September 6, 2013
More than two million men in the U.S. have been diagnosed with prostate cancer, and every year approximately 185,000 new cases will be diagnosed. Although prostate cancer is the most common cancer in men, it is highly treatable. Screening advances have allowed earlier detection of the disease, and, therefore, earlier treatment. However, earlier detection does not always necessitate earlier or aggressive treatment. In many men, the cancer grows so slowly, ‘watchful waiting’—or active surveillance, is the recommended course of action.
Several treatment options are available for men with prostate cancer. One of the most common treatments for prostate cancer is the complete removal of the prostate (open radical prostatectomy), which can be performed robotically. Another treatment is radiation therapy, which can be either external beam radiation or brachytherapy (involving the insertion of radioactive pellets). Other treatment methods include cryotherapy (freezing) and hormone therapy.
Selection of the appropriate treatment is made after discussion by the urologist and patient with consideration of the stage of cancer, if there is any spread of disease, outcomes, and typical side effects. Prostate cancer is a serious disease that should be diagnosed and treated early to provide the best possible outcome for healthy lives in men.
About the Speakers
Eric A. Klein, MD, is Chairman of the Glickman Urological & Kidney Institute and staff physician in the Taussig Cancer Institute at Cleveland Clinic. He is board certified in urology. Dr. Klein completed his fellowship in urology at the Memorial Sloan Kettering Cancer Center, in New York following his residency in urology at Cleveland Clinic. He received his medical degree from University of Pittsburgh School of Medicine. Dr. Klein’s clinical interests are all aspects of urologic oncology, including cancers of the prostate, bladder, testis and kidney, and including all major reconstructive procedures such as continent urinary diversion.
Nicolas Muruve, MD, associate staff physician in Cleveland Clinic-Florida’s Department of Urology, in Weston, Fla, is a board-certified urologist. Dr. Muruve completed a research fellowship and a renal transplant/renal vascular fellowship at Cleveland Clinic following his residency in urology at the University of Manitoba Health Sciences Centre, in Winnipeg, Manitoba, Canada. He completed his internship at Mount Sinai Hospital in Toronto, after graduating from medical school at the University of Manitoba, in Winnipeg. Dr. Muruve’s special interests are genitourinary oncology and renal transplantation.
Let’s Chat About Prostate Cancer: Diagnosis and Treatment
Moderator: Welcome to our "Prostate Cancer: Diagnosis and Treatment " web chat with Cleveland Clinic Glickman Urological and Kidney Institute Chairman Dr. Eric Klein and from Cleveland Clinic Florida, Dr. Nicolas Muruve. We are very excited to have both available to chat today!
Prostate Cancer Signs and Symptoms
rlfinely: My PSA has always been less than 1.0 for several years, but I do wake up each night to urinate at least a couple times. Is that a problem I should be concerned with?
Eric_Klein,_MD: That is a typical symptom of prostate enlargement that can easily be treated with medication to relieve your symptoms. I suggest you ask your primary care doctor or urologist about which drugs might work best for you.
cmack216: If your most recent PSA is 1.93, but you have trouble maintaining an erection, could this be a sign of prostate cancer?
Nicolas_Muruve,_MD: No. Erectile dysfunction (ED) is estimated to occur in one out of ten men at some point during a man’s lifetime. In the great majority of cases, ED is a symptom of an underlying problem. But it is not a sign of prostate cancer.
pilatesgirl: Are cancers spurred to greater growth with higher blood sugar levels?
Eric_Klein,_MD: I don't know of any direct evidence for this, although insulin is like a growth factor. Its receptor has been implicated in prostate cancer progression. Interestingly, though, diabetic men are at lower risk for getting prostate cancer.
PSA: Testing and Treatment Guidelines
ncnava36: I am 60 years old. I am currently up to date with my yearly blood test (PSA) and the rectal test. Is that all that I should currently get done? Is there any other test that I am missing to discard any cancer possibility?
Eric_Klein,_MD: That’s all there is for prostate cancer screening. It is best to ask your primary care doctor about screening for other cancers.
caqu39: How important is the PSA in treating prostate cancer? Why is the normal range for PSA different than it used to be?
Nicolas_Muruve,_MD: Upon the diagnosis of prostate cancer, the PSA limits change. This is because once the prostate is treated, the PSA should drop down to zero if you had surgery or less than one following radiation therapy. PSA should stay at that level after that and any elevation of PSA from those values can suggest possible recurrent disease. This would happen of course before the PSA reaches four. This is why the values are different for monitoring rather than for screening.
GroKenHaMMer: How significant is a PSA number in determining the presence of cancer? What are the treatments if alfuzosin is no longer effective?
Eric_Klein,_MD: PSA is the best way to determine cancer risk, along with digital rectal examination (DRE), family history and a few other factors. If an alpha blocker like alfuzosin is no longer working, you could add finasteride or dutasteride, or consider a laser TURP. It is best to get an opinion from a urologist on these options.
moonie: Are fluctuations in regular (every six months) PSA levels normal? Mine have ranged from 2.5 to 4.5 within a two-year window. I have recently had a 12-punch biopsy that was clear. I am on testosterone injections and have been for four years. I am 65 year old and very active.
Eric_Klein,_MD: Yes, PSA fluctuations are very common. Your PCA (prostate cancer antigen) number can help determine if your PSA is worrisome for cancer.
jimbob22: For a 71-year-old man, how high is too high for PSA? How much change in PSA over a six month period is of concern? My last PSA was 4.0 and the previous one was 3.7. How painful is the biopsy procedure and are there alternatives?
