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Prostate Cancer Treatment Options: Ask an Expert

Online Health Chat with Dr. Anthony Avallone

September 20, 2011


Introduction

Cleveland_Clinic_Host: Prostate cancer is the most common cancer in men, and the second leading cause of cancer deaths among men in the United States. Every year, about 185,000 new cases of prostate cancer will be diagnosed in the U.S.

Prostate cancer is a malignant tumor that usually begins in the outer part of the prostate. In most men, the cancer grows very slowly. In fact, many men with the disease will never know they had the condition. Early prostate cancer is confined to the prostate gland itself, and the majority of patients with this type of cancer can live for years with no problems.

With so many treatment options available for prostate cancer, it is easy to become overwhelmed with all of the information you’re receiving from many different sources. We would like to give you the opportunity to chat live with a prostate cancer specialist to have your questions answered regarding signs, symptoms, diagnosis, testing, and treatment options.

Dr. Anthony Avallone joined the Cleveland Clinic staff in 2009 and is part of the Glickman Urological & Kidney Institute. He specializes in urologic oncology, adrenal cancer, bladder cancer, kidney cancer, penile cancer, prostate cancer, testis cancer, and laparoscopic and robotic surgery. Dr. Avallone sees patients at Cleveland Clinic’s Main Campus, Fairview Hospital, and Westlake Family Health & Surgery Center.

Cleveland_Clinic_Host: If you would like to make an appointment with Dr. Avallone or any of the urologists in the Glickman Urological & Kidney Institute, please call 800.223.2273, ext.45600, or request an appointment online by visiting www.clevelandclinic.org/appointments. Thank you!

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Anthony N. Avallone. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


Screening and Assessment

zieglek2: What are the screening recommendations for the average man? Who does them?

Dr__Anthony_Avallone: Screening for prostate cancer remains controversial. However screened populations have a lower risk of death from prostate cancer.

Screening is by the PSA (prostate specific antigen) blood test. (It is used like mammograms in women. Early prostate cancer, like early breast cancer in women, often has no associated symptoms.) It allows earlier detection of prostate cancer. About 15 percent of newly diagnosed prostate cancer patient are still found with a digital rectal examination (DRE) and have a normal PSA, so DRE is done in conjunction with PSA testing.

The standard recommendation is for yearly PSA testing to be done starting at age 50. African Americans and men with a first degree relative with prostate cancer are at higher risk and, therefore, should be screened starting at age 40.

ztestis: My PSA test result this past July was 1.0. I'm 52 years old. Is this a safe level for someone my age?

Dr__Anthony_Avallone: There is no "normal" value for PSA. However, this is in an acceptable range as long as your DRE is OK.

Looking at the PSA over time can be more predictive for prostate cancer than the absolute level, so I would recommend checking it again in a year

wpresler_1: I am 53 and had a PSA of 4.6. Biopsy showed cancer was removed with robot. What should be next step?

Dr__Anthony_Avallone: It depends upon the final pathology report. If the final pathology report is OK, periodic PSA monitoring is in order. The PSA should fall to zero and remain so after surgery. A detectable PSA is usually a manifestation of recurrence.

pandora3: What would be the cause of a low free PSA reading other than cancer?

Dr__Anthony_Avallone: Low free PSA can be an indicator for prostate cancer, but is also seen in BPH (benign prostate hyperplasia).


Testing

pjhorvath: Is the PCA3 (prostate cancer gene 3) urine test sufficiently accurate to decide if a biopsy is necessary? My number was 2.4, whereas my PSA at age 74 runs from 5 to 9. I have had prostatitis twice. Thanks.

Dr__Anthony_Avallone: The most common current use for PCA3 is determining the need to repeat a biopsy in a patient who has undergone previous negative biopsy and has a persistently elevated PSA.

robm: I am 60 years old and my PSA went from 3.6 to 7.2 in one year. A second PSA showed 6.1. I have decided against further treatment and am on Proscar® (finasteride) until November. At what point do I need to take further action? How common is breast enlargement on Proscar®? What are the risks if I decide to watch the numbers? At what point should I take action?

Dr__Anthony_Avallone: If you are in good health, you should talk to your physician about undergoing a prostate ultrasound and biopsy to rule out prostate cancer, especially given the rate of change of your PSA.

Proscar® can cause breast enlargement rarely and can be irreversible.

pjhorvath: How reliable is the PCA3 urine test regarding the need to re-biopsy?

