"Prostate cancer will be eliminated, but it will take us a while to figure out how to personalize treatment," says Dr. Steven Clinton, director of the Prostate and Genitourinary Oncology Program at the James Cancer Hospital at the Ohio State University Medical Center (OSUMC).
In the years to come, personalized treatment will become routine, he says. This will not only improve the likelihood of a successful course of care, but also lessen "the potential overtreatment of many cancers," says Clinton, also a professor of internal medicine in OSU's oncology department.
In the meantime, several hundred new prostate cancer patients visit the James every year. Only skin cancer is diagnosed in American men more often. According to American Cancer Society (ACS) estimates, nearly 218,000 new cases of prostate cancer were likely be diagnosed in 2010 and 32,050 men would die of the disease, making it the second-leading cause of death by cancer. Only cancer of the lung is fatal to more men.
The ACS estimates one in six men will be diagnosed with prostate cancer at some point during his lifetime; those numbers are higher for African-American males. More than 2 million men in the United States are prostate cancer survivors.
‘A Symptom-free Disease'
In most instances, prostate cancer is a symptom-free disease, says Dr. John K. Burgers, a cancer specialist with the Central Ohio Urology Group. That is, he cautions, until the ailment has advanced. Then it can cause difficulty urinating, blood in the urine or pain in a man's bones, mostly the long ones.
The pain, according to Burgers, is "way worse than arthritis. It can start off as pain but if it gets into the spine, [a patient] can get paralyzed."
Once stereotyped as a disease of older men because the typical sufferer was in his 60s or 70s, today's prostate cancer patient can be younger, says Dr. Thomas J. Pedrick, a radiology oncologist affiliated with the Columbus Prostate Cancer Center and Riverside Methodist Hospital.
Because the James is a tertiary referral center, it sees more unusual and advanced cases. "We tend to see more aggressive cancers and younger patients who are more inclined to undergo research trials and cutting-edge treatments," says Clinton.
There is also an increased awareness of the link between family history and the likelihood of developing prostate cancer, Clinton says. "Twenty years ago, it was rare to see a patient under age 60," he says.
Doctors routinely use two annual screening exams to detect prostate cancer: a prostate-specific antigen (PSA) blood test and a digital rectal exam (DRA). PSA is a protein produced by the cells in the prostate. An elevated reading could indicate the presence of cancer cells. "About five years before cancer starts to spread, the PSA will increase fast," says Burgers.
The average Caucasian male is advised to begin screenings by age 50. African-Americans and others with a first-degree linkage to a prostate cancer patient are at a higher risk of developing the disease, and are advised to start earlier, between ages 40 and 45.
Several factors can increase the likelihood a man will develop prostate cancer. Family history may be the most significant. The more affected family members a man has, the greater his risk for developing the disease.
"One family member translates into twice the risk," says Burgers. Two family members means a patient is four times as likely to develop prostate cancer, while having three family members with the disease increases the likelihood to seven times, he explains.
Diet is another consideration. "Middle-age men should avoid the tendency of gaining weight and becoming lethargic," Clinton advises.
Another risk factor is an elevated PSA reading. PSA levels change as a person ages, says Burgers. If an abnormal reading is recorded, the urologist will order a prostate biopsy. "That will help diagnose whether you have cancer and at what stage," he says.
A pathologist studies the tissue removed during the biopsy and assigns a Gleason score. A Gleason score between two and four suggests a low-grade cancer that does not necessitate treatment, especially for an older patient. Five or six indicates a more aggressive cancer, although any score under six means the cancer is less likely to spread to other organs. A score of seven or higher predicts intermediate stages of prostate cancer and an increased probability of metastasis.
Geographic location may also impact a man's susceptibility to the disease. "Cities with higher daily averages of sunlight have lower rates [of prostate cancer]. Because it's often cloudy in Columbus, the rate is higher here," says Burgers.
