The power of a single word—CANCER—can’t be underestimated. Its deadliness is famous. Often patients have previous experiences with cancer striking a friend or family member. One of the biggest challenges prostate cancer specialists face is undoing what patients think they already “know” about cancer. Patients assume it’s a death sentence and rush into the first treatment offered while failing to realize that a single additional modifying word—PROSTATE—changes everything. Generally speaking, the worst type of prostate cancer is better than the best type of any other cancer. For example, the average survival of relapsed pancreas cancer is four months. The average for relapsed prostate cancer is thirteen years.
What we call prostate cancer is actually a constellation of illnesses that behave and respond to treatment quite differently. Fortunately, technology can now distinguish between the good and the bad forms of prostate cancer. Profiling is a much maligned word. However, profiling prostate cancer by into different “types” enables men to receive personalized treatment that is appropriate to their individual situation.
Cancer is termed “localized” when bone and body scans are clear. Localized prostate cancer comes in three types or risk categories: "Low-Risk, Intermediate-Risk and High-Risk.” High-Risk does not indicate a high risk of dying. “Risk” relates to the chance of the cancer relapsing after surgery or radiation, otherwise known as a “PSA relapse.” Relapse from breast, colon and lung cancer is almost always fatal. Prostate cancer relapse, due to the typically slow growth rate of the cancer and due to the effectiveness of salvage therapy with testosterone inactivating pharmaceuticals (TIP), is usually not fatal. The majority of men with PSA relapse die of natural causes related to advancing age rather than from prostate cancer.
In 2007, Peter Carroll, Chairman of Urology at University of California San Francisco, convened an international conference on Active Surveillance. He was concerned that too many men were receiving unnecessary radiation or surgery since men with Low-Risk prostate cancer rarely die or become ill from it, even if they never have treatment. The consensus from the 200 experts at the conference was that Active Surveillance was appropriate for men of any age who were in the Low-Risk category which means: PSA less than 10, Gleason score less than 7, no cancer felt on rectal examination, less than one third of core biopsies containing cancer and the absence of any single biopsy core more than 50% replaced by cancer.
Active Surveillance is defined as follows: PSA testing every three months, digital rectal examination twice a year and needle biopsy of the prostate after one year, and every two to three years thereafter. At Prostate Oncology Specialists we are actively monitoring over 400 men. In addition to the measures listed above, we also assess urinary PCA-3, imaging with Color Doppler Ultrasound and Endorectal MRI.
Active Surveillance is not a commitment to forgo treatment. It is a commitment to monitor closely and intervene at the first sign of growth or change in the cancer. Close observation over time is the best way to distinguish men who can be safely watched from the men who genuinely need treatment.
Intermediate-Risk patients have all the characteristics of Low-Risk patients except for one of the following: A PSA is between 10 and 20 or a Gleason of 7 or a small nodule can be felt on digital rectal examination or 33% to 50% of the biopsy cores with cancer.
Generally men with Intermediate-Risk disease require treatment. However, the following exceptions may suggest that Active Surveillance may be an option:
- Over age 70
- Favorable types of Intermediate-Risk disease
- Men placing an extremely high priority on maintaining sexual function
Men in the Intermediate-Risk category face the most challenging decisions. Plausible arguments can be made for almost any one of more than a dozen approaches. To decide the best treatment, we recommend working backward from the known side effects associated with each of the different treatment options. Quality-of-life should be the primary determinate because in expert hands, survival is equally good with all the different treatment options.
Our bias for younger men is brachytherapy at a center of excellence. Older men do well with intensity modulated radiation therapy (IMRT). Men with large prostates or excessive preexisting urinary problems can consider several options:
- Nine months of testosterone inactivating pharmaceuticals (TIP)
- Experimental focal treatment with cryotherapy (for men with unilateral disease)
- Surgery (robotic or open) at a center of excellence
High-Risk is defined as any one of the following: PSA over 20 or Gleason of 8 or higher or a sizable nodule felt on digital rectal examination or more than 50% of biopsy cores involved with cancer. Also, men with two or more Intermediate-Risk factors are often considered High-Risk. Generally, the best cure rates are achieved with a combination of radiation and testosterone inactivating pharmaceuticals (TIP), not surgery. All too often with High-Risk patients, surgeons leave cancer behind—a positive margin. Cutting a clear margin around the prostate is difficult because the gland is within millimeters of the bladder and rectum.