Dr__Anthony_Avallone: There is no test that is 100 percent reliable, but the PCA3 has added to our ability to counsel patients regarding the risk of prostate cancer and the need to re-biopsy. It is more specific than PSA.

Friedley: When a biopsy is done and 12 samples are taken, what are the chances of missing the cancer completely or by chance getting a more concentrated grouping of samples so it appears the cancer is more severe?

Dr__Anthony_Avallone: The extended biopsy pattern that you are referring to has a lower chance of missing clinically significant prostate cancer than the sextant (six biopsies) pattern that we used years ago. Nevertheless, no test is 100 percent accurate, so periodic PSA monitoring and PCA3 evaluations are performed and, when necessary, repeat biopsies, as some cancers are missed on the first set of biopsies.


Medications

gs4143ds: I'm on Lupron (leuprolide). Could Avodart® (dutasteride) and finasteride have fewer side effects?

Dr__Anthony_Avallone: Lupron is hormonal therapy used for treatment of prostate cancer. Avodart® and finasteride are medications used for lower urinary tract symptoms due to BPH (benign prostatic hyperplasia), which is a benign enlargement of the prostate all men develop (but only some of which develop symptoms that require treatment).


Surveillance

nancyh: After radiation and hormone suppression, what is best way to follow patients for recurrence or metastatic disease?

Dr__Anthony_Avallone: The PSA test is used for two purposes. One is for screening and the other is for tumor surveillance. Although screening remains controversial, there is no controversy in employing PSA in tumor surveillance, which means monitoring the disease. It is a very accurate test when used in this fashion and should be periodically checked after radiation and hormone treatment, or any definitive form of treatment.

robtoby: I had a laparoscopic radical prostatectomy nine months ago. I've already had one subsequent PSA test that was undetectable. Going forward, besides regular PSA tests, are there any other tests (blood or otherwise) I need to have?

Dr__Anthony_Avallone: PSA testing should be adequate as long as it remains undetectable.

zieglek2: (From Twitter) If my PSA has gone from 0 to .13 in 15 years, will it keep rising? This is after radical prostatectomy.

Dr__Anthony_Avallone: This is a very slow rise and is usually followed and not actively treated. PSA doubling time over 12 months can be managed conservatively in many patients, but should be discussed with your urologist

Friedley: I was diagnosed with prostate cancer a year ago. PSA 4.7, Gleason 6, Aureon 11. I have chosen active surveillance/watchful waiting. I changed my diet and increased exercise. Since doing that, the results of recent PSAs were: 12/13/10 4.2, 3/10/11 4.6 5/17/11 4.06 Free PSA 12/13/10 17 5/17/11 14. My question is: Is watchful waiting a reasonable approach for me; and more importantly, how often should a repeat biopsy be performed? Thank you kindly.

Dr__Anthony_Avallone: Whether or not active surveillance is reasonable depends upon your age and health, and what you are most comfortable with. If you are reasonably healthy, you should undergo repeat biopsies yearly, as PSA alone is not accurate enough for monitoring disease progression or growth of the prostate cancer.

willrich: My prostate cancer was biopsied 4 1/2 years ago with a Gleason Score of 7, PSA 10. My age is 86 1/2. I have opted for watch and wait. I had several clean bone scans and, in the last six months, a clean colonoscopy. The urologist reports no lumps or bumps, but a hard spot on the left side. No symptoms other than fatigue. The latest PSA is 254. I am still mentally alert and prefer to avoid hormonal therapy unless pain ensues. Do you have any thoughts on my condition?

Dr__Anthony_Avallone: A PSA that high is usually associated with disseminated disease. You should be followed carefully by your urologist with respect to symptoms, and you will likely require another bone scan if you PSA continues to rise. As long as you are feeling well and your bone scan is negative, it seems reasonable to withhold hormonal therapy, but this is a decision you and your physician should make.


Treatment

WALTER: Which type of external beam radiation is the most precise with the least side effects?

Dr__Anthony_Avallone: Over the last 20 years, we have seen tremendous advances in radiation treatment for CAP (cancer of the prostate). The newer forms of radiation allow the prostate to be targeted more accurately, with reduced short-term and, hopefully, long-term side effects.

