Prostate Cancer --- September 26, 2007

Eric A. Klein, M.D. Head, Section of Urologic Oncology Glickman Urological and Kidney Institute Cleveland Clinic

Cleveland_Clinic_Host: Welcome Dr. Klein, and thank you for joining us today. Let's begin with one of the questions!

Speaker_-_Dr__Klein: Thank you, it is great to be here with you.

Prostate Cancer

Norm: Is carcinoma considered to be aggressive cancer or slow?
Speaker_-_Dr__Klein: Carcinoma is just another word for cancer. The aggressiveness of the cancer is determined by its appearance under the microscope.

rwinter: I had a radical prostate removed 16 months ago. Other than PSA tests do I need to have any other testing done, that is MRI's or CAT scans?
Speaker_-_Dr__Klein: No, PSA is all that is needed.

aiden: Dr. Klein -what is the average length of healing time following open surgery to remove the prostate?
Speaker_-_Dr__Klein: An interesting study from the Univ. of Michigan that will be published soon showed that patients reported feeling 'back to normal' at 27-28 days after either open or robotic prostatectomy.

mell2007: What is a bone scan used for after a prostate has been removed?
Speaker_-_Dr__Klein: A bone scan is used to assess for the presence or absence of cancer in the bones and may be used before or after treatment. The usual indication for a bone scan after surgery is a detectable or rising PSA.

PIN

prostatecare: Would you please explain the nature of PIN and what it predicts, if anything?
Speaker_-_Dr__Klein: PIN is a pre-cancerous condition that results in cancer in 10-30% of patients. There is no specific treatment for PIN, but long term monitoring with digital exams, PSA and additional prostate biopsies is warranted.

s1970b: If a patient has high grade PIN; does it ever return to normal or will it continue forever?
Speaker_-_Dr__Klein: High grade PIN is considered a pre-cancerous condition and while it does not always progress to cancer, it usually does not disappear on its own.

Gleason Score

prostatecare: Would you please explain the "Gleason Score"?
Speaker_-_Dr__Klein: Gleason score is named after a pathologist (Donald Gleason) who described the most reliable way of grading prostate cancer to determine its aggressiveness. A Gleason score is assigned by a pathologist after reviewing the prostate biopsy. The pathologist will assign a primary and a secondary score of 1-5 each and the final score is the sum of primary and secondary score. Higher Gleason scores are more aggressive.

Active Surveillance

georgek: What does age have to do with watching and waiting when one is in excellent health otherwise with prostate cancer? When you decide to watch and wait after a diagnosis of cancer of prostate what methods do use to watch for cancer growth?
Speaker_-_Dr__Klein: A better term than watch and wait is 'active surveillance' which implies ongoing monitoring with treatment if and when the cancer becomes more aggressive. The routine for active surveillance is a digital rectal exam and PSA every 6 months with a prostate biopsy if either has changed significantly. Furthermore, prostate biopsy should be performed periodically even if the PSA and digital rectal exam do not change. There is no specific age cut off for active surveillance.

michael: I am 61 in excellent health an active tennis player and golfer. My Gleason score just came back as 3+3. My urologist says it’s a tossup between watchful waiting and surgery. My instinct is to have the surgery preferably laparoscopic or robotic. I have two questions: a) do you agree with my choice and b) how critical is to do quickly i.e. can I wait until April?
Speaker_-_Dr__Klein: There are advantages and disadvantages to what is now called active surveillance (rather than watchful waiting) vs. treatment for early stage prostate cancer. The advantage to active surveillance is the avoidance of treatment related side effects while the disadvantage is worry about the presence of untreated cancer and a small chance the cancer can become incurable. The advantage to treatment is that the cancer is likely to be cured, while the disadvantages are side effects related to urinary and sexual function following surgery.

