Frequently Asked Questions - Initial Treatments After Diagnosis of Prostate Cancer

Yes, I do. That belief is based upon my own published results, the research literature, my own prostate cancer screening studies, and my professional experience.

I am working at Northwestern Memorial Hospital in Chicago. My telephone number for scheduling surgeries is: 312 695-6126.

Usually, the patient is in the hospital for 2 to 3 days. The catheter remains for 10 days. The patient can drive once the catheter is out. No vigorous exercise should be performed for 6 weeks. The patient can return to work after 3 or 4 weeks, but he usually tires easily because of anemia for the first 6-8 weeks.

In the most recent tabulation of my surgical patients, now including more than 4,400 men, the 10-year prostate cancer-specific survival rate is 96%. This statistic means that whether or not there has been a recurrence of the prostate cancer, only 4% of men died of prostate cancer before 10 years after surgery. These statistics are for my patients. General statistics could be different.

I do not recommend specific surgeons in particular areas of the country, but I would recommend that you ask physicians in your community whom they would recommend and also that you check at some of the high-volume prostate cancer centers for information about their surgeons.

You want to know how frequently they perform nerve-sparing surgery and how many surgeries they’ve performed. Most doctors do not keep statistics on their operations, but I think it is reasonable to ask to talk with 10 previous patients of that doctor. Most surgeons should have a list of patients who have given their consent to be contacted by potential patients.

It is impossible to tell how long is safe. Obviously, it is best to have treatment as soon as convenient. Some patients delay for 3 to 4 months for various reasons. Hormonal therapy may be indicated for longer delays; however, hormonal therapy can make it more difficult to perform nerve-sparing surgery because it causes scarring around the prostate gland.

The short answer is “yes.” I believe that it will pay dividends to strengthen the muscles before surgery.

The nerves are like railroad tracks with the prostate being like a boxcar on top of the tracks. In this surgery, doctors try to gently lift the “box car” off the railroad tracks without damaging the “tracks.” If the cancer is detected early, then the prostate can sometimes be removed very nicely without disturbing the nerves. The nerves usually get bruised and stretched somewhat during the operation, which is why it can take 3 to 6 months for erections to begin to return after surgery. But with time, the nerves regenerate so it’s very important to detect the cancer while still on the inside of the prostate before it grows out into those nerves. Once it’s grown out into the nerves, it’s not possible to spare the nerves.

Patients who have good erections preoperatively and desire to remain potent are reasonable candidates for nerve-sparing surgery if their PSA is low, their Gleason grade is not too high, and their prostate examination does not suggest that the cancer has spread beyond the prostate gland. The final decision to do nerve-sparing surgery is usually made by the surgeon during the operation.

Most surgeons would say a CT is not necessary; however, I like to have a CT before surgery to ensure that no other important medical conditions are present that might affect the planned operation.

Usually, a surgeon does not cut into the prostate gland during removal of the prostate. Although it is theoretically possible that cutting into the prostate could encourage cancer cells to spread, prostate cancer is not a type of cancer that “implants” easily into other tissues. This worry would be much greater with some other types of cancers.

Sometimes, it is strongly advised when the pathology report shows positive surgical margins or extension of the tumor beyond the prostate gland.

Also, it is often advised when the PSA begins to rise after surgery.

There are two types of follow-up radiotherapy. 1. Adjuvant radiotherapy is given as a precautionary measure in patients who have adverse features in their pathology report. This radiotherapy is usually given 3 to 4 months after the operation when urinary continence has returned. It may be delayed further if continence has not yet returned. 2. Salvage radiotherapy is for a rising PSA, which means a recurrence of the cancer. This radiotherapy should be given before the PSA level rises above 1ng/ml.

Yes. Some serious ailments make a patient too great a risk for surgery. Even though I believe that surgery might be the best treatment for a tumor, it is not always the best treatment for the patient. This decision is best made in consultation with the surgeon and other physicians of the patient.

In my opinion, the answer is no, except for older men with low-grade tumors that are not very threatening.

For the vast majority of men with prostate cancer, early definitive treatment is indicated.

Some of the public information about prostate cancer is misleading. It suggests that prostate cancer is a toothless lion, i.e., that more men die with it than of it.

There is a difference between a dead man whose prostate is found to contain cancer when it is extensively examined at autopsy and a living man whose cancer has been found because of an elevated PSA or abnormal digital examination. And the younger a man is, the more likely he will benefit from being cured.

It is most likely that a clinically detected prostate cancer will progress with time. For example, waiting for a PSA to get up to 6-7 risks a 30% chance that the cancer would have escaped from the prostate at the time of treatment.

