Prostate Cancer: Diagnosis, Impact and Options for Treatments

With September being Prostate Cancer Awareness Month, we spent some time with Eddie E. Michli, MD, to discuss the disease, how it’s treated and what men can do to take care of themselves.

What should people know about prostate cancer?

Currently, there are over 3.1 million American men living with prostate cancer.  About 1 man in 8 will be diagnosed with the disease during his lifetime. Prostate cancer is the second most frequent cancer diagnosed in American men after skin cancer. It is estimated that about 250,000 new cases will be diagnosed this year leading to about 34,000 deaths. 

Many of us know at least one man who was diagnosed with prostate cancer. Clearly, it is a serious disease, but the vast majority of men with prostate cancer will not die from it. Prostate cancer often grows very slowly over the course of many years even decades. The medical community has realized that not all men with prostate cancer will benefit from treatment. In fact, the standard of care is to actively watch men with low risk cancer rather than treat them as their risk of mortality is low. For men diagnosed with more aggressive disease a multitude of treatment options are available that have proven to reduce mortality and improved quality of life.

What are prostate cancer risk factors?

Prostate cancer risk increases with age. It is rare in men younger than 45, in fact most men are diagnosed after the age of 65. African Americans have an overall increased risk of being diagnosed with prostate cancer. They also tend to be diagnosed at an earlier age and oftentimes have a more aggressive disease at time of diagnosis. A genetic predisposition has been associated with prostate cancer. Having a father or sibling diagnosed with prostate cancer doubles the risk of developing the disease. Still, most men diagnosed have no family history. Currently, there are no conclusive evidence linking prostate cancer to certain diets like dairy, smoking or chemicals such as Agent Orange used in the Vietnam War. In addition, there is no conclusive evidence that certain supplements such as saw palmetto reduce the risk of developing prostate cancer.

What’s the importance of early detection?

Early detection of prostate cancer involves screening men who otherwise have no symptoms and no reason to seek medical care. It involves a blood test called prostate specific antigen or ‘PSA,’ and a rectal exam. If these tests are abnormal a prostate biopsy may be recommended, which is the only way to diagnose the disease. PSA screening has been controversial over the years. While there is no question that PSA screening will detect prostate cancer 5-10 years before symptoms of the disease are recognized and statistically prostate cancer mortality in the US has declined since PSA screening became more widespread.  Some feel screening protocols have not conclusively lead to saved lives and the benefits of screening do not outweigh the risks of follow-up tests and cancer treatment. Taking all these factors into account the American Urological Association convened and after reviewing all the data made the recommendation to screen for prostate cancer in men ages 55 to 69 years old. Men in this age group derive the greatest benefit of reducing the risk of cancer related death against the potential harms associated with screening such as prostate biopsy related infection and side effects of treatments. Men age 40 to 55 years old who are at increased risk for developing prostate cancer including African Americans and those with first degree family history may start screening earlier.  Some men over the age of 70 years in excellent health and long life expectancy of 10 – 15 years may benefit from screening as well. Ultimately, after discussing the risks and benefits of PSA screening a shared decision-making between the physician and patient should dictate the approach.

What are the treatment options for prostate cancer?

It is important for most patients diagnosed with low risk prostate cancer to know that active surveillance is the preferred option recommended by the American Urological Association. Treatment may not increase life expectancy and poses increased risk of side effects.  Low risk prostate cancer grow slowly and is unlikely to lead to mortality and morbidity. Surveillance involves periodic PSA blood tests imaging studies such as MRI and prostate biopsies. If signs of cancer progression is detected especially on repeat biopsy surveillance is terminated and treatment can be employed.

Unlike many other cancer types, following the diagnosis of higher risk prostate cancer patients are faced with multiple treatment options. Advising on appropriate care will depend on the cancer’s aggressiveness as well as the patient’s health status and values.

The most common treatment for prostate cancer involves removing the prostate or “radical prostatectomy”. This procedure if commonly performed in a minimally invasive fashion using an advanced laparoscopic-robotic platform called the “da Vinci” robot.  This involves inserting thin instruments through a few key size holes into the abdomen. Using this approach, blood loss is minimal, post-operative pain is minimal and most men leave the hospital after a single night stay. Major side effects are uncommon. The most common side effects include urinary incontinence or the inability to control urination. This in fact improves over time and the majority of men fully recover. Erectile dysfunction or impotence is more common, but with newer techniques (nerve-sparing approach) and surgeon experience results are excellent.

Radiation treatment is another commonly used approach to treat localized prostate cancer especially in older men or men with multiple health issues posing increased risk for surgery. Brachytherapy (or internal radiation) involves implanting radioactive seeds into the prostate through the skin. The procedure takes 1-2 hours and most men go home the same day with minimal discomfort. External beam radiation therapy involves targeting the prostate with high energy x-ray with daily sessions lasting 15 minutes for 4-8 weeks. Side effects resolve in most men but can include urinary difficulties, bowel issues, fatigue and erectile issues that can present a few years after treatment.

Patients that fail treatment whether surgery or radiation present a unique challenge. Many of these patients will not be affected by their local cancer recurrence. Depending on individual characteristics some men will be watched and not treated. Others, who failed surgery may be offered external beam radiation treatment to try and eradicate the residual cancer. For those patients that present with disease outside the prostate a multitude of treatments are available including hormone therapy, chemotherapy, immune therapy and newer anti-androgen drugs that block testosterone’s affects on cancer growth. These treatments can help halt cancer progression and significantly extend life expectancy.

Anything else you would like to mention?

I try to convey to my patients that most treatment options are excellent and there is no “wrong decision” or “best treatment” rather an individualized tailored approach is implemented.  It is a complex medical decision and I often encourage patients to meet with different specialists including urology, radiation and medical oncology. The urologic tool chest is broad and our job is to help our patients navigate through  the risks and benefits of the various treatment options available and come up with a strategy that suits them best.

Eddie E. Michli, MD, is currently accepting new patients in Robotic Surgery – Urology, Urology.