Any of the newer forms of radiation work well. As far as I know, there are no head-to-head trials comparing the newer forms. It is important to be treated at a center that does its own planning with an on-site radiation physicist, such as we have at Cleveland Clinic.

engineer_no__121: I have clinical stage T2c prostate cancer (PSA=9.7' cancer in both lobes, Gleason scores 2@8 & 3@7; percent of tissue ranges from 5 percent to 30 percent). Is surgery or radiation the recommended treatment and why? My priority is long-term, regardless of short-term discomfort or inconvenience.

Dr__Anthony_Avallone: Radiation and surgery are both good treatments for prostate cancer. Unfortunately, we do not know which is more likely to cure clinically localized disease, which I presume you have. A thorough discussion, taking into account your age and overall health and risk preferences, should be undertaken with your urologist.

If you choose radiation, a discussion of hormonal therapy before and for a period of time afterward should be undertaken, as it is likely to increase your chance of cure in the presence of Gleason 8 disease.

Tstephan: I am 72 years old, in good health, RE shows mod. enlarged prostate without discreet nodules, induration, or asymmetry, annual PSA test since 1998 gradually rising from 1.6 to 10.1. in March 2011. Prostate biopsy in June 2011 shows adeno-Ca in right lobe only, Gleason score 3+3=6 involving less than 25 percent of entire specimen. What treatment would you recommend? If I choose active surveillance, when would you start with any therapy? Are there yet any genetic markers to indicate slow versus rapid progression of the tumor?

Dr__Anthony_Avallone: Low volume cancer with Gleason 6 pathology tends to have a good outcome with either radiation or surgery. Your PSA puts you on the fence between low risk and intermediate risk disease, though. Depending upon the size of your prostate and the number of cores involved, cryoablation might also be a good treatment, but we do not have long-term data as we do for surgery and radiation.

Depending upon the number of cores involved and the PSA density, you might be a candidate for active surveillance. If so, you would need to have another biopsy at one year, as PSA alone is not accurate enough to determine whether or not the disease is progressing.

gks: Would you recommend IMRT (intensity-modulated radiation therapy) following brachytherapy in a 65-year-old patient with a Gleason score of 9?

Dr__Anthony_Avallone: Brachytherapy with an external beam boost is sometimes utilized in high risk prostate cancer. This should be discussed with a radiation oncologist, as there are plusses and minuses to this approach just as with other forms of therapy.


Risks and Side Effects

tomgilbride: I was diagnosed with prostate cancer last month. My Gleason score is 7. My biggest concern is the side effects of any treatment that I will have. Can you comment on the side effects associated with treatment, especially incontinence?

Dr__Anthony_Avallone: Radiation has a lower risk of significant incontinence than does surgery, but it has other risks. The risk of significant urinary incontinence after undergoing open or robotic prostatectomy by an experienced surgeon is very low, less than 3 percent.

BigRog200: Over time, how do the various treatment options compare related to: incontinence, impotence, and recurrence?

Dr__Anthony_Avallone: Unfortunately, this is a very broad question and is related to the stage and grade of disease, body habitus, and other medical conditions. You should have a frank discussion with a urologist and a radiation oncologist to go over these questions.

robm: What are the possible adverse reactions to prostate biopsy? I have been reading the Invasion of the Prostate Snatchers and am concerned about any chance of incontinence. Before he passed away, my father had incontinence in addition to dementia.

Dr__Anthony_Avallone: There should be no chance of incontinence after biopsy. There is a very low chance of a serious infection. At Cleveland Clinic, we have recently instituted a new policy for broader spectrum antibiotic coverage before prostate biopsy to help minimize the risk of a serious infection.

tomgilbride: What do you mean by complications in a salvage procedure?

Dr__Anthony_Avallone: A regular radical prostatectomy, whether done by an open approach or robotically, is associated with a low chance of incontinence and a very low chance of rectal injury (requiring a temporary colostomy in some patients). A post-radiation salvage prostatectomy is associated with a very high chance of severe urinary incontinence and a chance of rectal injury (which after radiation is often treated with a permanent colostomy).


Cancer Recurrence

Revdwight: Five years ago in June, my prostate was removed at Cleveland Clinic in Weston FL. This July, I was told that my PSA, which had been undetectable for five years, had risen to 0.17. A month later, it had risen to 0.18. My local urologist indicated that if it reaches 0.2, I will need to consider radiation treatments. What do you think is going on?