Currently, there are watchful waiting studies of young men. It is called “active monitoring.” If the PSA rises or repeated biopsies show more cancer or high-grade cancer, then treatment is initiated. The downside of this approach is that for men whose cancer ultimately requires treatment, it is treated at a later time and the repeated biopsies can me it more difficult to perform nerve-sparing surgery.

I do not believe it is as effective as surgery. (Use the search engine in this website to find comparisons and studies for brachytherapy.)

I do not believe that cryoablation (controlled freezing of the prostate gland in order to destroy cancerous cells) is an effective primary treatment for localized prostate cancer. Some advocate it for men who have failed radiation therapy. It almost always results in impotency. Also, a major concern is that if cancer cells are near the urethra, the warming of the urethra (as a protection against freezing and a consequence of the thawing process after the freezing) allows the cancer cells to survive. Frankly, I do not recommend cryoablation to any of my patients.

Hormonal therapy is used by some doctors to shrink the cancer before surgery. Available evidence suggests that while hormonal therapy makes it more likely that the surgical margins will be “clear,” no convincing evidence exists to show it reduces tumor recurrence rates.

A possible disadvantage of hormonal therapy before surgery is that it may cause scarring around the prostate gland that sometimes makes it more difficult to perform nerve-sparing surgery.

Laparoscopic radical prostatectomy is feasible. It is performed at several centers throughout the US, including my institution. It is now considered to be in its “infancy.” However, I do not believe there are any material advantages for the patient compared with open radical prostatectomy.

In my opinion, it is far more difficult to get consistently good results because it does not afford the surgeon as much control as with the traditional operation. Also, it does not provide tactile feedback, and it is more difficult to suture laparoscopically.

With robotic surgery, suturing is less difficult, but it still has limitations of access and lack of tactile feedback. The surgeon cannot tell how hard the robot is grasping tissue, or, if the angle of the needle is wrong and if the needle does not pass through the tissues easily, the robot continues to “muscle” its way through.

With tactile feedback afforded by open surgery, the surgeon would “feel” the mistake and make the necessary adjustment.

At present, information is insufficient to determine whether long-term results will be as good as with standard nerve-sparing radical prostatectomy, especially in terms of preserving sexual potency and obtaining cancer-free surgical margins.

Having seen laparoscopic and robotic surgery performed by most of the world’s most experienced experts, I don’t believe it allows nerve-sparing to be performed with the same degree of fine control without risking thermal damage to the neurovascular bundles, and I do not believe removal of the cancer is as consistently complete.

With “high risk” prostate cancer, it is unlikely that the cancer can be cured by surgery or radiation alone. Options would include something as conservative as intermittent or continuous hormonal therapy or aggressive treatment with combinations of surgery, radiotherapy, hormonal therapy and/or chemotherapy.

I am often asked this question by patients. I believe that gene therapy will be developed first as a potential treatment for patients with the most advanced stages of prostate cancer for whom no other effective therapy is available. Then if gene therapy works in these patients, it will be moved into the realm of treating earlier stages of the disease.

Although exciting research is underway in gene therapy and other experimental treatment approaches for prostate cancer, I do not believe it is overly conservative to state that practical application of these new techniques is probably several years away.

In this method, x-ray treatments are given with a machine that sends high-energy x-rays through the patient’s body, aimed at the prostate gland and sometimes the pelvic lymph nodes.

External beam radiotherapy is a totally non-invasive treatment used as an option for men who are considered too old or too ill for a prostatectomy or who just don’t want surgery.

It is difficult to determine whether external beam radiation actually eradicates all of the prostate cancer because many patients in whom progression of the tumor is slowed or halted have persistent tumor on repeat rebiopsy. The best results are obtained when tumors are less than 2 centimeters in size at the time of therapy.

Both approaches can yield good results if the surgeon is experienced and has expertise in performing the operation.

In a radical perineal prostatectomy, the prostate gland is removed through an incision in the perineum, the area between the scrotum and the anus.

In a radical retropubic prostatectomy, the surgeon makes an incision in the lower abdomen to remove the prostate, which is located retropubically, or behind the pubic bone.

The principal advantage of the retropubic approach, in my opinion, is that the cavernosal nerves are more readily spared, because from the retropubic approach the prostate gland is lifted up off the nerves. In the perineal approach, the gland must be pulled down between the nerves.

Another advantage of the retropubic approach is less chance for injuring the rectum during the surgery and less chance of postoperative rectal incontinence.

