Prostate Cancer

The American Cancer Society’s estimates for prostate cancer in the United States for 2023 are: About 288,300 new cases of prostate cancer.

Fortunately, over 90% of males diagnosed in the US have either local or regional stages of cancer. The 5-year survival rate of these patients is close to 100%. For those men with distant spread of cancer (i.e., metastatic prostate cancer), the average survival rate is about 35% at 5-years. As suggested by these statistics, regular urologic evaluation, early detection and diagnosis and expert treatment can have a dramatic impact on patient outcomes.

RISK FACTORS

The exact cause of prostate cancer remains unknown. Nevertheless, there are certain risk factors that are linked to prostate cancer.

1. Age — The most common risk factor. Two-thirds of prostate cancer is diagnosed in males over the age of 65. Recommendations on screening are found in the next section.
2. Race — African-American Males are 60% more likely to be diagnosed, often with both a higher stage and worse overall prognosis than Caucasian Males. In comparison, Asian males have a lower incidence than Caucasian males. Hispanic males have the same risk as Caucasian males.
3. Family History — Paternal inheritance of prostate cancer strongly suggests a genetic factor. In fact, having a father or brother with prostate cancer can significantly increase a man’s risk of developing this disease. More aggressive cancers, cancer diagnosed at an early age as well as prostate cancer deaths at an early age seen in first-degree male relatives all significantly increase a man’s risk.
4. Diet — Red meat and/or high-fat diets have been linked to a higher incidence of prostate cancer. Most recent studies support that a “heart healthy” diet is a “prostate healthy” diet.
5. Exercise — Patients who exercise regularly have been shown to have a lower incidence of prostate cancer.

PROSTATE CANCER SCREENING

Currently, digital rectal examination (DRE) and Prostate Specific Antigen (PSA) blood test are the most validated methods of prostate cancer detection. Screening guidelines for prostate cancer generally suggest that all men 50 years of age or older should undergo annual DRE and PSA testing. For patients with previously mentioned risk factors, screening should start at age 40.

DIAGNOSIS

The diagnosis of prostate cancer remains solely based on a tissue diagnosis. Although screening blood and urine studies, physical exam and imaging modalities such as CT, MRI and ultrasound can suggest the possibility of prostate cancer, ultimately, a biopsy is the only way to confirm the presence of prostate cancer. In addition, the grading of the cancer regarding its aggressiveness, referred to as the Gleason Score, is also dependant on a pathologist’s assessment of the biopsy specimen.

A biopsy of the prostate is obtained by passing a small probe into the rectum. Ultrasound waves from the probe project images onto a video monitor which can be used to calculate prostate size and volume as well as identify areas suspicious for cancer. A systematic set of biopsies is performed by using a skinny needle device to retrieve a very small amount of prostate tissue. On average, most urologist sample between 6 and 15 different areas throughout the prostate. These tissue samples are then ultimately reviewed by a pathologist to determine the presence of prostate cancer, as well as the volume and grading of the cancer.

CANCER GRADING AND STAGING

The Gleason Score is an evaluation of the biologic aggressiveness of prostate cancer. Once an area has been identified with prostate cancer, a primary Gleason Score is assigned by a pathologist. This score can vary between 1 and 5. A Secondary Gleason score is also determined on a scale of 1 to 5 for any other less common patterns seen in the same area. Once this is performed, a combined Gleason score is calculated between 2 and 10. A combined Gleason scores between 2 to 4 indicates that the cancer is well-differentiated and therefore not likely to be very aggressive. A Gleason score between 5 and 7 refers to a moderately differentiated cancer. Gleason 8 to 10 cancers are poorly differentiated with the most aggressive behavior. Gleason scoring of prostate cancer remains one of the most important predictors in both treatment options as well as outcomes of patients diagnosed with prostate cancer.

Cancer staging is another important criteria used to determine treatment options and outcomes. The Urology Center uses the most standardized classification system developed by the American Joint Committee on Cancer (AJCC) called the TNM Classification System. Staging ranges from T1 to T4. As the staging increases from T1 (non-palpable prostate cancer) to T4 (metastatic prostate cancer), the overall prognosis and survival worsens.