Dr__Anthony_Avallone: A slowly rising PSA five years after surgery is commonly associated with microscopic disease recurrence, usually in the pelvis. You will need an evaluation with CT and bone scan, but these are usually negative in this circumstance. Radiation can be associated with a 60 percent cure rate in this setting.

donna: Hi. My father was diagnosed with prostate cancer five years ago. It was contained in only two lobes, but with a Gleason score of 8. He went through 42 radiation treatments. His PSAs have remained low until this year. Now they have gone up to 19. The radiation oncologist has started him on hormone therapy. His first PSA is now down to 0.3, so that is good. My father is a good 86-year-old, very active and alert. Are we going in the right direction with his treatments? I don't want him to be treated like he is old. Although he knows he is, he does not act or look it. Do you have any other recommendations? Thank you Donna

Dr__Anthony_Avallone: Your father has high risk prostate cancer because of his high grade, and recurrence in this setting is not uncommon. He should have had a bone scan and CT to evaluate him for metastatic disease.

Hormonal therapy should be preceded by a bone density evaluation. There are risks to hormonal therapy, including bone loss, hip fracture, and cardiovascular disease. These risks should be weighed against the status of his disease based upon staging studies. He should discuss the risks and benefits of hormonal therapy in his case with his physician.


New Technology

Tstephan: If there is recurrence of cancer after initial IMRT, what can be done then?

Dr__Anthony_Avallone: I am assuming you are referring to local recurrence. That is disease within the prostate, as opposed to recurrence elsewhere in the body. There is no standard treatment for local recurrence after definitive radiation therapy. Salvage radical prostatectomy is occasionally utilized, but has a very high risk of complications.

Investigations using cryoablation are being done at Cleveland Clinic by Dr. J. Stephan Jones and Dr. David Levy. Initial studies show promise in treating local radiation failures with cryoablation.

Ray: I am 55 years old. I have adenocarcinoma, Gleason grade 3+3=6 involving 1 core (10 percent 0. I am leaning toward surgery. I have heard about a newer technique that eliminates the need for catheter after surgery and provides for a higher level of normal functionality after surgery. Is there a new technique or is this more of a marketing spin?

Dr__Anthony_Avallone: I am guessing that you are referring to robotic prostatectomy with a suprapubic tube instead of a urethral catheter post operatively, which some centers are doing. Unfortunately, there is not enough data to say whether or not this will influence the chance of developing scar tissue where the urethra and bladder neck are connected during surgery after prostate removal.

Years ago, we would leave a catheter in place for three weeks after prostate surgery. Nowadays, most patients have a catheter for five to seven days post-op and seem to tolerate it well, whether they undergo open or robotic surgery.

WALTER: When do you think HIFU (high intensity focused ultrasound) will be approved by the FDA?

Dr__Anthony_Avallone: Unfortunately, there is no way to know if or when it will be approved.

WALTER: Isn't the FDA doing clinical trials for HIFU in cases of recurrence after initial IMRT?

Dr__Anthony_Avallone: I do not know if there are clinical trials for HIFU for patients with radiation failure. At Cleveland Clinic, Dr. Stephen Jones and Dr. David Levy utilize prostate cryoablation for recurrence after radiation failure in selected patients.

While we currently don’t offer the treatment, because it’s not FDA approved, we can talk with patients to see if it’s an option they should consider. If they are interested in HIFU, they can see a Cleveland Clinic physician and discuss it with them.


General Questions

gks: What clinical trials would you recommend for prostate cancer metastases to bone?

Dr__Anthony_Avallone: There are numerous clinical trials. Here is the link to ones at Cleveland Clinic: clevelandclinic.org/research/clinical_trials. You can also check the National Institutes of Health (NIH) Web site at www.clinicaltrials.gov.

Friedley: What effect have you seen in prostate health of avid cyclists who spend a lot of time sitting on a bicycle seat?

Dr__Anthony_Avallone: I have not seen any effects, but many cyclists now use seats with cutouts that prevent perineal pressure.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Anthony N. Avallone is now over. Thank you again, Dr. Avallone, for taking the time to answer our questions today about Prostate Cancer Treatment.

Dr__Anthony_Avallone: I enjoyed it! Thanks.


More Information

If you would like to make an appointment with Dr. Avallone or any of the urologists in the Glickman Urological & Kidney Institute, please call 800.223.2273, ext. 45600, or request an appointment online by visiting www.clevelandclinic.org/appointments. Thank you!

A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit www.eclevelandclinic.org/myConsult.

If you need more information, click here to contact us, chat online or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272 ext. 43771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!

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This chat occurred on 9/20/2011

This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. ©Copyright 1995-2011 The Cleveland Clinic Foundation. All rights reserved.


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