Cleveland_Clinic_Host: Today’s online health chat will focus on Prostate Cancer with Michael Gong, MD, PhD. Prostate cancer remains the second leading cause of cancer death in men, yet it is highly curable if discovered while still confined to the prostate gland.
Each year, Cleveland Clinic physicians treat more than 1,000 men with prostate cancer. Glickman Urological and Kidney Institute specialists consider many factors when recommending the most appropriate treatment for prostate cancer.
A variety of surgical techniques can be used to remove the prostate gland, a procedure called prostatectomy. Radical prostatectomy can be performed by open, laparoscopic and robotic techniques, each of which has its own unique advantages. Other treatment options include radiation, interstitial brachytherapy (seed implants), cryotherapy, hormone therapy and chemotherapy.
Welcome everyone, and thank you Dr. Gong, for being with us to discuss prostate cancer. We look forward to an interesting chat today. Let's begin with one of the questions!
tjohnson: What is the procedure for a prostate biopsy?
Speaker_-_Dr__Michael_C__Gong: An ultrasound probe is placed into the rectum to image the prostate. The ultrasound is also used to help guide the prostate biopsies through the rectum. In general, numbing medicine (either topical or injected) is used prior to the procedure. The procedure is usually performed in the physician's office without sedation or pain medication. To avoid infection an antibiotic is given prior to the procedure.
Prostate Cancer Risks
hotrodcity: I was once told by the urologist that vasectomies may contribute to prostate cancer. Is there any validity in this? Any connection between vasectomy and prostate enlargement?
Speaker_-_Dr__Michael_C__Gong: There was a report about 10 years ago linking vasectomy to increase risk of prostate cancer. However, this has not been validated and currently vasectomy is not considered a risk factor for developing prostate cancer. As far as I know, there is no correlation between vasectomy and risk of developing prostate enlargement.
piglet1640: How can I prevent cancer in every part of the body?
Speaker_-_Dr__Michael_C__Gong: This is a very broad question to address. Assuming you are speaking about prostate cancer, several nutrients have been associated with a lower risk of developing prostate cancer. These nutrients include: selenium, lycopene, Vitamin E and a low fat diet. However, none have been definitively proven and it is unclear whether these nutrients will help patients already diagnosed with prostate cancer.
jln: My father had prostate cancer in his 70's. I am 51 and have regular digital rectal exams (DRE's) - but have not had a PSA level yet. Should this be occurring and what is the chance that I will be genetically predisposed to prostate cancer?
Speaker_-_Dr__Michael_C__Gong: Generally, discussions about the risks and benefits of prostate cancer screening are initiated around age 50. For patients with a family history of prostate cancer, these discussions are initiated around age 40. Prostate cancer screening is controversial and thus you need to discuss this with your primary care doctor or a urologist. Hereditary prostate cancer is approximately 10% of all prostate cancers.
Understanding Gleason Score
ams520gds: My husband has been biopsied and then diagnosed with what the radiation oncologist has called aggressive prostate cancer cells. Does that type of cell indicate to you that one or other of the various treatments would be more beneficial for him?
Speaker_-_Dr__Michael_C__Gong: The Gleason score is an estimate of the aggressiveness of the prostate cancer. Treatment decisions are influenced by the Gleason score and in particular with radiotherapy. A higher Gleason score will generally be treated with higher dose radiation therapy and possibly in conjunction with a short course of androgen deprivation therapy.
countrylover: What Gleason score is the dividing line between aggressive and non-aggressive cancers? What Gleason score etc. identifies so-called “intermediate” and “high risk” prostate cancers?
Speaker_-_Dr__Michael_C__Gong: In general, low risk Gleason score is 6 or less; intermediate risk is Gleason score 7 and high risk is Gleason score 8-10. You should also know that the risk stratification system also includes PSA levels and digital rectal exam findings.
Prostate Cancer Treatment
ams520gds_2: We are trying to understand the pros and cons of the very different treatment possibilities. I understand the side effects are part of the consideration, but are the outcomes or cure rates different?