Nicolas_Muruve,_MD: The upper limit of normal for PSA differs from office the office. Some doctors use an absolute value of four as the maximum level, and others use age-adjusted levels. For someone older than 70 years old, an upper limit of 6.5 has been used. As far as PSA change, this can be difficult to assess on single values, and should be done over multiple values to see the trend. In general, the PSA velocity of 0.7 per year is considered acceptable. Biopsy does not need to be painful if done in experienced hands. Local anesthesia can be used to minimize discomfort making it tolerable.
drjnov: What would be the next step to take when a PSA goes from 2.65 to over nine?
Eric_Klein,_MD: It depends on why it went up—prostate enlargement, infection or cancer. It is best to see a urologist to help distinguish between these possibilities.
DZ: Does a PSA of three or four mean the cancer is still contained to the gland?
Nicolas_Muruve,_MD: Not necessarily. Approximately five percent of all prostate cancers do not produce PSA. These can be better appreciated through physical examination and a grade of the tumor.
iP64: My PSA is 8.4. Do I have to be concerned and take care of that?
Eric_Klein,_MD: It depends on your age and health, and whether you have a prostate infection. I suggest you see a urologist to discuss these issues.
Aloysius: What would be the best treatment for a rising PSA? The first treatment was radiation and hormone therapy with Casodex® [bicalutamide] and Lupron Depot® [leuprolide acetate for depot suspension] with a PSA doubling time of 14 to 15 months. On presentation, I had Gleason 7 (3 -4) with PSA in the 40s. Right now my PSA is 1.8. I also have congestive heart failure with ejection fraction of mid 20's. I also have chronic obstructive pulmonary disease. Functionally I am much better than I appear on paper. I exercise about one hour and 15 minutes five or six days per week.
Eric_Klein,_MD: The best initial option is observation alone if the PSA doubling time is slow (i.e., doubling more slowly than every six months). If the doubling time shortens (i.e., PSA doubles in a shorter period of time), then hormone therapy is appropriate.
genodoc: Ideally, at what age should we stop doing PSA evaluations? At what age should we ignore a recurrence with a positive PSA after total prostatectomy?
Eric_Klein,_MD: If your PSA is less than one obtained when you were 60 years old, the chance of getting metastatic prostate cancer is miniscule and PSA testing can probably be stopped. Sorry, I can't answer the second question without more detail on the clinical situation of the patient.
Prostate Cancer Antigen 3 (PCA3) Test
jmatz: My PSA was three last December and a biopsy resulted in an e-coli infection and hospitalization, but thank God no cancer. My PSA was six in July, and my urologist wants to do another biopsy at the hospital under antibiotics. What are some alternatives that could be performed at Cleveland Clinic, and if cancer was discovered could treatment be initiated at that time? How long should I wait for the test? What else could result in my high PSA? I have an appointment with my general practitioner in September and may request another PSA. Is this a good idea or a waste of money?
Eric_Klein,_MD: There is an FDA-approved test that we routinely use for men with a negative biopsy to help decide if another is indicated. It is called PCA3, and is performed on urine following a digital rectal exam. If it is below the cut-off of 25 or so, your risk of prostate cancer is low. If it is higher than 25, then another biopsy is reasonable. Another alternative is to use a 5-alpha reductase inhibitor (finasteride or dutasteride) that reduces the risk of getting prostate cancer by 25 to 30 percent, smoothes out fluctuations in PSA, and makes PSA a better screening test for cancer.
circusman: I am 73 years young. My PSA in March 2012 was 4.31 and in March 2013 it was 5.51. Is continued checking of the PSA warranted at my age?
Eric_Klein,_MD: If you are in good health and have a reasonable life expectancy (10 years or more) then, yes, I suggest you consider a PCA3 test to determine if a biopsy is indicated.
donrobi: I am 72 years old and have an enlarged prostate. My prostate was last biopsied three years ago when my PSA reading was 9.0. It had increased 10 percent from the PSA reading at the time of my prior biopsy. Is the current standard that another biopsy will be recommended when my PSA increases to 9.9 (or higher), constituting a 10 percent increase from the PSA reading at the time of the last biopsy?
Eric_Klein,_MD: No, I suggest you have a PCA3 test to determine if the high PSA is due to cancer. This test is more specific for cancer, and is a better way to decide on the need for biopsy.
5155: I am a poster boy for the problems with PSA. I am 64 years old with a significant family history of prostate cancer. Most family members were diagnosed in their 60s although everyone eventually died of something else. I have had erratic PSAs over the last 10 years. Every time the PSA jumped, I have had a biopsy. All four of them have been negative. My last PSA in May 2013 was 9.7—a two-point jump in six months. The physician doing the biopsy this time, when he got the ultrasound documented size and weight of the prostate, implied that the elevated PSA was due to a prostate three times the normal size. I had never been told that my prostate was more than slightly enlarged, although urinary symptoms had escalated in the past couple of years. My last free PSA was 26.7. What criteria should I use for getting another biopsy? Since basic PSA is not a helpful indicator for me, it seems to me that there might be a correlation between PSA and size that can be useful. Even if it requires the ultrasound it is a whole lot more pleasant than a biopsy (and cheaper).
Eric_Klein,_MD: I suggest two things. First, use PCA3 rather than PSA to decide if another biopsy is needed. Second, consider taking finasteride or dutasteride, which will establish a new lower baseline PSA value and make PSA a better screening test for you.
gatorfrog: My husband is scheduled for a prostate biopsy and, naturally, we are worried. He does have some signs listed, but not all of them. I am just wondering if a firm prostate is almost always indicative of cancer or not. His previous urologist did not seem to think he needed a biopsy. When we had to switch doctors because of insurance, and the new one ordered the biopsy.