IMRT (Intensity-Modulated Radiation Therapy) is one of the best forms of radiation therapy. It is computer-controlled radiation that delivers precise doses to malignant tumors or specific areas within a tumor with minimal effect on other tissue. The technology allows for higher and more effective doses to be delivered without damaging surrounding tissue.

But there is a statistical issue about how the results are reported that make them appear 10% to 20% better than they really are. I do not believe that IMRT is as effective as surgery in appropriately selected patients.

You should be told the tumor stage (which tells how far it has spread) and the tumor or Gleason grade (which tells how aggressive it is or how fast it is growing).

You should also be given treatment options for your particular tumor and then recommendations for the preferred treatment for that tumor. A list of treatments available to everyone is not particularly helpful to an individual patient. Good decisions are made based upon specific tumor characteristics.

I am skeptical about the efficacy of Provenge.

In the early studies, it only showed a benefit in patients with advanced, but low-grade prostate cancer. The great majority of prostate cancer patients with advanced disease have high-grade cancer.

I would be surprised if Provenge has much to offer.

In my experience, most patients have three main priorities concerning their treatment outcomes, usually in the following order:

1) to survive prostate cancer 2) to recover urinary continence, and 3) to recover erections. This threesome has been called “achieving the trifecta.”

Of course, men have other secondary priorities, such as the discomforts associated with treatment, the time required for recovery, and the time to return to normal activities.

All of these priorities are important, and different surgeons (and different treatments) vary in achieving them.

Few surgeons keep accurate tabulations of their outcomes. Not surprisingly, studies have shown that high-volume surgeons generally (but not always) achieve better results.

One practical solution for the prospective patient is to be diligent in finding out about the experience and reputation of the surgeon.

He should also ask the surgeon to provide the contact information of 4 or 5 of his or her patients who have had good outcomes (I routinely ask my patients whether they are willing to be contacted by prospective future patients, and most are happy to do so and sign a HIPAA release form).

If several patients are pleased with their outcomes, it shows that at least in these cases, the surgeon was able to achieve good results.

Planned preoperative radiation therapy is not used in treating prostate cancer because radiation damages the blood supply to the tissues so they do not heal as well after high doses of radiation.

Such radiation makes the complications and side effects of radical prostatectomy far more likely than if the tissues had not received radiation.

Sometimes, so-called “salvage” radical prostatectomy is performed in patients who were treated initially with radiation and subsequently have a cancer recurrence. Salvage prostatectomy is associated with a far greater risk for complications and is substantially less likely to cure the cancer.

The options are a Veterans Administration Hospital (if a veteran) or a public hospital, such as a county or city hospital.

In addition, almost all private hospitals provide low-cost or free care to some patients who have no health insurance and a low income. Men in such a situation can call urology departments of private hospitals to see what options are available.

Also, many private hospitals have social work departments and the staff there is trained to help with special needs. Men can ask to see someone in that department for advice.

It is possible to remove the prostate gland after radiation therapy, but the complication rate is far higher (25% to 50% risk of incontinence, almost certain impotence, and a significant risk for rectal injury during surgery that might require a temporary or permanent colostomy).

Accordingly, most surgeons, including myself (Catalona), do not perform salvage prostatectomy.

IMRT can be used as the sole treatment for prostate cancer.

In fact, it is one of the most effective forms of radiotherapy for treating prostate cancer.

However, in my opinion, it is not as effective as surgery for treating organ-confined tumors that might be resistant to therapeutic doses of radiotherapy, and it does not prevent future new cancers from developing in the prostate gland.

In my opinion, the results with robotic surgery are not as consistently good as they are with open surgery by a surgeon who specializes in nerve-sparing radical prostatectomy.

Robotic surgery is being aggressively marketed all over the country, and there are claims that robotic surgery is as good, but I do not believe that it is true.

How many tests are indicated before proceeding with treatment is a controversial subject. To some extent, it depends on the individual’s risk for having cancer that has spread.

For instance, if the patient has a low PSA, low Gleason grade and normal feeling prostate, some would argue that no further testing is indicated, including lymph node biopsy.

On the other hand, if the PSA or Gleason grade are higher, further testing such as a bone scan and abdominal and pelvic CT or MRI scan might be indicated.

Some of the tests currently available, such as Prostascint, ploidy, PAP, color endo-rectal MRI, complexed PSA, provide little additional useful information, in my opinion.

I am usually comfortable if the patient has a bone scan with appropriate follow-up imaging studies of any abnormalities that might appear and an abdominal-pelvic CT scan.

