Prostate Cancer: Get Informed
Online Health Chat with Andrew Stephenson, MD
September 21, 2012
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 in the U.S., about 185,000 new cases of prostate cancer will be diagnosed.
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 have 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.
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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.
Other 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.
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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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About the Speakers
Andrew Stephenson, MD, is the director for the Center of Urologic Oncology at Cleveland Clinic's Glickman Urological and Kidney Institute and a staff member of the Taussig Cancer Institute. Andrew Stephenson, MD is the Director of Urologic Oncology. Dr. Stephenson, who joined the staff of Cleveland Clinic in 2006 specializes in prostate cancer, bladder cancer, testis cancer, kidney cancer, transitional cell cancer, urethral cancer, robotic prostatectomy, robotic cystectomy, prostate disease and urinary diversion.
Dr. Stephenson is board-certified in urology by the American Board of Urology and the Royal College of Physicians and Surgeons of Canada. He has received several awards from organizations such as the Prostate Cancer Foundation, American Society of Clinical Oncology and Society of Urologic Oncology. He is listed as one of the Best Doctors in America. This year, he received the Urology Teacher of the Year award from Cleveland Clinic.
His research focus is on the development of prognostic statistical models called nomograms that provide accurate predictions of treatment outcome for prostate cancer and are widely used for patient counseling. For patients with prostate cancer, Dr. Stephenson performs nerve-sparing robotic and open radical prostatectomy.
Dr. Stephenson completed his fellowship in urology from Memorial Sloan-Kettering Cancer Center in New York. He completed his residency in urology at McGill University in Montreal after graduating from medical school at the University of Western Ontario, London, Ontario, Canada.
Let’s Chat About Prostate Cancer: Get Informed
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic expert Dr. Andrew Stephenson. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.
New Prostate Screening Guidelines
elthomssen: What are your thoughts about the U.S. Preventive Services Task Force study (USPSTF)? Also, do you use the Progensa® PCA3 assay? If so, under what circumstances and how do you perceive the results?
Dr_Stephenson: My opinion is that the USPSTF took a rather extreme position in recommending against all forms of screening. The USPSTF appropriately sensitized the public and the medical community that there are important limitations and harms to screening, but it failed to recognize that there are benefits (which equate to a 20 to 25 percent relative risk reduction in the risk of death from prostate cancer with screening). My approach to PSA screening is very similar to the American Cancer Society. I believe a man should be informed of the risks and benefits of PSA screening before having the PSA test, and he should make an informed decision based on his values and preferences. The Foundation for Informed Medical Decision Making has produced a very good and unbiased video about the advantages and disadvantages of screening called, 'Is a PSA Test Right for You?', which you might find helpful. It is available at: https://www.healthcrossroads.com/example/crossroad.aspx?contentguid=d6cbffd8-0052-44e9-8605-adc774d38d40.
There is a 20 to 25 percent relative reduction in the risk of dying from prostate cancer with screening. The problem with screening is the risk of identifying a cancer that may pose a minimal threat to a man's longevity and quality-of-life. In the past, the vast majority of these men have received radical therapy to treat these cancers without benefit. This is called overdiagnosis and overtreatment. The USPSTF addressed the problem of overdiagnosis and overtreatment by recommending against PSA screening entirely. I think this problem could have been better addressed by supporting informed decision-making and by encouraging active surveillance for men with low-volume, low-grade cancers (see my related responses to previous questions). There is currently no role for PCA3 assay as a screening test for prostate cancer. It may be useful to determine the need for a biopsy in men with an elevated PSA level.
Testosterone and Prostate Cancer
Francois: As testosterone is needed for prostate cancer growth and progression, could one conclude that elderly men with lower sex drive would have a relatively lower risk of dying from prostate cancer even though their risk of getting the cancer is unrelated to their testosterone level?
Dr_Stephenson: Men tend to have declining testosterone levels as they age. Men with lower testosterone levels may have a lower risk of developing prostate cancer. However, men with low testosterone levels who do develop prostate cancer tend to have more aggressive disease. While low testosterone levels may be the cause of depressed libido, the majority of those with low sex drive have normal testosterone levels. Thus, I would not conclude that a low sex drive correlates with a lower risk of dying from prostate cancer among elderly men.
cincytau: Please provide a detailed explanation of the Gleason score.