Eric_Klein,_MD: Abnormalities of the prostate on digital rectal examination (DRE) are very subjective. Biopsy is usually predicated on a concern about PSA levels. You could ask about having a PCA3 test before the biopsy to confirm if the biopsy is really needed.
ckenn001: Is it true that the more biopsies taken, the greater the risk of spreading the cancer? Also is a prostrate biopsy the only way to measure the growth and spread of prostate cancer? If not, what are the alternatives?
Nicolas_Muruve,_MD: Biopsy does not increase the risk of cancer. There have been studies to look at whether cells can travel through the needle tract, but no evidence for this has been found. Once cancer has been found, PSA can be used to monitor the aggressiveness of the cancer. Biopsy is the only way to make the diagnosis.
Diagnostic Tools: CT, MRI and Ultrasound
ADev221: Is sonogram imaging helpful in following progression of cancer in prostate?
Nicolas_Muruve,_MD: No. Changes in PSA are off in the early signs of progression of disease. Bone scan and CT scan are still the mainstay of monitoring disease progression. PET scan can be used on occasion, but existing isotopes are less sensitive. However, new isotopes are being developed and are promising
Prostate Cancer Prognosis
DZ: Are patients with prostate cancer at a higher risk for developing other cancers in the future? If so, which types and why?
morsch: Please discuss active surveillance and NCI (National Cancer Institute) active surveillance MRI study. Could you also discuss the benefits of calcium supplements, fish and fish oil?
Eric_Klein,_MD: Active surveillance is a strategy for men with NCCN (National Comprehensive Cancer Network) definition of very low- or low-risk disease wherein initial treatment is skipped and the patient is monitored periodically (every three to six months) to determine if the tumor is treading water or progressing. Using this approach many men can delay or avoid therapy (surgery or radiation) until it is necessary and still be cured. I am not familiar with the specifics of the NCI MRI study that you refer to, but there is some evidence that if a tumor cannot be seen on MRI that it has a low chance of being biologically worrisome. Another way to assess the aggressiveness of the cancer is a gene expression test that can indicate if the cancer has worrisome biological characteristics and if surveillance is safe. There are two on the market, Oncotype DX® prostate cancer test by Genomic Health, Inc. and Prolaris® testing by Myriad Genetics. There is no evidence that calcium supplements or fish oil prevent prostate cancer. Eating whole foods like fish is likely to be more beneficial than taking a specific supplement.
fjpor: I am 12 years out after retropubic prostate surgery after which my PSA levels remained at 0.0 for approximately five years. After that my levels began to climb, but never reaching more than 2.56 or so. I have settled there and even dropped to around 1.0 on last test. My doctor prefers to wait and see what happens, and do nothing unless and until the PSA rises above five— at which time he recommends hormone therapy. I am 76 years old and in fairly good health after a triple bypass in September. I have had no symptoms, and I am existing on the remaining enlarged artery and two collaterals that formed. I have controlled hypertension and type 2 diabetes. Should I have other tests and more aggressive treatment suggested—or is what the doctor recommends sufficient? My Gleason score before and after surgery was 5/6 and 6/7.
Eric_Klein,_MD: I think observation is a great choice given your age and other medical issues. If the PSA stays low, then no other imaging tests or treatments are needed.
AndreisGrandpa: I am 85 years old. Four years ago my PSA was 7.0, and I tested positive for genetic marker PCA3. My urologist took a biopsy of my prostate, which he said felt slightly asymmetric. The biopsy showed adenocarcinoma in one of 12 specimens submitted. My highest Gleason score was 3+3=6; highest PT-1 (human prostatic carcinoma oncogene) = 20 percent. All other specimens were benign. The results of a full body bone scan and an MRI of my prostate with coil DX-185 were all normal. The doctor advised Lupron Depot® (leuprolide acetate for depot suspension) injections. I had two series of Lupron Depot®. By February 2012, my PSA was down to 0.2, and my prostate gland was smooth and symmetric. A sonogram showed the prostate was not significantly enlarged.
I had severe side effects from my second series of Lupron Depot®. By June 2013, my PSA was up to 6.0. My doctor advises that I start taking Casodex® (bicalutamide) now and he said the side effects will be negligible. Should I start bicalutamide, or would I be better off with active surveillance? What would that entail?
Eric_Klein,_MD: At your age with low-grade cancer, I think surveillance is the best option with DRE (digital rectal examination) and PSA performed every six months and no further therapy—unless there are signs that the cancer is progressing or it causes some symptoms.
Concerned2: I've been diagnosed with very mild prostate cancer and I am under active surveillance. At what point do I and the doctor decide to pursue treatment, and how is that decision made?
Nicolas_Muruve,_MD: The decision to pursue treatment is often made if this been a change in the clinical findings such as a rapid acceleration of the PSA or change in the biopsy for more aggressive tumor. Other reasons to pursue therapy include patient anxiety over active surveillance or simply a change of mind to pursue therapy. Consider continuing with observation.
dliving41: I am an otherwise healthy 72-year-old male with prostate cancer. A biopsy in December 2010 showed one core sample with five percent of the tissue affected and, Gleason six. A repeat biopsy in December 2011 was similar (one core sample and approximately five percent of the surface area), but the Gleason score was 3+4=7. My latest PSA was 5.33. My urologist feels my chance of dying from the disease is minimal. However, in a prior web chat from June 25, 2013, it was indicated that 11 percent is the proper percentage. I am scheduled for another biopsy in February 2014. However, I am not comfortable with this wait-and see approach, although I do understand that treatment does have consequences. What is your advice?
