Prostate cancer is the second most common cancer and second leading cause of cancer death in men. An estimated 11.2% of men will be diagnosed with prostate cancer during their lifetime. When detected and treated early, prostate cancer is a treatable and potentially curable condition with an estimated 98% five-year survival rate. Risk factors include age, ethnicity and family history of prostate cancer in a first-degree relative. African-American men are at increased risk of prostate cancer and developing higher risk, more advanced pathology.
Men with prostate cancer are often without symptoms. The American Urologic Association guidelines recommend screening in men 55+, with earlier screenings for men at higher risk. Prostate cancer screening includes an annual physical exam, digital rectal exam and blood test for Prostate Specific Antigen (PSA). Any abnormality in rectal exam or PSA level should be evaluated by a urologist.
Patients found to have an abnormal rectal exam or elevated PSA are recommended to have a prostate biopsy. The biopsy provides pathology that will determine the volume and type of prostate cancer present, which in turn guides the treatment options available. Further workup with radiologic testing may be indicated in patients with higher PSA or more aggressive pathology to determine presence of cancer outside the prostate gland.
Several grading systems are used to evaluate cancer cells and provide disease risk stratification. The Gleason Grading System is used to classify prostate cancer cells and ranges from Gleason 6 to 10. A more recent Grade Group Classification (Grade Groups 1 to 5) is now used, with Grade Group 5 having the most aggressive prostate cancer. We can provide a disease risk stratification—very low, low, intermediate and high risk—by incorporating the patient’s PSA, Grade Group Score and clinical stage. Patients with lower risk prostate cancer have higher rates of overall and disease-free survival.
A diagnosis of prostate cancer can be difficult and overwhelming for the patient and their family. It is important to understand the extent and type of prostate cancer found, as most prostate cancers tend to be slow growing and have high rates of cure. The urologist’s role is to relay the appropriate information, discuss treatment options and answer questions. Several treatment options are available for clinically localized prostate cancer based on the overall risk stratification, and may include Active Surveillance, surgery, Radiotherapy or Cryotherapy. More recent focal therapies, including High Intensity Focused Ultrasound and Focal Therapy (HIFU) or Proton Beam Therapy (PBT), are available but lack robust evidence of efficacy. The appropriate treatments are based on patient’s age, comorbidities and extent of prostate cancer.
Active surveillance is a reasonable management approach for patients with low volume, low Gleason Score prostate cancer. Patients on active surveillance are closely monitored with routine PSA and prostate exams and are encouraged to have confirmatory and surveillance imaging and biopsies. If progression in disease is seen on PSA, imaging or biopsy, the patient will then be offered definitive therapy based on the new risk stratification.
Surgery for prostate cancer, known as Robotic Radical Prostatectomy, involves removal of the prostate, seminal vesicles and regional lymph nodes. It is now a minimally invasive surgery using the Robotic Da Vinci ® platform, which allows for smaller incisions, faster recovery with 1-day hospital stay and lower degree of blood loss during surgery. Removal of the prostate can also improve obstructive symptoms that many older men experience and is the preferred treatment for those who can tolerate surgery. Younger and healthier men are more likely to experience cancer control benefits from prostatectomy than older men.
Radiotherapy options include External Beam Radiotherapy or Brachytherapy and can be offered as monotherapy or combination therapy with anti-androgen medications based on risk classification. Oncologic outcomes for radiotherapy is equivalent to surgery and may be the preferred treatment option in men who are older, are not surgical candidates or prefer to avoid surgery. Cryotherapy may be considered in low or intermediate risk patients who are not suitable for surgery or radiotherapy but have a reasonable life expectancy.
Understanding post-treatment expectations and symptoms is crucial. Erectile dysfunction and urinary incontinence are common effects of all prostate cancer treatments. Immediately after prostatectomy, erectile dysfunction and urinary incontinence are common but can improve over time. With radiotherapy, in contrast, these treatment effects develop over the following years and progressively worsen without improvement. Patients with radiation therapy are also at risk for development of radiation cystitis or proctitis. Patients should be well-informed of the risks and side effects prior to initiating prostate cancer therapy.
Contact Dr. Kiavash Nikkhou: 805.309.2555.