In general, it is believed that prostate cancer that arises in the peripheral zone is more aggressive than that which arises in the transition or central zones. The apex includes the transition and peripheral zones.

The blood bank blood is now very safe, but nothing is safer than your own blood. I usually have my patients store one pint of their own blood, which I usually give back to them after surgery, and it is very unusual for them to have to receive blood from another person.

Several tables called “nomograms” provide information on the probability that a tumor would be totally contained within the prostate and whether or not there will be a later recurrrence.

These tables are called Partin tables, Kattan tables, or D’Amico tables, named after the authors who devised them.

They contain an estimate of the probability, but there can be variation around these estimates.

Factors to determine the likelihood that the tumor would be “contained” are: the Gleason grade, the PSA level, the rectal and ultrasound examination findings, the bone scan findings, and the number of biopsy cores involved with cancer, the percentage of the biopsy tissue involved with cancer, and whether or not the pathologist saw “perineural involvement” on the biopsy specimens.

In general, I believe that these tables provide a slightly pessimistic estimate, because as time goes on, prostate cancer is discovered earlier and earlier.

Now that we are detecting prostate cancer much earlier due to PSA testing, it is rare to find lymph node metastases.

Predictors of lymph node involvement are high PSA level (greater than 20), Gleason grade higher than 7, many biopsy cores containing cancer, and a very abnormal feeling prostate on digital rectal examination.

Lymph node biopsy is not mandatory in the absence of any of these features. My policy is to remove a small tissue packet containing 1-3 of the so-called “first echelon” lymph nodes near the prostate.

Lymph node involvement is an unfavorable prognostic sign. However, two small case-control studies from Johns Hopkins and the Mayo Clinic suggest that the outcome is better if the prostate is removed in patients with minimal lymph node involvement. About 95% of my patients elect to proceed with removal of the prostate even if the lymph nodes are involved.

At age 72, your father still has a 10-year life expectancy that could be shortened by prostate cancer. Age 72 is “borderline” for a radical prostatectomy, but if he were otherwise healthy, he would be a legitimate candidate for the operation.

There is no reason to believe that surgery would “destroy everything,” if he chooses a good, experienced surgeon. His other option for cure would be radiotherapy. Hormonal therapy would almost certainly slow the progression of the cancer, perhaps for the rest of his natural life, but that result could not be guaranteed.

Yes and No.

If the biopsy suggests the cancer is low volume and low grade, the final prostatectomy specimen will confirm this impression 80-85% of the time.

However, the biopsy is only a sample, and in 15-20% of cases, there will be significantly more cancer or cancer at or beyond the margin of the prostate gland or higher Gleason grade cancer.

Therefore, I advise my patients to wait only 6 weeks after the biopsy to let the inflammation subside and then schedule surgery as soon as they conveniently can schedule it.

You could refer to the article appearing in the Fall 2010 Quest (page 10) and see what the response is or select another experienced surgeon who specializes in open nerve-sparing radical prostatectomy.

Many good ones are in use every day including free and total PSA, PSA velocity, PSA density, Gleason grade, amount of cancer in biopsy specimens, findings on prostate exam, ultrasound, CT or MRI scans. Other new tests include the [-2] ProPSA test (waiting for approval by the FDA).
These tests all are useful in predicting the aggressiveness of a prostate cancer.

Where the real problem lies is in patients who appear to have low-risk tumors (Gleason of 6 or less, low amounts of cancer in the biopsy specimens, and PSA less than 10). One-third or more of these tumors will ultimately prove to behave aggressively.

How can we better identify the wolves masquerading as lambs? This answer is perhaps the holy grail of current prostate cancer research.

(See page 1 article in the Winter 2010 Quest: Which Prostate Cancers Are Aggressive and Which Aren’t?)

My hospital requires that our pathologists confirm the diagnosis.

I would not advise this practice. Trying to shrink the prostate with hormone therapy sometimes causes scarring around the prostate that makes it difficult to perform a nice clean nerve sparing operation. Also some prostate cancer cells are resistant to hormone therapy and if they are present, they could continue to grow and perhaps spread during the six months. In my opinion, one should be wary of using drugs that are not approved for prostate cancer treatment unless the reason is very compelling.

I usually recommend waiting for six weeks to allow the inflammation from the biopsy procedure to subside. This time increases the chances that the surgeon can perform a nice, clean operation. If the prostate gland and the surrounding tissues are inflamed, it can compromise complete removal of the entire tumor with clean margins and the ability to perform nerve-sparing surgery. A risk is present that the cancer might spread in the interval, but it is unlikely and is just another example of life’s tradeoffs.