One theory is that because sunlight provides the body with vitamin D, there may be a correlation between vitamin D levels and prostate cancer. A study now under way at Harvard Medical School is exploring that possible link.
Clinical trials are a constant at OSUMC, whose current projects include Crops to the Clinic Research. "It engages not just traditional cancer researchers but also agricultural studies. We're looking at how we can enrich [farm products] to prevent cancer," says Clinton.
One focus: the effect of soy on cancer prevention. "It's interesting because in countries where men consume [soy] all their lives, like Asian countries, prostate cancer is very low," Clinton says. Laboratory results have shown soy to possess "anti-cancer" potential. "Now we need to prove it in human studies," he says. One such study involves soy bread. Since bread is a staple of the average American diet, researchers hope to learn if fortifying it with soy could reduce the incidence of prostate cancer.
Men diagnosed with prostate cancer have several treatment options based on the extent of the disease, the patient's age and overall health. The most common protocols are surgery to remove the prostate or radiation therapy.
"If it's thought the cancer is localized to the prostate, we consider the patient's age and co-morbidity," meaning whether he is facing other illnesses, says OSUMC's Clinton. If all signs indicate a localized case and the patient is otherwise healthy, "watchful waiting" is the standard protocol. That means the disease will be closely tracked and treated, as necessary.
Age comes into play again if treatment is recommended. "If we decide they have a life expectancy of seven years or more, most men should choose between radiation or surgery," Clinton advises.
Surgical options are classified as invasive or minimally invasive. During an invasive, or open, prostatectomy, some or all of the prostate and surrounding tissue are removed. However, more than 90 percent of today's prostatectomies are performed robotically, says Clinton. Benefits of the minimally invasive procedure include less blood loss, reduced pain and discomfort following surgery and a shorter hospital stay.
Another type of minimally invasive surgery is laparoscopy, says Dr. Ronney Abaza, director of Robotic Urologic Surgery at the Ohio State University Medical Center and the OSU Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute. During a laparoscopic prostatectomy, surgeons perform the robotic-assisted surgery through "keyhole" cuts. "We can do the surgery without big incisions," Abaza says. About 80 percent of the prostatectomies that Abaza performs are robotic, with the remainder done via open surgery.
Despite the advantages of minimally invasive surgery, some patients still opt for the more traditional procedure. One factor is the surgeon's skill level. "The robot doesn't make the surgery successful. It's the surgeon," Abaza says. Another issue is whether the patient is healthy enough to undergo a robotic procedure, which can be significantly longer than an open surgery.
Patients who opt for radiation may undergo either external radiotherapy or brachytherapy, a form of localized treatment where the surgeon implants small radioactive seeds in or near a tumor. The seeds emit high doses of radiation designed to kill the cancerous cells. Pedrick says brachytherapy "has long been an acceptable alternative to radical surgery" for treating prostate cancer. However, its popularity is declining amid new technologies that use imaging techniques to deliver targeted external radiation.
One form of stereotactic radiotherapy is Intensity Modulated Radiation Therapy, which uses 3-D computed tomography scans to pinpoint tumors. "IMRT, Intensity Modulated Radiation Therapy, has increasingly become a preferred noninvasive choice for men who are not suitable or uninterested in surgery with equal cure rates," Pedrick says. The technology has been around for a decade, but has become mainstream in the last five years, he says. "Our brachytherapy rates have declined significantly and IMRT has dramatically increased as a viable choice for many men."
Meanwhile, another new, but somewhat controversial, weapon has recently been added to doctors' arsenals: CyberKnife, a nonsurgical robotic system that uses image guidance to deliver targeted high-dose stereotactic body radiation therapy, or SBRT.
Dr. Doug Widman is medical director of Columbus CyberKnife, located at Mount Carmel St. Ann's Hospital, and a radiation oncologist at Mount Carmel East Hospital. "CyberKnife has the potential to turn radiation treatment upside down. It is a radical departure because it takes an eight-week course of [radiation] down to just five days," he says.