Speaker_-_Dr__Michael_C__Gong: Both radiation and surgery can result in similar outcomes of cure. If one treatment was considered to have superior cure rates- that would be the only option offered.
ams520gds_2: When a prostate cancer Gleason score indicates an aggressive cancer does that mean there is a greater chance that the malignant cells have seeped (?) out of the prostate into other parts of the body?
Speaker_-_Dr__Michael_C__Gong: The Gleason score is an assessment of the overall aggressiveness of the prostate cancer. Therefore, a higher Gleason score would be associated with a higher risk of prostate cancer spreading to other parts of the body versus a lower Gleason score. One has to also consider other factors such as PSA level, DRE findings and how much cancer was apparent in the biopsies to estimate overall risk of prostate cancer escaping the prostate.
brownbug: I am 78 years old. I had external radiation 3 years ago. My PSA (twice a year) has fluctuated from 0.2 to 0.7 until March, when it was 1.1. Is that normal and how high can it go before further tests are needed? I also had 2 hormone shots.
Speaker_-_Dr__Michael_C__Gong: PSA can fluctuate for 2-3 years after radiation therapy. In general, a recurrence will be evident if the PSA continues to rise. A current definition of recurrence is the lowest PSA achieved plus 2. Therefore, by this definition most physicians would not perform further tests on you at this time. However continued PSA monitoring is warranted.
Ollie: I am 85 yrs old and just diagnosed with urinary bladder urothelial transitional cell carcinoma. I have had a nephrostomy since May '08. Because the tumor appears aggressive - I am scheduled for surgery next week. The plan is to do a radical cystoprostatectomy, right nephrectomy and urinary diversion. Believe is or not - I still maintain an active sex life with my wife of over 50 years. Is it necessary to take the prostate? Am I facing erectile dysfunction with all of this?
Speaker_-_Dr__Michael_C__Gong: Removing the prostate is a standard part of the radical surgery for bladder cancer. Nerve-sparing technique can be utilized to help recovery of erections after this type of surgery. It is possible to perform prostate -sparing surgery; however it is still under investigation.
ruthearp: My PSA was 169. It has already spread to lymph system. The size of my prostate is 10c .7c x 7c. My treatment was started and I am taking Casodex 50mg once a day; Lupron every 4 months. Am I getting the right course of treatment?
Speaker_-_Dr__Michael_C__Gong: Typically, androgen deprivation therapy is initiated when prostate cancer appears to be outside of the prostate and progressing. However, there are many side effects of androgen deprivation therapy (ADT) and thus the timing of initiation and duration is controversial. Are you getting the right course of treatment? Without a complete review of your medical records and physical exam it is difficult to make definitive recommendations.
DavidD: I'm 59 yr old male, good health with mild hypertension. I just received biopsy report of a prostate nodule (found on routine exam) to be cancerous on right side only. My Gleason score 7/10. PSA 0.62, no other symptoms (enlarged prostate, frequent urination, etc.). I am confused as to choose surgery or to choose radiation therapy. If it were you, what would you do?
Speaker_-_Dr__Michael_C__Gong: Unfortunately this is a very individual decision. As you are aware, there are several treatment options available to you. It is important for you to consider the extent of what the treatment entails as well as the potential side effects. For example, incontinence may be a potential side effect of a given therapy. This might be a very bothersome side effect for some people, and for others it may be an acceptable risk. These are truly individual choices. Since the potential outcomes are difficult to predict, you need to be educated about all treatment options.
calabulator: I had my prostate removed, via an incision under the scrotum, in 1996. The catheter fell out while I was still in the hospital and had to be re inserted. After this there was a lot of incontinence that stopped after about two months. My PSA was just under 5.00 just prior to surgery.
After surgery my PSA dropped to around .02. About four years ago the PSA began to go up and the doctor started Lupron injections about every four months. On January 29, 2008 my PSA was less than 0.03 and they did not give me an injection. On June 2, 2008 my psa was 0.10. I did not receive an injection at this time. I have a doctor appt. in late October and assume my PSA will be up to a point where the urologist will want to give me another injection.