Dr_Stephenson: The Gleason score describes the glandular architecture of prostate cancer that the pathologist sees under the microscope. If the prostate cancer resembles normal prostate tissue, the pathologist will assign a low Gleason score. 3+3 = 6 is the lowest grade that is assigned now. If prostate cancer looks like normal prostate tissue, it behaves like normal prostate tissue. It does not grow rapidly, and has low potential to invade outside the prostate and spread via blood vessels or lymphatic channels.
If prostate cancer does not look like normal prostate tissue, the pathologist will assign a high Gleason score (Gleason 4+4 = 8, 5+4 = 9, or 4+5 = 9.Gleason 10 is extremely rare). If it does not look like normal prostate tissue, the cancer does not behave like normal prostate tissue. It has a high growth rate, invades into to surrounding tissues, spreads outside the prostate quickly, and spreads via blood vessels and lymphatics quickly. The resemblance to normal prostate tissue amazingly correlates very closely with the biological aggressiveness. The lowest Gleason score that one can have is a Gleason 6 and the highest is Gleason 9. (Gleason 10's are very rare.)
The reason is that pathologists no longer assign a Gleason pattern of 1 or 2. Thus, Gleason 1+1, 2+1, and 3+2 are not seen anymore. It isn’t that they have disappeared—it's just that pathologists in the past that used to assign a Gleason 4 or 5 to a low-grade cancer will now just assign a Gleason score of 6. It’s confusing, even for a surgeon like me!
parwez: My three-month postoperative PSA (prostate specific antigen) is <0.02. I had IMRT intensity-modulated radiation therapy) in June. After IMRT, my six-week repeat PSA after IMRT was <0.02 and the scans were negative. How can I avoid cancer from reappearing?
Dr_Stephenson: So far, so good. I would monitor you closely with PSA checks three to four times annually.
gardener2b: At age 73 with 8.6 to 9.4 biopsy. What are the risks for the next step involving biopsy?
Dr_Stephenson: Biopsy is associated with some discomfort and a risk of bleeding in the rectum or urine, and infection. With appropriate precautions, the risk of bleeding and infectious complications with biopsy is less than 2 to 4 percent.
EdNov: Is there a PSA level that once reached indicates that a patient should obtain a biopsy?
Dr_Stephenson: Great question! We used to think 4 ng/mL was an appropriate cut point, then 2.5 ng/mL! Now there is no appropriate cut point. Even men with PSA <1 ng/mL may have a five to 10 percent risk of cancer! Not all cancers are worth detecting, so I wouldn't rush to get a biopsy if your PSA was 0.8 ng/mL. There are several risk calculators that consider multiple risk factors (including PSA, ethnicity, family history, etc.) that can accurately predict the risk of cancer and, more importantly, the risk of high-grade or aggressive cancer. We use these in patients to determine the need for biopsy.
Prostate Cancer Prognosis
robtoby:I had a robotic laparoscopic prostatectomy in December 2010. So far, my PSA has been undetectable at < .1 in three 6-month intervals. (Hooray!) Is there any point where someone is considered 'cured' or will this hang over my head forever?
Dr_Stephenson: In truth, you should probably have a PSA checked periodically until you're at least five years out from surgery. A PSA level <0.03 ng/mL five years after surgery is probably a good indicator that you're cured!
Penis Retraction Diagnosis
books4bert: My partner was diagnosed with prostate cancer this year. He's received two injections for hormone treatment. He has an ongoing problem with his penis retracting, sometimes several times, especially when he stands up. Is this related to the cancer or is something else? It's very uncomfortable for him.
Dr_Stephenson: Retraction of the penis can occur with surgery, most often. It is unlikely to be related to prostate cancer unless he has locally advanced disease (which the treating physician should be aware of).
DavidP: My PSA number increased from 3.4 to 9.6 between August 2011 and August 2012. A subsequent biopsy in late August 2012 yielded three specimens with PICs [SIC] from a total of 10 specimens. Cancer was not found. I am scheduled for another PSA test in six months. No other action is scheduled. Is there any proactive action or medication I can take to improve my chances of preventing the PICs from becoming cancerous?
Dr_Stephenson: I think you are referring to either atypical small acinar proliferation (atypical glands or ASAP) or high-grade prostatic intraepithelial neoplasia (or HG PIN). For ASAP, a patient should have a repeat biopsy within three to six months. ASAP is not a precursor lesion for prostate cancer—rather it is a descriptive term for 'cancerous'-appearing glands that the pathologist sees, but there is not enough present for the pathologist to make the diagnosis. About 40 percent of men with ASAP will be found to have prostate cancer on a subsequent biopsy (which indicates that the funny glands do not represent cancer in many cases). HG PIN is not thought to be a risk factor for developing prostate cancer. There are preventive agents one can take for prostate cancer (including medications like dutasteride and finasteride), but none have been approved by the FDA for use in preventing prostate cancer. Be warned, vitamins and micronutrients (Vitamin E in particular) may actually increase your risk of prostate cancer. Be sure to consult with your physician before taking any preparations, medications or vitamins to prevent the development of prostate cancer.
mlg944: I have had my family physician test me for prostate size, and he says it feels normal. I still experience getting up during the night two to three times to urinate. Is there another test that can be performed to determine if I have a prostate issue? I'm concerned about cancer.
