Introduction
Did you know that prostate cancer is the most common non-skin cancer for men in the united states? It is important for men to know their risks and when they should be screened. This podcast – featuring prostate cancer expert Dr. Anthony D’Amico, Chief of Genitourinary Radiation Oncology at Brigham and Women’s Hospital and Chief, Prostate Cancer Radiation Oncology Service at Dana-Farber/Brigham and Women’s Cancer Center – will answer commonly asked questions.
What is prostate cancer?
Prostate cancer is the most common non-skin cancer in men in the United States, affecting nearly 250,000 men in 2007, with that number expected to increase over the next few years due to the use of PSA screening. The prostate gland is located in front of the rectum and below and behind the bladder. The function of the prostate is to ensure that a man is functional for the act of conception. Prostate cancer is a cancer that is specific to the prostate gland.
What are the risk factors for prostate cancer?
The major risk factor is aging. Beginning at age 50, men are at increased risk for contracting the disease. Race also plays a major role in risk, with African-Americans, Latinos, and Hispanics being at a higher risk for prostate cancer than Caucasians or Asians. Also, if a man has a dad or a brother that has been diagnosed with prostate cancer, they're twice as likely to develop the disease.
What can a man do to improve his chances of not getting the disease?
The single most important factor is screening. Specifically, at the age of 35, just like we do with a mammogram in women, a man should get his baseline prostate specific antigen blood test. It's called the PSA test, and it's simply a blood test that can be obtained with himself and the primary care physician. After age 35, it should be obtained again at age 40 and every year thereafter. If, in any given year, thePSA rises by more than one point, he should be seen by a urologist – who is a doctor who specializes in the prostate – and this should occur so that futher testing can be performed. A urologist can diagnose if prostate cancer is present and also help to determine how aggressive this often slow-growing disease is.
Recently, the U.S. Preventative Task Force released new prostate cancer screening guidelines. What do they mean?
The recommendation states that for men over age 75 prostate cancer screening with an annual PSA and rectal exam is no longer recommended and that for men under the age of 75, it remains controversial, pending the results of the large screening studies that are being performed in the United States and Europe. Because older men are more likely to get the most aggressive types of prostate cancer, I’d like to suggest that age by itself should not be used as the breakpoint for when to recommend prostate cancer screening. This is for the simple reason that a man’s age does not necessarily dictate how long he will live. Prostate cancer when more aggressive, which is more likely in older rather than younger men, can take a man’s life within five years of diagnosis. If a man has at least a 10-year life expectancy, which could be when he is 78 or when he's 58, prostate cancer screening should be recommended. Primary care physicians should take into account a man’s other health issues and not just their age when deciding whether to recommend prostate cancer screening or not. Men should discuss with their primary care physician their overall health status to come up with their life expectancy and determine the best approach for screening.
If diagnosed with prostate cancer, how do doctors determine if it is aggressive?
There are three main pieces of information that can be used to assess whether the prostate cancer is aggressive or not. The first indicator is the level of the PSA. It the level is more than 10, that's more consistent with aggressive disease, whereas when it's under 10, it's considered less aggressive. Also used in diagnosis and measurement of aggressiveness is the gleason sum score. The gleason sum score is an integer that can go from five to 10 inclusive. This number is assigned by a doctor that looks at the prostate cancer cells under a microscope. If the man’s Gleason sum score is five or six, then the cancer is less aggressive, whereas if the score is eight, nine or 10, then the cancer is considered aggressive. A seven is considered intermediate in terms of aggressiveness, between the five and six or the eight, nine and 10. The final piece of information is the rectal exam, which determines the stage and how aggressive the cancer is. Stage 1 is when the cancer cannot be felt by the examining physician and therefore not aggressive, and this is the kind of cancer that is most likely to be diagnosed if a man gets his PSA annually. Stage 2 is when the doctor feels the cancer but believes it is still confined to the prostate gland. And stage 3, which is the more aggressive type, is when the doctor can not only feel the cancer, but the doctor feels that is has moved beyond the prostate. It is important to also know that there are some forms of stage 2 that can also be aggressive.
What are treatments for prostate cancer?
Treatment options are based on how aggressive the disease is. If the cancer is not aggressive, meaning that the man has a PSA under 10, a Gleason sum score of five or six, and a cancer that can not be felt on exam - that is stage 1 - then the options include surgery - removal of the prostate, seed therapy - placement of high radioactive sources into the prostate, or image-guided external beam radiation therapy. If the cancer is more aggressive, where the PSA level is more than 10 , or the Gleason sum score is seven, eight, nine or 10, or it's in clinical stage 3 or some of the later stages of clinical stage 2, then it's important to know that the disease is definitely still curable, with a very high cure rate, but now the treatment, instead of involving a single therapy, involves more than one treatment. This treatment is usually external beam radiation and hormonal therapy or those two treatments combined with surgery.
Can you tell us more about the various types of treatment?
As for the treatments specifically, with surgery there are two major approaches to the operation – one is the traditional open approach and the other is the more contemporary laparoscopic robotic approach. While there is no difference in the cancer cure rates, there are important differences in the hospital stay and the amount of blood loss and the recovery time. All of these are shortened and improved with the laparoscopic robotic as compared to the open approach. Similarly, for seed radiation therapy, there are traditional and more contemporary approaches. The traditional approach is to use a pre-defined approach, or plan, for the placement of the radioactive seeds, whereas the contemporary approach is to design the plan for the placement of the seeds during the actual seed procedure, when you can see all of the normal tissues such as the rectum that you want to spare. Again, there is no difference in the cancer cure rate with these two approaches, but the side effects can be markedly decreased when you use an intra-operative approach to seed placement. With any sophisticated technique, such as seed therapy or surgery, studies have shown that experience matters. Specifically, centers where physicians have done at least 200 of these procedures find that the outcomes, in terms of side effects and cancer control rates, are improved. These more technically advanced procedures are performed by high volume physicians at the Brigham and Women’s Hospital.
Are there clinical trials for more aggressive prostate cancer?
Yes, at Brigham and Women’s Hospital we are running several important studies. And it's my opininion that these studies provide hope, to men facing prostate cancer, for better success. One particular study is an international study, evaluating the drug, a chemotherapy agent called Taxotere. This drug has been studied in thousands of men with prostate cancer that has spread beyond the prostate to the bone and has been shown to prolong their lives significantly, and so we are now studying this drug in men who are receiving radiation and hormonal therapy for aggressive prostate cancer that is either of the type of Gleason score seven, eight, nine or 10 or a PSA more than 10. It is our hope that this therapy will be able to help men with this type of prostate cancer is aggressive.
What are other services are available at Brigham and Women’s Hospital?
In addition to surgery and seed implantation, for patients at high risk for the more aggressive type of disease there have been several advances in the delivery of external beam radiation that specifically includes our ability to localize and target the prostate cancer each time before and during treatment. This approach has been shown already to lead to lower rates of toxicity and already has had lead to less toxicity, and when you couple this treatment with hormonal therapy, you actually improve cancer cure rates. Our goal with hormonal therapy is to do a thorough evaluation of a man’s overall health - particularly his cardiovascular health – prior to the start of prostate cancer treatment to assure that he not only gets the benefit of hormonal therapy but avoids the potential risks.
Dr. D’Amico, thank you for your time and for providing this valuable information on prostate cancer. For more information on prostate cancer or to make an appointment, call 1-800-BWH-9999 or visit us at brighamandwomens.org.
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