ADDITIONAL WORK-UP

Once a diagnosis of prostate cancer is made, additional tests may be required to accurately stage the cancer and determine whether the prostate cancer has spread to other areas of the body. The most commonly used x-ray studies used include: 1) Bone Scan to identify spread of prostate cancer to the bones and 2) CT Scan of the Abdomen and Pelvis to identify either local spread of the cancer or regional spread to the lymph nodes. Some urologists as well perform cystoscopy, a procedure using a small lighted scope, as a part of the evaluation prior to certain treatment options.

TREATMENT OPTIONS

There are many different treatment options available for varying stages of prostate cancer. As previously mentioned many patients who are diagnosed with prostate cancer have localized disease (i.e., low stage) and are therefore candidates for “curative treatments”. The most accepted definitive treatment options are either radiation or surgical-based therapies.

The two radiation-based approaches include brachytherapy or external-beam radiation. The two surgically-based treatments include open radical prostatectomy or robotic (daVinci) radical prostatectomy. A potentially definitive treatment which is still under investigation includes cryotherapy or freezing of prostate cancer with lethal ice. Although prostate cryoablation is offered at the Urology Center, we observe a very strict set of criteria for patients to be recommended this therapy.

Other commonly used treatment options include: observation or watchful waiting, hormonal therapy as well as systemic chemotherapy.

External-Beam Radiation

External radiation refers to the delivery of radiation to the prostate from a source outside of the body. This procedure is performed by a radiation oncologist, a physician specializing in radiation treatments for cancer. Radical improvements in radiation technology have occurred over recent years. Our patients receive the most advanced form of radiation treatment called IMRT or intensity-modulated radiotherapy which has two distinct advantages over older forms of external radiation: 1) better targeting of radiation to minimize injury to the rectum and bladder 2) a higher delivery of radiation to the prostate due to better targeting. Unfortunately, due to potential injury of neighboring organs by delivering all of the radiation as a single dose, small doses of radiation or “fractions” must be delivered over 8 to 9 weeks.

Complications associated with external-beam radiation include urinary and rectal bleeding, alterations in bowel movements, urinary frequency and burning, urinary incontinence, erectile dysfunction and fatigue. Rare complications include fistulas (a communication between the urinary and rectal systems) or severe urinary bleeding.

Feduciary Marker Placement

The Urology Center now offers the most advanced approach in delivering external radiation. Prior to starting IMRT, three gold markers are placed under ultrasound guidance which then acts as a “GPS system”. This allows the radiation oncologist to more accurately track the prostate during external radiation treatments. Gold markers have been shown to not only increase the accuracy and therefore the total radiation dose delivered to the prostate, but also to help minimize the exposure of radiation to the bladder and rectum which translates in lower side effects. Much like a prostate biopsy, a rectal probe is used to accurately place the gold markers. Discomfort related to the procedure is minimal. We encourage our patients to inquire about this helpful option.

Prostate Brachytherapy

Brachytherapy refers to the delivery of radiation on or into cancerous tissues. Prostate brachytherapy can be performed with a low dose rate (LDR) approach using tiny permanently implanted radioactive pellets or “seeds” or with a high dose rate (HDR) approach using specially designed “flexiguides” that are placed into the perineal area (the area located between the scrotum and rectum) which are removed after treatment. Low dose rate brachytherapy (or “permanent seed placement”) has gained enormous popularity largely due to excellent cancer control rates as well as patient convenience.

Permanent brachytherapy is an extremely well tolerated operative procedure. Patients are admitted the day of surgery and given either spinal or general anesthesia. Once anesthesia is administered, a rectal ultrasound is inserted and used to careful measure and “map out” the prostate. A team consisting of a radiation oncologist, urologist and physicist then decides the number of radioactive “seeds” and distribution to effectively kill the prostate cancer. The radioactive “seeds” are then systematically distributed throughout the prostate using a specially designed device. Upon completion of brachytherapy, the patient is discharged the same day of surgery or the next morning.

Brachytherapy has the distinct advantage over external radiation in that all of the radiation can be delivered to the prostate in one day as opposed to over the period of several months. As well, recovery is much more rapid than open or robotic prostatectomy. Complications associated with prostate brachytherapy are identical to external radiation. However, patients do generally experience more urinary irritation, burning with urination and urinary retention (inability to urinate) with brachytherapy.

Radical Retropubic Prostatectomy

Radical retropubic prostatectomy refers to complete surgical removal of the prostate and seminal vesicles through an incision made in the lower abdomen with reconstruction of the bladder to the urethra. For several decades, this surgical approach has been the most popular surgical treatment for prostate cancer mainly due to the ability of a surgeon to perform a “bilateral nerve-sparing prostatectomy” with this approach.