Nicolas_Muruve,_MD: Treatment is ultimately a decision made by the patient. A watch-and-wait approach works well if both patient and doctor comfortable with that. While we can never tell for sure who will progress and who won’t, treatment is often recommended if either the doctor or patient becomes uncomfortable with the watch-and-wait plan. This in itself is treatment as it is alleviates stress in the individual and obviously can affect the quality of life if the patient is always concerned about the risk of disease spread. Although there are risks with intervention, there are clearly risks with watchful waiting such as the patient’s concern regarding their disease. The risk of dying from this disease is low. However, if you're more comfortable with proceeding with therapy, I would go ahead with that as treatments do not always have major complications.
Yoculan: I am 65 years old with no symptoms, but I was diagnosed with prostate cancer in July 2013. I chose active surveillance for now. At what point should I contact Cleveland Clinic for a second opinion and to explore other options? I have some concerns regarding the removal of my prostate, specifically incontinence and impotence. Is there a treatment that lessens or eliminates these conditions? If I were to choose brachytherapy, is surgery at a later time still a possibility if needed?
Eric_Klein,_MD: Please come to us anytime for a second opinion. It is always a good idea. A genomic test can help decide if surveillance is a reasonable option. Removal of the prostate is indeed possible after brachytherapy.
mhsraleigh: I am a 52-year-old male diagnosed with prostate cancer in November 2012 with PSA 3.7 and Gleason 3+3=6. Three cores had cancer, but a low amount of cancer in each core. Repeat biopsy in April, 2013 with no significant changes, but PSA of 4.3. My next PSA test in July was 3.9. I am on an active surveillance program at University of North Carolina. I have PSA tests done every three months and biopsy yearly, or more, depending on PSA results. My next PSA test is in November. Do you agree that I am a candidate for surveillance? What PSA score is of concern and would require another (painful) biopsy? Is there a study of men in active surveillance who are in my age range (40 to 60 years old)?
Eric_Klein,_MD: It sounds like you are a good candidate for surveillance. I suggest you learn about genomic tests that can predict likelihood of aggressiveness to help you decide whether to continue and how often to be monitored. Since benign prostatic hyperplasia also influences PSA, it is not the most reliable indicator for biopsy in men on surveillance. Check out the NCI (National Cancer Institute) at NIH website (www.cancer.gov) to learn about clinical trials that may be available to you.
asl: I am an 83-year-old patient in good health. My biopsies tested positive for only one sample with Gleason six. Is active surveillance alternative of choice? When is it contraindicated? Please detail active surveillance, and what is included in this procedure. Is 3 Tesla MRI viable alternative to subsequent biopsies?
Eric_Klein,_MD: Surveillance is indeed the best choice. MRI has been suggested as an alternative to repeat biopsy, but there is no long-term data on its use and whether it is safe to omit subsequent biopsy. I suggest a genomic-based test instead, like Oncotype DX® prostate cancer test by Genomic Health, Inc. and Prolaris® testing by Myriad Genetics.
Genomic Tests for Cancer Aggressiveness
BF: What is the risk of attentive surveillance? I have a Gleason score of 3+3 and was diagnosed one year ago. My PSA is 3.1, but I am concerned that by waiting the cancer could spread. I am wondering if I should choose a treatment now to cure the cancer before I wait too long. Also, do you think I should repeat the biopsy before deciding to pursue more aggressive treatment? That would also allow me to have the Oncotype DX® prostate cancer test. Do you think this test is useful? Finally, do you have an opinion on the prostate cancer treatment called ProstRCision®? The literature looks interesting and compelling.
Eric_Klein,_MD: Currently, tests like the Oncotype DX® by Genomic Health, Inc. are the best way to judge tumor aggressiveness and decide if surveillance is safe. (The test was developed here at Cleveland Clinic and is very useful). ProstRCision® is a combination of external beam radiation and brachytherapy that is not appropriate for low- grade cancers. Brachytherapy alone would work just as well with fewer side effects and less risk of a severe complication.
Mcduff: At what point should I be concerned with my Gleason score? Two years ago, my biopsy indicated a Gleason score of four with a somewhat enlarged prostate. In February 2013, another biopsy indicated a Gleason score of six. My urologist said many of those findings are subjective and is not necessarily concerned. I am 70 years old, work every day as a courier, and in otherwise excellent health. My father died at 87 years old with prostate cancer. My brother died at 69 years old with esophageal cancer. My mother is 93 years old and in excellent health. I do not want to wait until it is ‘too late.’ If I need to have the prostate removed, or select a treatment, I want to be in good health at that time. Or, is active surveillance sufficient?
Eric_Klein,_MD: A Gleason score describes what is seen under the microscope and is the sum of two Gleason grades of the most prominent tumor cell types seen in the prostate tissue biopsy. The biopsy resemblance to normal prostate tissue correlates very closely with the biological aggressiveness. More recently genomic tests like Oncotype DX ® by Genomic Health, Inc. can help determine how aggressive the cancer is. I suggest you ask your urologist to order this for you. It can tell you whether surveillance is a safe option.
OpieTaylor: After a recent biopsy, I was diagnosed with a Gleason score six (two of 10 cores) non-palpable prostate cancer. As a 58 year old, I was a bit reluctant to consider active surveillance until I learned about the Oncotype DX® test by Genomic Health, Inc. that will score the aggressiveness of the cancer. Can you give a summary of what this test does? With my specific condition how should I use such a genetic test to determine if surveillance is an appropriate option?
