Prostate Cancer Q&A with Eric Klein, MD
Eric Klein, MD, Institute Chair
Glickman Urological & Kidney Institute Cleveland Clinic
Q: Is carcinoma considered an aggressive cancer or a slow one?
A: Carcinoma is just another word for cancer. The aggressiveness of the cancer is determined by its appearance under the microscope.
Q: I had a radical prostate removed 16 months ago. Other than PSA (prostate-specific antigen) tests, do I need to have any other testing done, such as MRIs or CAT scans?
A: No, PSA is all that is needed.
Q: What is a bone scan used for after a prostate has been removed?
A: 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.
Prostatic intraepithelial neoplasia (PIN)
Q: Would you please explain the nature of PIN, and what it predicts, if anything?
A: PIN is a pre-cancerous condition that results in cancer in 10% to 30% of patients. There is no specific treatment for PIN, but long-term monitoring with digital exams, PSA, and additional prostate biopsies is warranted.
Q: If a patient has high-grade PIN, does it ever return to normal or will it continue forever?
A: 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.
Q: What is the "Gleason score"?
A: The Gleason score is named after pathologist Donald Gleason, who described the most reliable way of grading prostate cancer to determine its aggressiveness. A pathologist assigns a Gleason score after reviewing the prostate biopsy. The pathologist will assign a primary and a secondary score of 1 to 5 each, and the final score is the sum of the primary and secondary scores. Higher Gleason scores are more aggressive.
Q: What does age have to do with watching and waiting in a person with prostate cancer who is in excellent health otherwise? When you decide to watch and wait after a diagnosis of cancer of prostate, what methods do use to watch for cancer growth?
A: 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, a prostate biopsy should be performed periodically even if the PSA and digital rectal exam do not change. There is no specific age cutoff for active surveillance.
Q: My Gleason score just came back as 6 (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. Do you agree with my choice?
A: 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 the worry about the presence of untreated cancer and a small chance that 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.
Q: I am 51 with a PSA of 4.1 and a Gleason score of 7 (3 + 4). Cancer is present on one core and involves 5% to 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?
A: This is a good question. Three good treatment options for prostate cancer have roughly similar cure rates at 10 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 years 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.
Q: What is preferable for curing prostate cancer, ADT or radiation methods?
A: 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.
Q: What is the difference between ProstRcision® and seed implant/external beam radiation combination?
A: ProstRcision is merely a brand name for the combination of seeds and external beam radiation.
Q: Has cryoablation method been improved, and is it approved by Medicare?
A: 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.
Q: Is there a clear decision between choosing open radical surgery vs. robotic surgery? I have done quite of bit of research on your website and others. My urologist says I also qualify for brachytherapy, but I'm favoring surgery at this time.
A: 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.
Q: Is post-surgery scar tissue a risk with open radical or robotic surgery, and how often does this occur?
A: Scarring at the juncture of the bladder and the urethra that causes difficulty urinating occurs in 2% to 4% of patients after any form of radical prostatectomy.
Q: I have scar tissue from laparoscopic hernia repair, making surgical removal impossible. Can the da Vinci® robot solve this?
A: 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.
Q: If I choose surgery vs. radiation treatment, how can I find out how qualified a surgeon is, ie, how many surgeries he or she has performed?
A: 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.
Q: I live in Connecticut. If I were to choose treatment at Cleveland Clinic, how many times must I return for post surgery follow-up?
A: Our usual routine is for two post-operative visits, one to remove the Foley catheter 5 to 10 days after surgery and again one month later to assess overall recovery. If there is a physician at home that can remove the catheter, it can be done there and a phone call can be substituted for the second visit.
Q: What is new in treating male incontinence from prostate surgery?
A: There are two new treatments. The first is a new form a urethral sling that seems to work better than the older versions. The second, which is not widely available in the US, is gene therapy that stimulates the growth of muscle. Clinical trials are under way with both.
Q: I had a laparoscopic prostatectomy three years ago. I regained fairly good bladder control in three months. However, I still have urgency and frequency problems, with considerable leakage at night. Should I make an appointment with a urologist?
A: Persistent urinary leakage problems should be evaluated by a urologist and usually be treated successfully with either medication or relative minor surgical procedures including a urethral sling or an artificial urinary sphincter.
Q: I had my prostate removed over a year ago. Dr. Gill said he removed all of the cancer. With prostate cancer being the number two killer of men, when could I expect to see a recurrence, if any? Where do recurrences occur in the body?
A: About one-half of all recurrences take place in the first three years 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.
Q: 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?
A: 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.
Q: Can you talk about the link between genetic susceptibility and predisposition to infection as it relates to prostate cancer?
A: This is a fascinating story. Men with a history of sexually transmitted disease or prostatitis have a higher risk of developing prostate cancer. Furthermore, variations in the DNA of certain genes that predispose animals to infection also seem to increase the risk of prostate cancer in humans. Although no specific infectious agent has been shown to cause prostate cancer, there are many interesting leads including a virus called XMRV discovered at the Cleveland Clinic. We are currently working to determine if XMRV causes prostate cancer. If it does, we may be able to develop a preventative vaccine.
Q: If an individual has a father who died of prostate cancer with a Gleason score of 8 and has a brother who was diagnosed with high-grade PIN, at what PSA level would you recommend having a biopsy?
A: Men with a family history of prostate cancer are at double the risk of the general population for developing risk of prostate cancer. Since you have both a father and brother with prostate cancer, your risk may be even higher. Rather than a specific PSA level that should trigger biopsy, it might be more appropriate to follow the pattern of your PSA levels over the past few years. If it is rising, then a biopsy is recommended even if it is still below 4.