"CyberKnife tracks the movement of the prostate during treatment and corrects for that movement so it delivers a more precise treatment. We can be more confident we aren't damaging surrounding organs," Widman says.
Condensing the course of treatment does come with a price. At $6 million, a CyberKnife machine is quite an investment for a surgical oncology department, and therefore a more costly form of therapy for patients.
But because CyberKnife has only been used to treat prostate cancer for about three years, not all physicians are on board. The American Society for Therapeutic Radiology and Oncology released a position statement in 2008 saying, "There is not sufficient or mature data to demonstrate equivalency to existing standard treatment modalities and, in our view, SBRT for prostate cancer patients does not represent a ‘standard of care.' "
Living with Side Effects
No matter which method of prostate cancer treatment a patient chooses, there are two common side effects: incontinence and impotence. According to Widman, incontinence is less likely to occur as a result of radiation therapy than prostate removal. "But we still have problems with impotence, just like surgeons do. While it's still a big problem, it's less so with radiation than with surgery," he says.
James L. Rieder was 67 when he was diagnosed with prostate cancer in 2003. He had already been seeing a urologist due to an enlarged prostate. His PSA score was slowly creeping up, so he underwent biopsies in 2001 and 2002. Both tests came back normal. However, in 2003, doctors found cancer.
Although his Gleason score of six was "relatively low," Rieder says he underwent a radical prostatectomy within two weeks of the diagnosis. "That was before the advent of robotic procedures," he says.
Rieder had quarterly follow-up appointments with his urologist for the first two years after surgery, then biannual appointments for the next two years. Today, the visits are annual. He still suffers from a urinary retention problem, but it's only a minor nuisance, he says. Erectile dysfunction has also occurred, but, he says, "I live with it."
Another patient, "Leo," who asked not to be identified by his real name, recalls being "startled" when his prostate cancer was diagnosed in December 2008. Leo, 51, says he didn't have any symptoms when the cancer was discovered. His older brother had been diagnosed with the disease a decade ago, when Leo was 40. Soon afterward, Leo began undergoing the two annual screening tests.
Following his diagnosis, Leo sought the advice of other prostate cancer patients. He also researched treatment options. "I consulted with two urologic surgeons and a radiologist with a specialty in prostate cancer," he says.
Leo ultimately opted to undergo robotic surgery to remove his prostate. He dealt with incontinence problems for six months afterward, but hasn't had a recurrence in more than a year. He had nerve-sparing surgery, which preserves the nerves that control a man's ability to have an erection, "because of my age. It's a risk I was willing to absorb," he says. Leo says he has been able to engage in sexual intercourse since his prostatectomy.
David P. Houchens was 64 when he was diagnosed with prostate cancer in 2001. He spent his professional career as a cancer researcher, primarily for Battelle. Because of his firsthand knowledge of the disease, he says he was "a bit surprised, but not shocked" by his diagnosis. He underwent an open prostatectomy performed by Burgers since robotic surgery was not yet an option.
Houchens says he admires his wife, Kathie, whom he married in 1963, for her positive approach to the potentially harrowing ailment. "The diagnosis of any disease is hard on any relationship. To many men, prostate cancer affects their manhood. It can have a physical and emotional impact, which can affect a relationship," he says. The couple travels the country, speaking to groups about coping with prostate cancer while maintaining the integrity of a marital relationship.
Rieder, Leo and Houchens all are actively involved in Us Too International, a support group for prostate cancer sufferers and survivors. The Columbus chapter, one of 325 across the United States, meets at the James on a monthly basis so men can share their anxieties and questions while offering support and guidance to one another. Houchens and Rieder are on the organization's national board of directors.
Tami Kamin-Meyer is a freelance writer.
Reprinted from the February 2011 issue of Columbus C.E.O. Copyright © Columbus C.E.O.