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I Have Prostate Cancer. Now What?

What men need to consider when making treatment decisions.

Photo credit: Getty Images

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In 2018, more than 164,000 men in the U.S. will learn that they have prostate cancer—the most common type of cancer in men (after skin cancer), and the second leading cause of cancer deaths (after lung cancer).

Like any cancer diagnosis, the news can leave men and their loved ones feeling anxious and unsure about the future. And with so many different options available for treating prostate cancer—including surgery, radiation, hormonal therapy, and even the option to initially do no treatment at all—the decision-making process can often be complicated.

To find out more about prostate cancer treatment options and the various factors that both doctors and patients must consider when making a decision, I spoke to three Northwell Health physicians who care for patients with prostate cancer: Dr. Louis Potters and Dr. Richard Byrnes, who are radiation oncologists, and Dr. Lee Richstone, a urologist.

Here’s what they had to say:

Q: I’ve heard that prostate cancer is often so slow growing that many men will die of something else before the prostate cancer kills them. But I’ve also heard that it can be very aggressive and can spread quickly. Which is true?

  • Dr. Richstone:
    Actually, both of those statements are true. It has the potential to be a very serious illness, and I’ve had many patients, unfortunately, who’ve succumbed to prostate cancer, as young as in their 50s. But on the other hand, it is true that many prostate cancers can be extremely slow growing.
     
  • Dr. Potters:
    There’s a fear and hyper-anxiety when it comes to cancer in general that is not necessarily appropriate with prostate cancer. There’s a real “forest for the trees” type of discussion that needs to happen with patients about their overall prognosis for prostate cancer, life expectancy, and the fact that they’re often more likely to outlive their disease, maybe eventually dying with it rather than from it. I generally like to paraphrase it by saying it’s like a ‘small c’ cancer rather than a ‘capital C’ cancer.

Q: What are the factors that go into making the treatment decision?

  • Dr. Byrnes:
    We start by looking at three important clinical factors. The first is the stage of the cancer. Most men will present with only an elevated prostate-specific antigen test (PSA) or a stage IC cancer, where there are no abnormal findings on the digital rectal exam (DRE).

    Next, we look at the grade of the cancer, or how the pathologist describes the cancer, called the Gleason Score. This outlines how aggressive or not the cancer is.

    The combination of the DRE findings, the PSA value and Gleason Score help to define the risk group that the patient is in: low, intermediate or high risk. And risk is the final factor that will help to define the best treatment approach.
     
  • Dr. Richstone:
    In addition to these clinical factors, there are also several patient factors that we take into consideration, including the age and overall health and fitness of the patient. Someone might have a pre-existing medical problem that would suggest they’re not a good candidate for a particular type of treatment.

    There's also a lot of personal bias that exists. Some patients have a natural aversion to surgery or to radiation. Maybe they have family members or neighbors who have had a good or a bad experience with a treatment, and so that colors their own thinking. And you also have to find out what’s most important to someone. Is it a sense of being cancer-free? Or are they putting a tremendous amount of stock into maintaining urinary or sexual function?

    When you put all of that together, more often than not, the right treatment emerges fairly easily. It’s not that there aren’t tough decisions to make. But most people, after a consultation and a couple of days to think about it, usually come to the decision that is right for them.

Q: What are some of the reasons why a man might choose to have surgery?

  • Dr. Richstone:
    There are several factors that make surgery an appealing treatment option for men with prostate cancer. First, it’s the only treatment that allows you to get full pathology results on the entire prostate, the seminal vesicles and lymph nodes. This is important because biopsies can underestimate the grade and stage of cancer in up to a third of cases. Knowing exactly what’s going on with the cancer can also help you make decisions about whether or not additional treatments are necessary. If you do need a secondary treatment for your cancer, it’s better to have surgery before radiation rather than the other way around.

    It’s also a time tested treatment for prostate cancer with some of the best follow-ups supporting its efficacy. It’s certainly one of the true gold standards for prostate cancer treatment.

    Finally, surgery gives you a very clear benchmark on treatment success because after surgery, your PSA becomes undetectable, meaning it’s less than 0.01.
“In 2018, more than 164,000 men in the U.S. will learn that they have prostate cancer—the second most common type of cancer in men (after skin cancer), and the second leading cause of cancer deaths (after lung cancer).”

Q: How do you decide if a man is a candidate for doing no treatment at all, or so-called “active surveillance?”

  • Dr. Byrnes:
    For men who have very low risk prostate cancer, we do active surveillance, meaning that every six months, you have your PSA tested. At least once a year, you have another biopsy and/or MRI test. We monitor the cancer and stay on top of it. Upward of 60 percent of men eligible for active surveillance may never need treatment.
     
  • Dr. Potters:
    From a physician’s perspective, it’s so easy to say, “This is what we’re going to do. We’re going to do radiation or surgery.” It’s not easy to tell a patient who’s been diagnosed with cancer, “We’re not going to do anything.” And so it takes a time to educate the patient and their loved ones about active surveillance so they walk out of the office feeling comfortable with that decision. The idea is to keep an eye on the disease so that if treatment is needed, the patient’s outcome is not compromised.

Q: One of the newest types of radiation therapy for prostate cancer is called CyberKnife. What does this entail and who is a candidate for it?

  • Dr. Byrnes:
    CyberKnife is a trade name of one type of machine that delivers stereotactic body radiation therapy (SBRT). Another machine that does the same treatment is called the TrueBeam Accelerator. SBRT involves using hundreds of radiation beams that are all focused at one point, which in this case would be the prostate gland. Each beam by itself is very weak, but the point where all of those beams intersect receives an extremely high dose of radiation. This allows us to accurately give a very high dose of radiation to the prostate gland and not the other organs around it.

    When treating the prostate gland with SBRT, we put gold marker seeds into the prostate gland so the robot can actually see the prostate. While the treatment is going on, the robot is taking pictures and looking at the position of the prostate gland. If the prostate moves during the treatment, the robot will move to keep the target in focus.

    The duration of treatment is much shorter than traditional radiation. While standard radiation treatment for prostate cancer requires a total of 28 or 45 treatments over many weeks, we can compress the radiation treatments into just five days.         

Q: Does prostate cancer treatment always end up leaving men with urinary and sexual function problems?

  • Dr. Richstone:
    Not necessarily. There certainly is a risk for these side effects after treatment, and a lot depends on the individual patient and the type of surgery or radiation that’s involved. But many men do fabulously well and have a return of both urinary and sexual functions after either surgery or radiation treatment.

Q: What are the best treatment options for someone who is in the high-risk category?

  • Dr. Richstone:
    For patients with high-risk disease, the central treatment options are either surgery or radiation combined with a type of hormone therapy known as androgen deprivation therapy, which is oral medication that reduces levels of male hormones in the body.
     
  • Dr. Potters:
    Men with high-risk prostate cancer need to meet with both a radiation oncologist and urologist to discuss which approach may be best. Not everyone is a candidate for radiation or for surgery, so each patient requires a multidisciplinary review to develop a personalized and best treatment approach. The good news is that we have all the tools and technology at Northwell, as well as the expertise of the physicians, to use them correctly and with the highest quality and best outcomes possible.

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Published June 12th, 2018

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