Eric_Klein,_MD: The test can give you an estimation of how likely you are to have more aggressive elements in your prostate, based on a core of one to 100, with lower numbers indicating a lower likelihood of worrisome cancer features. It can help you decide if surveillance is safe.
DZ: What is Oncotype DX® testing?
Eric_Klein,_MD: Check out www.genomichealth.com for information.
T3959: Please compare cryotherapy with other leading prostate cancer treatments. After reviewing other leading treatments, I am leaning towards cryotherapy, but would like another opinion.
Nicolas_Muruve,_MD: Cryotherapy is currently indicated as a primary therapy for prostate cancer. However, studies have determined that the recurrence risk is slightly higher than surgery or radiation. Also, the risk of erectile dysfunction is higher with cryoablation than with radiation or surgery. As a result I don’t recommend cryoablation as a salvage procedure for failed radiation therapy rather than as primary therapy to treat someone's cancer initially. All options are good. However, I feel that erectile function can be preserved better with surgery or radiation.
rollingbus: I had cryosurgical ablation of my prostate in February 2013. Why does my left testicle and the left side of my penis feel numb? Also, there is a frequency to urinate and issues controlling the flow sometimes. Would you comment?
Nicolas_Muruve,_MD: This is a common complication of cryotherapy. This is usually due to freezing of the nerve that goes to the penis, which is located above the prostate. This can often resolve itself with time but can take up to one year. Trouble with urination is also common after cryotherapy and results from initial swelling of the prostate gland after treatment. This may persist later because of scar tissue that forms around the prostate and prevents proper urination from occurring. This can be diagnosed with a simple cystoscopy.
Hormone Therapy and Beyond
pennsylvania man: What is your position on hormone (both oral and injections) treatments?
Eric_Klein,_MD: They are highly effective and appropriate for men with metastatic prostate cancer, and in combination with external beam radiation therapy in men with locally advanced or high-grade disease.
pennsylvania man: Are hormone treatments (both oral and injections) necessary before deciding on a external beam radiation treatment, or can you bypass hormone treatments and start external beam radiation treatments right away?
Eric_Klein,_MD: It depends on the aggressiveness of the cancer. For low-risk disease, hormones are not necessary. For intermediate risk disease they are optional, and should always be used for high risk disease. Check out the American Urological Association (AUA) or National Cancer Comprehensive Network (NCCN) websites to get details on what risk category you fall into.
pennsylvania man: What definitive prostate cancer treatment would you recommend that has the least side effects after hormone treatments?
Eric_Klein,_MD: This is a common question—which treatment, surgery, radiation, seeds, cryotherapy or high-intensity focused ultrasound (HIFU) —has the least side effects. The answer is a clear ‘none of the above’ because all treatments have side effects that relate to urinary and sexual function and sometimes bowel function. I would need more detail from you about the specifics of your general health, body type, BMI, and disease extent that could provide further information about the best treatment option for you.
RM0929: I have been diagnosed with prostate cancer with a Gleason score of 4.4 within a period of six months. My urologist suggested radiation plus seed therapy, but my oncologist suggested 45 days of radiation only. I am 75 years old. Which treatment would you recommend?
Nicolas_Muruve,_MD: Radiation is certainly a good option. It is, however, associated with some complications that can affect you immediately. If your Gleason score is low (around six or seven), then active surveillance is also an option. This involves monitoring a PSA every three to six months and undergoing a general checkup. Often a repeat biopsy in one year is also done to ensure that the disease stays low grade. This plan often works well for patients whose prostate cancer may take eight to 10 years to progress and would avoid the complications of therapy. Either option is good in your scenario.
Calypso® 4D Localization System™
DZ: What is Calypso® 4D Localization System™, and how does it differ from external beam radiation?
Eric_Klein,_MD: Calypso® is an adjunct to external beam radiation, not a treatment itself. It is a way of placing radiofrequency transponders in the prostate, so the beam can be accurately targeted.
Cyberknife® Robotic Radiosurgery System
DZ: Is Cyberknife® Robotic Radiosurgery System the same as Calypso® 4D Localization System™? What are the advantages and disadvantages? Who are the best candidates?
Nicolas_Muruve,_MD: No, these are different techniques, but try to do the same thing. Cyberknife® Robotic Radiosurgery System technology tries to focus radiation to a very specific point within the body where as Calypso® 4D Localization System™ uses technology to guide radiation towards the tumor. That result of both is try to minimize radiation exposure to adjacent organs and concentrate radiation towards the tumor.
DZ: Is proton therapy the same as external beam radiation?
Nicolas_Muruve,_MD: No. Proton beam therapy is a different way of delivering ionizing radiation to the tumor bed. In theory, proton beam offers less spread of radiation to other organs, but no comparative trials between the two modalities have been done to see whether one is better than the other.
PSA Accuracy after Radiation
jprostate: How soon after radiation treatment for prostate cancer is a PSA test accurate?
Nicolas_Muruve,_MD: There is a period of time where PSA will initially increase after radiation treatment. PSA starts to go down immediately after the radiation treatments stop, but may not be accurate until at least one month after the end of treatment. Most urologists will wait three to six months before measuring PSA after radiation.
Brachytherapy (Seed Therapy) Side Effects
steelers: After my seed therapy for a large prostate and Gleason seven, how long do you think I will have urinary incontinence? At what period after the surgery will this be the worst?