Treatment Questions

Norm: I am 51 with a PSA 4.1, Prostatic Adenocarcinoma Gleason Score of 7 3+4 with Carcinoma present on one core and involves 5-10% of the core. What would be the advised treatment? What would be my life expectancy if I did nothing in the way of treatment?
Speaker_-_Dr__Klein: This is a good question. There are 3 good treatment options for prostate cancer that have roughly similar cure rates at ten years These options are radical prostatectomy, brachytherapy and external beam radiation (EBRT). For younger men, surgery has the advantage of getting a complete pathology report of the removed prostate so that the chance of cure can be accurately estimated and the need for additional treatment is determined. Furthermore, radiation based approaches may have side effects that occur many yrs. after treatment that are not seen with surgery. The likelihood of dying of untreated Grade 7 prostate cancer is approximately 60% during the next 15 years.

gritterjc1: I had a Radical Prostatectomy (12-2005), followed by 38 External Beam Radiation (7-2006) and now have received 2 6-month shots of Eligard. My PSA has been at .002 or lower since taking Eligard only. Do you recommend intermittent or continuous treatment? Do you feel Mono therapy is best or would you recommend multiple hormonal treatments?
Speaker_-_Dr__Klein: As long as your PSA remains undetectable, monotherapy is fine. If you are tolerating hormone therapy without side effects, it is okay to remain on it continuously. If side effects become bothersome, then intermittent therapy can be considered. The available data suggests similar survival whether hormones are used intermittently or continuously.

aiden: Would you consider taking Lupron and casodex before and a radical surgery to remove the prostate. There is a Gleason of 3+3 and a psa of 3.09
Speaker_-_Dr__Klein: No. There are a number of completed studies that showed no advantage to doing this. Furthermore, even short courses of hormone therapy have significant and potentially life threatening side effects.

dpb75: I'm a 75 year old who was diagnosed with prostate cancer almost 4 years ago. I had IMRT radiation which brought my PSA down to 0.03. Six months later my PSA began to rise. I was then given hormone therapy (Lupron) when my PSA continued to rise. The hormone therapy didn't stop my PSA from rising. It went as high as 47. I then began an experimental chemo treatment called E7389. My PSA began to drop but the cancer spread to my lymph nodes. My lymph nodes have grown to 3cm. I am scheduled for chemotherapy using Taxotere and would like to know if this is the treatment you would recommend or is there anything else.
Speaker_-_Dr__Klein: Taxotere chemotherapy is FDA approved for your clinical situation and it probably the next best treatment.

mell2007: What is preferable for curing prostate cancer, ADT or Radiation methods?
Speaker_-_Dr__Klein: I presume by ADT you are referring to Androgen Deprivation Therapy. If so, ADT is never curative but does increase the cure rate when used with External Beam Radiation for men with locally advanced disease.

Norm: I am in Stage 1 4.1 PSA 7 Gleason: Quality of life is more important than length. How do I determine which type of treatment would best accomplish this?
Speaker_-_Dr__Klein: In order to answer this type of question in this venue, I would need to have additional information including your age, general health, other medical problems, urinary symptoms, etc. I would emphasize though that all treatments have side effects.

Seed Implant /External Beam Radiation

hinf101: What is the difference between prostRcision and seed implant/external beam radiation combination?
Speaker_-_Dr__Klein: prostRcision is merely a brand name for the combination of seeds and external beam radiation.

Cryoablation

hinf101: Has cryoablation method been improved and is it approved by Medicare?
Speaker_-_Dr__Klein: Yes, to both questions. Recent improvements result in fewer urinary symptoms and a lower risk of rectal fistula. However, there is no long term data on the efficacy of cryosurgery for prostate cancer.

Surgery

bobbyb: I'm 54, recently diagnosed and leaning strongly toward surgery. Can you tell me when comparing laparoscopic to open, what factors need to be considered and the pros and cons? Why would anyone go with the open option? Thanks
Speaker_-_Dr__Klein: The most important factor in getting a good outcome after surgery is the experience of the surgeon and not the method that is used to remove the prostate.

happytrails2u: Is there a clear decision between choosing open radical surgery vs. robotic surgery? I have done quite of bit of research on your clinic website and others. My Urologist says I also qualify for brachytherapy, but I'm favoring surgery at this time. Age: 64, excellent health, very active - walking and biking. Recently diagnosed with early stage (Gleason=6, two of 12 biopsy samples left apex 10-15% , 2 left base 20-25%).
Speaker_-_Dr__Klein: The most important factor in ensuring the best chance for cure and good functional outcomes after radical prostatectomy is the experience of the surgeon and not what approach is used. My best advice is to find the most experienced surgeon you can and let him choose the surgical tools that work best in his hands.