Cancer spreading just outside the capsule of the gland or into the seminal vesicles with otherwise clear scans is termed locally advanced. Modern radiation can effectively control locally advanced cancer when the cancer is confined to the region immediately surrounding the prostate. However, since microscopic metastases may be present, radiation to the pelvic lymph nodes should be discussed. When pelvic radiation is administered, testosterone inactivation pharmaceuticals (TIP) should be added.
Fears about the existence of microscopic metastasis should never be the basis for the decision to forgo treatment to the prostate. Rather, an aggressive approach using every potential means to eradicate the cancer is indicated.
Prior to modern scans, extra-capsular disease was only detected prior to surgery if the doctor felt an abnormality in the area of the prostate with his finger. Now, modern imaging and biopsy technology enables us to detect much smaller degrees of cancer spread outside the capsule. Despite proven spread past the capsule of the gland, modern radiation with IMRT, often with a brachytherapy boost, can be very effective at controlling the primary tumor.
Larger tumors extending outside the prostate that can be detected by digital rectal exam require aggressive treatment. The best results are achieved by combining intensity modulated radiation therapy (IMRT), high-dose temporary radioactive seed implantation and testosterone inactivating pharmaceuticals (TIP). With bulky disease the risk of microscopic metastases to the pelvic lymph nodes is high. A short course of adjuvant Taxotere chemotherapy should be discussed.
The situation where only one or two isolated metastases are present is termed oligometastsis. Traditional oncology lore dictates that when any detectable metastases are present, it’s only the tip of the iceberg and that even a single metastasis always indicates that additional microscopic metastases are located in other areas of the body. This belief originated in the era when scans were crude and only large metastasis could be detected.
In the modern era, the possibility of administering targeted radiation to an isolated metastasis should not be overlooked. Forgoing potentially curative treatment almost always leads to further metastases down the line. Its sad when straightforward treatment with radiation to an isolated lymph node or bone metastasis is withheld simply out of a fear that it “won’t work.” When oligometasteses are treated with radiation, the chance for long-term remissions will be further enhanced with the addition of testosterone inactivating pharmaceuticals (TIP) and a course of Taxotere chemotherapy.
Typically, metastases are first detected by scans. To be visible on a scan, metastases need to be at least a half-inch in diameter. Occasionally an enlarged lymph node may be felt manually in the groin area. Microscopic metastases are tiny tumors that are too small to detect with the best modern scans. The presence or absence of microscopic metastases can only be estimated based on factors related to the size and grade of the main tumor in the prostate. The likelihood of microscopic metastasis being present can be predicted with nomograms.
Prior to the advent of intensity modulated radiation therapy (IMRT), lymph node radiation could cause irreversible damage to the intestines with the development of unremitting bloating, diarrhea and pain. These devastating effects strongly discouraged the use of pelvic radiation. Now that IMRT is available, pelvic lymph node radiation is much safer. As of 2011 we have seen IMRT safely administered to over 50 patients in various centers of excellence without serious toxicity. We usually combine testosterone inactivating pharmaceuticals (TIP) with the radiation because studies have shown that the combination of radiation with TIP gives better long-term results than either radiation alone or TIP alone. Evidence is also mounting that adding a course of Taxotere will improve the chances for long-term disease control.
When metastases are extensive at diagnosis, standard radiation is no longer feasible because radiation to multiple areas of the bone is too damaging to the bone marrow where blood is formed and the immune system resides. Testosterone inactivating pharmaceuticals (TIP) are the mainstay for treatment in men with bone metastases. There is also some evidence that adding Taxotere chemotherapy to TIP improves cancer control rates. Bone supportive agent such as Zometa or Xgeva should also be administered. Injectable radiation with Samarium or Strontium can be effective for controlling widespread pain when other treatments like TIP or Taxotere don’t seem to be working. However, like standard radiation, injectable radiation can have a long lasting suppressive effect on the bone marrow.
Liver or Lung Metastasis
Uncommonly, usually in its very late stages after hormone resistance develops, prostate cancer spreads to lung or liver. Men with lung metastases often respond well to a variety of treatments. Liver metastases are more dangerous and less likely to respond to hormonal treatment. When liver metastases are present, immediate chemotherapy is indicated. Additional treatment with radioactive “spheres” or chemotherapy infused directly into the blood supply of the liver may be appropriate.