Nicolas_Muruve,_MD: Urinary symptoms at the seed implantation can last up to one year after the procedure. The majority of men who undergo seed implantation report that they are back to original urination patterns at that time. Incontinence after seed implantation can often be related to other procedures—including a past history of TURP (transurethral resection of the prostate) —which would make leakage worse and less likely recover.
steelers: What medications could you suggest to help with incontinence after seeds are placed?
Nicolas_Muruve,_MD: This depends on the type of incontinence you're having. Most of the time leakage from seed implantation occurs because of urgency—having to rush to the bathroom and not making it on time. Medications such as anticholinergic drugs can help improve symptoms until the effects of radiation have gone. Another cause of leakage is urinary retention. Your doctor should assess you to see which of these conditions you have and recommend treatment accordingly.
bigtwithz: I had brachytherapy done in February. I urinate four times a night—when the urge comes, I have under a minute to get to the bathroom. Also, there is no ejaculation and the urge for sex is nil. Is this normal?
Eric_Klein,_MD: Urinary frequency is the norm after brachytherapy for many months. You should be re-evaluated by your urologist to be sure that you do not have an infection and are emptying completely. It is likely that some medications can alleviate your symptoms. Loss of ejaculation is also normal after brachytherapy because the radiation from the seeds dries up the prostate secretions. Loss of sexual drive is not a side effect of brachytherapy and could be caused by a low testosterone level. This too can be checked by your urologist.
avel1371: I am 60 years old and have early-stage prostate cancer with PSA of six. I am thinking about having brachytherapy (seed implant and radiation) this year. What the worst side effect after brachytherapy? Is it six months of using the self-catheter? Also, if my brachytherapy treatment failed, what is the next option for treatment?
Eric_Klein,_MD: Most patients experience urinary burning, urgency and frequency for a few months after brachytherapy, and only rarely require self-catheterization. Treatment options for failure include surgery, cryotherapy or hormones.
theora1: I had seed surgery in December 2012. I am still having soft bowel movements, two to three per day, but no other problems from surgery. Is this normal?
Eric_Klein,_MD: It is not uncommon after seeds. Try a bulking agent like Metamucil®.
MRI and Focal Laser Ablation
cj251: What is your view of the efficacy of focal laser ablation? What is your opinion concerning the decision between surgery and focal laser ablation for a young patient (under 50 years old), with one small lesion of prostate cancer (per MRI and extensive biopsy), PSA 3.5, and Gleason grade 3+4?
Eric_Klein,_MD: I am not a fan of focal therapy. There is no long-term data on efficacy, or whether those who recur can still be cured by additional treatment later. There also are no imaging studies that can rule out the presence of cancer in other parts of the prostate.
OpieTaylor: Can you comment on the use of the MRI in identifying a prostate tumor or in using it as a tool in focal therapy for someone diagnosed with prostate cancer?
Eric_Klein,_MD: This is an evolving field. In general I think the evidence on MRI and focal therapy is not as good as it is being touted. It is the rare patient who has single tumor visible on MRI that is amenable to true focal therapy, and there is no clear-cut way to determine if other cancers were missed. There is no data on how to follow patients after focal therapy, and no data on whether those so tested can be salvaged if the cancer recurs.
sjackson: I am a 68-year-old male with controlled diabetes, and had a quadruple by-pass in 2007 for blockages (with no heart attacks). I am overall healthy and active. My PSA went from 1.9 to 5.9 in one year. I took antibiotics for 30 days. My three-month follow-up PSA was 4.9. I had a biopsy for a total of 12 samples with elevated prostate specific antigen level of 4.9. My right prostate, needle core biopsies showed adenocarcinoma with Gleason’s grade 3+4. Tumor is present in three of six cores, with approximately 50 percent of tissue submitted. In my left prostate, needle core biopsies showed atypical small acinar proliferation. What do you feel are my best options for treatment? I am leaning toward a robotic prostatectomy. What are the advantages and disadvantages vs. radiation? How many robotic prostatectomy surgeries should a surgeon perform to be efficient? What is the continence rate after surgery? What percent require blood transfusions? What is average rate of positive margins?
Nicolas_Muruve,_MD: Treatment for prostate cancer would depend on your overall life expectancy. In someone with existing heart disease oftentimes aggressive therapy may not be the best choice. If the bypass completely resolved your disease and you do not have problems occluding grafts and a life expectancy greater than 10 years, then surgery or radiation would be a good choice. As for physician experience with robotic surgery, different people will give different numbers. However, a surgeon with at least 100 cases should have enough experience to perform a good procedure. Continence rate and erectile dysfunction rate with robotic surgeries are no different than open surgery. This ranges from around 50 percent for erectile dysfunction and 10 to 20 percent for incontinence. Transfusion rate with robotic prostatectomy is very low. Positive margin rate and kidneys are around 10 to 15 percent.
jbslam: I have read and have been told that the recoveries from open and robotic prostatectomy are about the same after 30 days. Is this correct?
Eric_Klein,_MD: Indeed they are! Both require usually one night in the hospital, a week with a urinary catheter, and about three weeks of recovery. Overall recovery of continence and potency are the same with both techniques, and depends upon the skill of the surgeon.
DMar: If you are diagnosed with prostate cancer Gleason six, stage T1c with 143 cc size prostate and elect robotic surgery, what is the protocol on whether or not to remove associated pelvic lymph nodes, seminal vesicles, or other ducts from the prostate to the testicles? Also, does surgery protocol automatically include the removal of surrounding tissue?