Erectile dysfunction has long been a dreaded complication for patients undergoing surgery to treat their prostate cancer. The “nerve-sparing” approach, where nerves responsible for erections are systematically preserved, offers patients an opportunity to not only treat the cancer but also preserve their sexual potency.

Through multiple refinements in technique over the past few decades, what was once viewed as a “challenging” operation can now be performed in the hands of a skilled urologist in less than two hours with very acceptable blood loss (usually under 500 ml). In addition, a bilateral nerve-sparing can be performed in most circumstances in which prostate cancer is detected in an early stage.

Patients receive general anesthesia for an operation that takes roughly two hours. Most patients require a two to three day hospitalization. Lastly, most patients can comfortably return to work within four to six weeks following their surgery.

The most common risks of surgery include bleeding, infection, rectal or bowel injury, slowed return of bowel function, urinary leakage, and erectile dysfunction as well as a vesicle neck contracture (scar tissue between the bladder and urethra).

Laparoscopic Robotic-Assisted Prostatectomy

The Urology Center is proud to announce that we offer “robotic”, or daVinci Prosatectomy (dVP), as a safe and effective surgical alternative for patients diagnosed with prostate cancer. The Urology Center not only pioneered this procedure in Northern Colorado, but we have the most experience in this type of surgery.

Although the entire prostate is removed much like a radical retropubic prostatectomy, there are some key differences and advantages to robotic prostatectomy. One important difference is that instead of operating through a 5 to 7 inch length incision, the entire operation is done from outside of the body. Five to six laparoscopic ports are placed in the lower abdomen by making anywhere from ¼” to 1 and 1/2 inch incisions. Carbon dioxide gas is used to inflate the abdomen and create a working space for the operating urologist. Through these ports, specialized laparoscopic instruments can be placed to perform a number of surgical tasks including cutting, cauterizing and sewing.

During robotic surgery, the operating urologist spends time placing the necessary laparoscopic ports in the patient. Once this is completed, a sterile bedside robot is brought in to hold the camera and operate two of the instruments. At this point, the operating surgeon removes his sterile gown and operates at a specialized console approximately 10 feet away from the patient. An assistant urologist remains at bedside to assist and to provide bedside feedback to the operating surgeon.

The daVinci robotic system offers some unique advantages over both open prostatectomy and traditional laparoscopic prostatectomy. The specialized instruments controlled by the robot have a revolutionary Endowrist that enables the surgeon to reproduce exactly the same motions with the laparoscopic instrument that he creates with his hands and wrists. As a result, the operating surgeon can perform tasks such as cutting and sewing with much greater precision and accuracy. Additionally, unlike a standard laparoscopic camera, the daVinci system possesses two camera mounted side by side. As a result, the operating surgeon is provided with a magnified, three-dimensional view of the prostate and neighboring organs.

The main benefits of a robotic prostatectomy include less blood loss, less post-surgical pain, shorter hospitalization and a faster recovery. More recent advances in “nerve-sparing” using the robot suggest not only a faster return of erections but a higher rate of potency following surgery.

Patients receive general anesthesia for an operation that takes roughly 3-4 hours. Most patients require a 2-3 day hospitalization. Lastly, most patients can comfortably return to work within 4 to 6 weeks following their surgery.

The most common risks of surgery include bleeding, infection, rectal or bowel injury, slowed return of bowel function, urinary leakage, and erectile dysfunction as well as a vesicle neck contracture (scar tissue between the bladder and urethra).

Again, the Urology Center is the first urology practice in Northern Colorado to offer the daVinci robotic prostatectomy. As well, we offer the most experience in Northern Colorado. Not every prostate cancer patient is a good candidate for robotic prostatectomy. Nevertheless, we encourage our patients to inquire about this option.

SUMMARY

Prostate cancer is one of the most common cancers in males. Age and family history are the most common risk factors for developing prostate cancer. Most prostate cancers diagnosed in the US are detected in an early stage and therefore have an excellent chance of being curable. The most common treatments for early stage prostate cancer include external radiation, brachytherapy, radical retropubic prostatectomy and daVinci Prostatectomy. The Urology Center offers all of the mentioned treatment options as well as others including hormonal ablation and watchful waiting. Ultimately, the best treatment option is one that best suits the individual patient. We strongly encourage a discussion regarding these different treatment