Dr_Stephenson: Fortunately, voiding symptoms are more often related to benign enlargement of the prostate rather than prostate cancer. It may be reasonable to check a PSA (prostate specific antigen) and do a test to measure the residual urine volume after urination (called a bladder scan) and a prostate exam. In addition, it would be helpful to complete a questionnaire such as the AUA (American Urological Association) symptom score to assess the severity of your symptoms. If your PSA is low and the prostate exam is normal, then most likely your symptoms are related to benign enlargement. There are many medical and surgical treatment options for men who have bothersome voiding symptoms from an enlargement prostate, and these are usually very effective.
Active Surveillance vs. Radical Therapy for Gleason Score 6
hedr749: I am 61 years old and was diagnosed with prostate cancer in July 2012. My Gleason score was 3+3 and only on core biopsy of 12 was positive. I had a cardiac catheter with a stent placed shortly after my diagnosis, and the stent that was placed was a drug eluting stent. I need to be on Effient® for at least six months prior to surgery. Is this a safe option for me to wait for a six-month period, and are there other treatment options until that time? I had a brother die of prostate cancer two years ago at the age of 65. I am worried the cancer may grow and become more advanced. Everyone just says six months is OK with this stage cancer, but I am just having a tough time waiting.
Dr_Stephenson: Certainly, active surveillance is a reasonable (and some would argue preferred) treatment option for a 61-year-old male with low-volume, Gleason 6 who has known heart disease. In general, heart disease poses a far greater risk to a man's longevity than low-volume, Gleason 6 prostate cancer. The risk of thrombosis of the cardiac stent off Effient®, and the consequences of that, should take precedence over any issues related to Gleason 6 prostate cancer. For reassurance that you do not have a more aggressive cancer, you may consider a prostate MRI to rule out a large, invasive cancer. If the MRI is does not suggest this, you can very safely wait until it is safe to come off the Effient® before addressing what to do about your prostate cancer. Typically, for men interested in active surveillance, we recommended a repeat prostate biopsy shortly after diagnosis to ensure we are not under-appreciating the amount and grade of a man's cancer. If the repeat biopsy confirms low-volume, Gleason 6 prostate cancer, surveillance would be a very reasonable option to consider. The likelihood that treatment will be needed over the next five to seven years for evolving or growing cancer is exceedingly low (less than 10 percent in our experience at Cleveland Clinic).
Bella1: I have left lateral apex prostatic adenocarcinoma with a Gleason score of 6 (3+3) with approximately 10 percent of the specimen. Perineural invasion is absent. Should I monitor and take PSA blood test every six months, or opt for radiation or surgery?
Dr_Stephenson: For low-volume Gleason 6 prostate cancer in an otherwise healthy male, the treatment options are active surveillance versus radical therapy (surgery, radiation therapy, brachytherapy and cryotherapy). There are advantages and disadvantages of each. There is uncertainty of cancer status and risk of progression (albeit low) on surveillance. Yet, active surveillance provides preservation of urinary, bowel and sexual function versus high cure rates with all the standard treatment options. The defined risks of urinary, bowel and sexual dysfunction may significantly impact the quality of life. In my personal opinion, the risk of cancer progression on active surveillance for a man with low-risk prostate cancer is very low. A recent randomized clinical trial showed no improvement in survival among men receiving radical therapy versus watchful waiting for low-risk prostate cancer. Although not reported in this trial, I suspect the men who received radical therapy had significantly increased problems related to urinary, sexual and bowel function compared to those on watchful waiting.
pmharper: My husband who is (66 years old had a Gleason score on two samples of 3+3. He had a biopsy on 14 samples from his prostate in February 2012. The initial results were benign except for five slides that were labeled: three suspicious, two adenocarcinoma and one high-grade PIN (prostatic intraepithelial neoplasia). They were re-submitted to the same laboratory (Bostwick Laboratories) and all five came back labeled suspicious. We requested a third review and the Johns Hopkins laboratory reported three high PIN, three suspicious and the others benign. The recommendation is a repeat biopsy. The problem is the first biopsy was apparently so painful that my husband is refusing to undergo another. Is there somewhere he can have a biopsy where a light anesthetic can be administered (i.e., as in a colonoscopy)? Based on the brief information that I supplied, is watchful waiting an appropriate option for him?