happytrails2u: Is post surgery scar tissue a risk with open radical or robotic or both and how often does this occur--is there a cause?
Speaker_-_Dr__Klein: Scarring at the juncture of the bladder and the urethra that causes difficulty urinating occurs in 2-4% of patients after any form of radical prostatectomy.

hinf101: I have scar tissue from laparoscope hernia repair making surgical removal impossible. Is this solved with the Da Vinci robot?
Speaker_-_Dr__Klein: The robot will not solve the problems created by the laparoscopic hernia repair. An alternative surgical approach is a perineal prostatectomy where the incision is made between the scrotum and the rectum, thus avoiding the scar tissue. Radiation based approaches can also be used in this circumstance.

happytrails2u: If I choose surgery vs radiation treatment, how can I find out how qualified a surgeon is -how many surgeries he/she has performed?
Speaker_-_Dr__Klein: The best way to assess surgeon’s qualifications is to ask other physicians you know about his reputation. I would also recommend meeting with the surgeon and specifically asking him about his personal results with respect to cure, continence and potency.

Seeking a Second Opinion

happytrails2u: I live in Connecticut. If I were to choose treatment at Cleveland Clinic, how many times must I return for post surgery follow-up?
Speaker_-_Dr__Klein: Our usual routine is for 2 post-operative visits, 1 to remove the Foley catheter 5-10 days after surgery and again 1 month later to assess overall recovery. If there is a physician at home that can remove the catheter, it can be done there and phone call can be substituted for the 2nd visit.

georgek: Age 79 in excellent health. I was just diagnosed with cancer after TURP surgery. Had a needle biopsy last year and a couple of years before that and no cancer found. My Dr. plans to watch and wait having PSA tests done every 6 months but no more biopsies. Gleason score was 3+3=6. My physician thinks encapsulated but not sure. Should we get another opinion?
Speaker_-_Dr__Klein: It sounds like you have gotten appropriate advice, but getting a 2nd opinion is always a good idea.

shipmad1: I am a 65 year old male. I have over a twenty five year history of prostatitis. In the past three years I have had high PSAs resulting in 3 biopsies over that period of time. The first one was benign. The next one showed high grade PINS. The most recent one, done on 9/12/07 showed 5 high grade PINS sites, and one "suspicious" site (left lateral mid), described as "abnormal glands, suspicious for, but not diagnostic of, Adenocarcinoma/high grade. This tissue has been sent to Johns Hopkins for their opinion. My urologist feels that they will probably come back with the same ambiguous opinion. He advised me that the Cleveland Clinic has an MRI procedure (not available here-Sarasota, FL) which could very well classify this area. Could you comment on this and recommend a course of action?
Speaker_-_Dr__Klein: My first suggestion is to wait for the 2nd opinion from Johns Hopkins as to whether or not the biopsy shows cancer. If it is only read as suspicious, then a prostate MR exam using an endorectal coil and incorporating tissue spectroscopy may be helpful in identifying suspicious areas in the prostate that were missed with the initial biopsies. This could be used for more directed biopsies targeted to the suspicious areas.

Recurrence

rwinter: I had my prostate removed 16 months ago. My pre surgery Gleason score was 6 (3plus3) and my post surgery Gleason score was 7 (4plus3) Dr. Gill said he removed all of the cancer. With Prostate Cancer being the number two killer of men, what and when could I expect to see a recurrence, if any? Where do recurrences occur in the body? Thank you, Rich
Speaker_-_Dr__Klein: About one half of all recurrences occur in the 1st 3 yrs after surgery. The most common form of recurrence is a rising PSA without obvious manifestations of cancer. Eventually recurrences can turn up in the lymph nodes or bone.

mell2007: Hello, my dad previously had his prostate removed and now his "PSA" test levels are up and they say the cancer has returned. How is this so?
Speaker_-_Dr__Klein: It is likely that he had some prostate cancer cells that had escaped from his prostate prior to its removal. Typically, these are not detectable by preoperative X-rays or blood tests.