As you know the effects of this type of treatment are sometimes troublesome to say the least. I am 68 years old and currently a heart patient at the Cleveland Clinic. I am currently in a heart study program at the clinic that will probably not permit me to enter another program at this time. Is there a different type of treatment available at this time or a research study I can get into?
Speaker_-_Dr__Michael_C__Gong: Generally, at this point it sounds like androgen deprivation therapy (ADT) is likely to be restarted if the PSA rises (also known as intermittent ADT). However, it is unclear at what level PSA to re-initiate therapy, generally there is a consideration for the rate of rise of the PSA as well as the absolute value of the PSA. There may be some clinical trials available but by definition they are experimental.
You may not be eligible for some of these as some trials enroll patients with rising PSA after failure of androgen deprivation therapy (you have not failed androgen deprivation therapy) or patients with rising PSA that have not received any prior androgen deprivation therapy treatment. You can find available clinical trials at www.clinicaltrials.gov.
tjohnson: My husband just had a digital rectal exam and was told his prostate was slightly enlarged, but for his age it was normal. He is 56. His PSA was 4.02. Is this considered very high? I know under 4 is considered normal.
Speaker_-_Dr__Michael_C__Gong: In general, we no longer use absolute PSA cut-offs to determine abnormal or normal. Currently, we try to assess a risk of finding prostate cancer at various PSA levels. With a PSA between 4-10, the risk of finding prostate cancer on biopsy is almost 50%. Again - discuss these concerns with your physician.
crusher: There is some new controversy over whether hormone therapy is as beneficial as once thought. I have had it once and it appeared to have had a positive effect. I have been advised to have another course of treatment but now read that it might not truly be beneficial and may have some increased risks. What are your thoughts on hormone therapy? Thank You.
Speaker_-_Dr__Michael_C__Gong: Hormonal therapy is still considered a standard treatment for prostate cancer. You are correct in that current literature is reporting side effects that were not evident some years ago. This is a decision that you need to discuss with your physician about the risks and benefits of additional hormonal therapy.
superK: There has been a lot of press lately about prostate surgery being unnecessary. When is surgery appropriate and when should you 'watch and wait'?
Speaker_-_Dr__Michael_C__Gong: There are many factors that may influence a patient's choice of treatment. Generally 'watch and wait' (active surveillance) is becoming a more popular option since many men will die with prostate cancer rather than of prostate cancer. Patients choosing active surveillance will have the benefit of no treatment side effects while attempting to monitor the prostate cancer during the rest of their lives.
This option is also called delayed therapy, in that some men under active surveillance may progress and undergo treatment at a later date. Early studies have suggested that the delay in therapy has not resulted in worse outcome. Thus, this option will be chosen by patients who feel they are likely to die from other causes rather than prostate cancer.
Prostate cancer is the second most common cause of cancer death in males in the United States. However it is difficult to ascertain the risk of dying from prostate cancer as well as the overall life expectancy of the patient. This is a very individual decision about risk assessment.
Robotic Surgery for Prostate Cancer
jaybird: I understand that robotic surgery is performed for prostate cancer procedures. What are the advantages or disadvantages? Also, is there a criterion for who is a candidate for robotic surgery?
Speaker_-_Dr__Michael_C__Gong: Robotic surgery for prostate cancer has been utilized for approximately the last 7 years. In general, two of the major reported advantages (versus open surgery) are decreased blood loss and quicker recovery time. The short-term outcomes for cure rates and side effects appear to be similar to open procedures.
A major factor in surgical outcomes is the surgeon's expertise. For robotic surgery, most patients are possible candidates. In general, previous major abdominal surgery such as left colon resection may preclude candidacy for robotic prostate surgery.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Gong is now over. Thank you again Dr. Gong, for taking the time to answer our questions today.
Speaker_-_Dr__Michael_C__Gong: Thank you for giving me this opportunity to answer questions. It was a pleasure.
This chat occurred in September 2008.
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