Eric_Klein,_MD: It is very rare to have lymph node involvement from a Gleason six, stage T1c cancer, so removing the lymph nodes is optional and I usually don't do it for low-grade disease. It is also optional to remove the seminal vesicles, although the vas (the tubes that carry sperm from the testicles to the urethra) do need to be cut to remove the prostate. There is a little fat on the prostate that is typically removed, but no other tissue is removed.
Adjuvant Radiation after Prostatectomy
tggesq: If a patient has undergone prostatectomy and surgical pathology finds adverse findings, such as positive margins, vesicle invasion and extraprostatic extension (EPE), do you suggest adjuvant treatment immediately?
Nicolas_Muruve,_MD: This depends on the Gleason score and a PSA after surgery. Sometimes adjuvant radiation is indicated and will be given after the patient has recovered from the procedure. If the positive margin was small or Gleason score and PSA were favorable, this can also be observed. Early radiation treatment can cause the rate of erectile dysfunction and incontinence to increase. So, if radiation therapy is being considered, it is often best to wait until these have recovered fully.
Catheters After Treatment
ckenn001: Catheters are used for drainage after some prostate cancer treatment procedures? Can an external catheter and leg bag be used instead of internal catheters?
Nicolas_Muruve,_MD: Catheters are often used after radical prostatectomy and cryotherapy. External drainage bags will not work because the catheter is used to help drain the bladder cuts of swelling associated with cryoablation and to prevent leakage after surgery in the new anastomotic site where the bladder is attached to the urethra. The physical presence of the catheter is required at the sites in order to achieve this. Therefore, an external device would not be effective.
jprostate: How soon after radiation therapy is salvage surgery a reasonable option if the cancer reoccurs and is still localized to the prostate?
Nicolas_Muruve,_MD: Salvage treatment can be considered any time a local recurrence has been diagnosed. In general, local recurrence is considered if there have been either three consecutive rises in PSA after baseline was reached or PSA has gone above the lowest value by two. These are all varying and as well as the criteria to define failure by PSA. However, once the decision has been made that failure has occurred, salvage therapy should be done if biopsy has proven recurrence in the prostate and CT and bone scan show no evidence of disease outside of the gland. In that scenario there is a 50 percent chance that salvage therapies will work.
Benign Prostatic Hyperplasia Treatment
bernie1936: When one had known benign prostatic hyperplasia (BPH) and has an annual PSA under 1.0, is there any prevention or approach that can be done to prevent more problems? What about surgery such as transurethral resection of the prostate (TURP)? Does TURP usually result in erection difficulty? Is there a solution to BPH which does not affect erection ability??
Eric_Klein,_MD: The best approach to prevent the need for surgery is the use of alpha blockers and 5-alpha reductase inhibitors. There are several of each on the market. Surgery for BPH rarely results in erectile problems (unlike radical prostatectomy for cancer).
Role of Diet and Exercise on Prostate Cancer
JoeW: I have been diagnosed with early prostate cancer. Are there any rules for diets to reduce risk of progression and how about exercise?
Nicolas_Muruve,_MD: A well-balanced diet and exercise will help the individual battle many diseases. The healthier patient who is more active can help his body deal with illness better than one a patient who is obese, diabetic or has other medical conditions.
cruzrnb: I am just a few weeks away from beginning a five-week external beam radiation therapy treatment, to be followed by brachytherapy. What nutritional advice would you offer someone during this course of therapy to minimize, if possible, the effects of the therapy, to improve or optimize the re-growth of damaged healthy cell tissue, and for an overall better, healthier, quicker recovery?
Nicolas_Muruve,_MD: A well-balanced diet low in fats and high in vegetables and fiber is good for any illness. A diet such as this combined with an active lifestyle will help any individual undergoing therapy. Complications tend to be more frequent when other health issues are present, such as obesity, hypertension or diabetes—all of which are improved with a good diet and exercise.
pilatesgirl: What is the best tactic being recommended today post-prostatectomy to prevent metastasis? Do you think metastasis can happen early in cancer development rather than just as a more serious event later in its development? My husband had prostatectomy six years ago. His cancer was close to the external edges of the prostate. Do you have statistics or thoughts about what best ways to protect him moving forward?
Eric_Klein,_MD: There are no proven ways to prevent metastases, but we do have good tools to predict how likely they are to occur, which could influence often he has a PSA done. The best advice for preventing recurrence of all cancers is to eat a heart-healthy diet (i.e., low-fat, mostly plant based), do not smoke, and exercise every day.
Lifestyle Influences on Cancer
Karolay: Can self-esteem issues or being in a hectic situation caused a rise in PSA?
Eric_Klein,_MD: No this has not been shown to be the case. Although PSA may be elevated in men with prostate cancer, there are other non-cancerous conditions that may cause a man’s PSA to rise such as prostatitis (inflammation of the prostate) and benign prostatic hyperplasia (BPH or enlargement of the prostate.)
pilatesgirl: Do you know anything regarding turmeric and cancer resistance, non-promotion.
Newer Therapies and Treatment for Advanced Disease
Postman: Besides hormone therapy, what would be the usual course of action if the cancer returns? That is, after being treated with external beam radiation.
Eric_Klein,_MD: It depends on the age and health of the patient, and whether the cancer has returned only in the prostate or metastasized. For local recurrences only in the prostate, cryotherapy is a reasonable option. For metastatic disease, hormones come first, followed by newer therapies like sipuleucel, abiraterone, alpharadin (radium-223 chloride), chemotherapy or enzalutamide, depending on the individual patient's situation.
pennsylvania man: I am presently on hormone treatments (both oral and injections) for my prostate cancer. What definitive treatment would you recommend that would kill the cancer cells after completing the hormone treatments, and why?
