenty of time for the shock of diagnosis to wear off, giving you enough time to get educated about the scientific facts. Published studies comparing outcomes are available. The PCRI in particular publishes articles that translate scientific information into a patient-friendly format. Ultimately, all claims about treatment should be supported by references published in the scientific literature. Selecting treatment for prostate cancer is a high stakes proposition, potentially risking sexual function, urinary function, even life itself. I want to encourage patients to take a leadership role in the treatment-selection process.
"You mean you have never heard of diffusion-weighted imaging” Exclaimed a recently-diagnosed prostate cancer patient to his doctor. How could his doctor be unacquainted with this important aspect of modern prostate imaging? It’s shocking when a patient realizes he possesses more medical information than the “expert.”
No One Can Be an Expert in Everything
Actually, in this modern era, this situation is being encountered more and more frequently. It’s not so surprising when considering the explosive growth rate of new medical information. It’s humanly impossible for anyone to stay abreast of every new medical development. For example, even though urologists “specialize” in diseases of the urinary system, their area of responsibility demands expertise in a wide variety of unrelated but important areas such as urinary infections, prostate enlargement, prostate infections, sexual dysfunction and kidney stones. They also have to be expert at the surgical treatment of such problems as congenital defects, bladder cancer, testicular cancer and kidney cancer… just to name a few.
Prostate Cancer by Itself is Quite Complex
Prostate cancer alone is intricate enough to keep a specialist occupied full time. For example, simply staging prostate cancer is complicated. Prostate cancer staging uses a multimodality profiling system that estimates the likelihood of microscopic metastases outside the prostate using PSA, Gleason grade, and a percentage of cancer-containing biopsy cores. Now, new imaging techniques are providing further information about the size and location of the cancer within the prostate gland. And even more recently molecular profiling has become commercially available. Staging prostate cancer properly has become a continually developing art form.
Seeking Advice—Delivered from a Level Playing Field
Equally important is the need to seek out unbiased treatment advice. Unfortunately, the process of rendering advice about treatment options is usually very slanted. Urologists (who are surgeons) usually recommend surgery. Radiation therapists usually recommend radiation. This is not to imply that these physicians have less than the best intentions. Over time they just become convinced that what they do is the best option for their patients who are consulting them.
What You Don’t Know Can Hurt You
The number of treatments available for men with newly-diagnosed disease is rapidly expanding. For example, what was previously known simply as “radiation” now includes IMRT, Proton therapy, Cyberknife, two types of Brachytherapy as well as various combinations of these different radiation modalities. Hormone therapy options have now expanded beyond traditional Casodex and Lupron to include Zytiga and Xtandi. The management of the potential side effects of hormone therapy requires special training in diet physical fitness, bone integrity and sexual health to limit the risk of lingering damage after treatment is completed. These days, relapsed or advanced prostate cancer requires physicians who are conversant in genetic typing, modern PET scans, immunotherapy and injectable radiation.
Every Journey Begins with a Single Step
So newly diagnosed prostate cancer patients are faced with daunting situation. Clearly there is no simple answer to this tangle of complicated issues. However, the newly diagnosed cancer patient is far from helpless. He has two overriding responsibilities. First, he must learn as many facts as possible by getting thoroughly educated about the different treatments for his specific type of prostate cancer. Second, he must use discernment in the selection of which physicians to consult.
There is Time to Learn
With prostate cancer there is rarely a need to rush into making a treatment decision because it is usually slow growing. There is plenty of time for the shock of diagnosis to wear off, giving you enough time to get educated about the scientific facts. Published studies comparing outcomes are available. The PCRI in particular publishes articles that translate scientific information into a patient-friendly format. Ultimately, all claims about treatment should be supported by references published in the scientific literature. Selecting treatment for prostate cancer is a high stakes proposition, potentially risking sexual function, urinary function, even life itself. I want to encourage patients to take a leadership role in the treatment-selection process.
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