Eric_Klein,_MD: I would need more information about how extensive your disease is and whether you are having any symptoms before this can be answered. There are lots of new treatments for men whose cancer progresses while on hormone therapy, including ketoconazole, sipuleucel-T, abiraterone, alpharadin (radium-223 chloride) and docetaxel. Some of these may be appropriate for your situation, so you should discuss them with your doctor.
SCOREO: I am 68 years old with prostate cancer since 2001. I have tried all of the hormones, and have rejected all of them due to the severe side effects. I am presently on ‘wait-and-watch’ as my PSA climbs 10 to 15 points at every check up (every three months). Is there anything on the horizon to give someone like me a glimmer of hope? I am at the London Regional Cancer Clinic, in London, Canada. Are there any answers or any treatments for a person such as myself? My PSA is over 50, but I feel good most days!
Eric_Klein,_MD: It is hard to make an asymptomatic patient better, and, unfortunately, almost all treatments have some side effects. It is reasonable to defer any additional treatment until such time as your disease actually causes some symptoms. If you have bone metastases you might consider alpharadin (radium-223), a newly approved injectable drug that has minimal side effects. You might also consider abiraterone or enzalutamide—both of which have a side effect profile that is different than standard hormone therapy.
ckenn001: Are there any new experimental treatment options available or pending approval that are being considered for near term use (i.e., one to two years) by Cleveland Clinic? If yes, please describe and give benefits and potential side effects. Is high-intensity focused ultrasound (HIFU) any closer to getting U.S. approval?
Eric_Klein,_MD: A lot is available or pending approval, but it depends on the specifics of the patient’s situation. I would need to know more detail before we can say what you may be eligible for. Only the F.D.A. knows if and how close HIFU may be approved in the U.S.
pennsylvania man: My urologist recently put me on hormone treatments (both oral and injections) for my localized prostate cancer. I will eventually need to select a ‘definitive’ treatment after the hormone treatments are over. I am considering a treatment called hyperthermia which has fewer side effects than other definitive treatments. I understand that hyperthermia treatments are being used in Germany with good results. I would like to know your position and thoughts on hyperthermia treatments.
Eric_Klein,_MD: We have no experience with this therapy, so I cannot comment on its effectiveness.
Cancer Care: Multidisciplinary Team Approach
DZ: Which specialists are involved in the team approach to prostate cancer care?
Nicolas_Muruve,_MD: The surgeon, medical oncologist, radiation therapist, social worker and nurses are involved.
Cleveland Clinic Glickman Urological Institute Appointments
ADev221: How quickly can I get in for an appointment, and what paperwork do I need to bring?
Eric_Klein,_MD: Many times we offer same-day appointments if your schedule allows. Be sure to bring any pertinent lab work, X-rays and a copy of your medical records or chart. If you would like to make an appointment with one of our urologists, please call 800.223.2273, ext. 4500.
Moderator: I'm sorry to say that our time is now over. Thank you, Dr. Klein in Ohio and Dr. Muruve in Florida, for taking the time to answer our questions today about prostate cancer.
Eric_Klein,_MD: We would like to thank you all for your questions today. We hope that this information is helpful to you.
If you would like to make an appointment with a urologist in the Glickman Urological & Kidney Institute, please call 800.223.2273 x45600 or request an appointment online by visiting www.clevelandclinic.org/appointments. Thank you!
For More Information
On Prostate Cancer
On Cleveland Clinic
Cleveland Clinic’s Center for Urological Oncology, located in the Glickman Urological and Kidney Institute, specializes in the treatment of prostate, testicular, bladder and kidney cancer. The Center for Urologic Oncology collaborates with physicians from the Taussig Cancer Institute. For prostate cancer, the Center for Robotic & Laparoscopic Surgery offers a robotic procedure for select patients, and has one of the world’s largest bodies of collective experience in urologic laparoscopic and robotic surgery. Many prostate treatment methods were pioneered at Cleveland Clinic, giving us one of the world’s largest experiences in treating localized cancer using surgical and non-surgical methods.
Our specialized centers within the Glickman Urological and Kidney Institute for treatment of urologic and kidney conditions include: the Center for Male Infertility, the Center for Genitourinary Reconstruction, the Center for Reproductive Medicine, the Minority Men’s Health Center, the Center for Renal Transplantation and the Center for Female Pelvic Medicine & Reconstructive Surgery.
The Glickman Urological and Kidney Institute merges Cleveland Clinic’s urology and nephrology programs. This consolidation of disciplines allows us to better serve patients in the prevention, diagnosis and treatment of kidney disease while we continue to provide high-quality patient care and carry on innovative research in all aspects of urology. The Glickman Urological & Kidney Institute offers innovative treatments, including minimally invasive, scarless options for urologic procedures and medical management of kidney disease.
Urology and nephrology physicians and scientists at Cleveland Clinic are recognized worldwide for excellence in patient care, teaching and research. This year, U.S. News & World Report ranked our urology and kidney disease programs best in Ohio and second in the U.S.
In addition to Cleveland Clinic’s main campus, our urologists and nephrologists practice in the community at Cleveland Clinic family health and surgery centers and in our affiliated medical offices. Whether your doctor refers you or you make your own appointment, you can feel comfortable knowing that the Cleveland Clinic doctor who will care for you is experienced in diagnosing and treating many patients with your condition.
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