Dr_Stephenson: The pathological assessment of prostate cancer can be highly subjective. That is why I insist on expert pathological review before committing to therapy. The Bostwick and Johns Hopkins laboratories have excellent reputations (not to suggest the pathologist who originally read the slides was not an expert). If two independent pathologists with expertise in prostate cancer failed to identify prostate cancer in the slides, I would not commit to any therapy and would insist on a repeat biopsy to clarify his disease status. If the repeat biopsy confirmed the original diagnosis (low-volume, Gleason 6 prostate cancer), active surveillance would be a very reasonable management strategy.
Tom724: I was diagnosed with prostate cancer, and following a monitor option. What methods and tests are there for monitoring the cancer spread?
Dr_Stephenson: Our practice in men with prostate cancer that is appropriate for active surveillance is to repeat the prostate biopsy shortly after diagnosis to confirm favorable biopsy features before committing to active surveillance. If the repeat biopsy suggests no aggressive features, we usually monitor patients every six months with a prostate exam and PSA checks. We also recommend a prostate biopsy every two to three years. We seldom recommend intervention based on PSA changes alone in the absence of evidence of aggressive features on biopsy. The purpose of monitoring patients with PSA is to determine whether a biopsy should be repeated sooner than the scheduled biopsy, which is typically done every two to three years. The benefit to other tests such as a PCA3 is uncertain, although we are actively investigating this. Likewise, the use of medications, such as finasteride and dutasteride, in men on active surveillance is highly controversial. A randomized clinical trial of dutasteride versus placebo among men with low-risk cancer on active surveillance reported a lower treatment rate with radical therapy for men on dutasteride. However, there are important limitations to this clinical trial, and there are concerns about the impact of these drugs on the biology of prostate cancer.
loujanelle: What is the current view with regard to active surveillance versus aggressive treatment. Are there statistics that favor one over the other?
Dr_Stephenson: The benefits of active surveillance are that treatment-related side effects are avoided, and quality of life is preserved without affecting survival. A randomized trial called the PIVOT trial (prostate intervention versus observation trial) was recently published, which compared radical prostatectomy versus watchful waiting in men with prostate cancer. The study showed no significant benefit for surgery in terms of survival and death from prostate cancer at approximately the 15-year time point after enrollment. There appeared to be a benefit to surgery in reducing the risks of death and prostate cancer mortality only for those with high-risk features.
jaffa: What percentage of patients on active surveillance die of prostate cancer?
Dr_Stephenson: Less than two percent. However, you need to choose the patient’s treatment protocol appropriately and patients need to be monitored appropriately.
CC_Account: I was diagnosed with localized prostate cancer (T1c, Gleason 3+3) in February, and have chosen active surveillance as my treatment option for now. Does the Cleveland Clinic have a preferred method of differentiating between tumors that will grow slowly and tumors that will grow aggressively and require more aggressive treatment? (This assumes that diagnostic tools exist to do this.) What are your thoughts on PCA3 as a way to assess the aggressiveness of prostate cancer?
Dr_Stephenson: Active surveillance is a reasonable (and, some would argue, preferred) treatment option for slow-growing tumors. To determine a more aggressive cancer, you may consider a prostate MRI to rule out a large, invasive cancer. Typically, for men interested in active surveillance, we recommended a repeat prostate biopsy shortly after diagnosis to ensure we are not under-appreciating the amount and grade of a man's cancer. If the repeat biopsy confirms low-volume, Gleason 6 prostate cancer, surveillance would be a very reasonable option to consider. The likelihood that treatment will be needed over the next five to seven years for evolving or growing cancer is exceedingly low. There is currently no role of PCA3 as a screening test for prostate cancer. It may be useful to determine the need for a biopsy in men with an elevated PSA level.
Tom724: I have been diagnosed with prostate cancer, but my PSA has always been, and remains low (1.9). Does monitoring via PSA make sense? Why?
Dr_Stephenson: A low PSA alone does not necessarily indicate you have low risk cancer, You also have to consider the clinical stage, the biopsy, Gleason score, and the number and location of the positive biopsy scores. If all of these parameters are favorable, active surveillance would be a reasonable strategy to pursue for men of all ages and life expectancy. I would recommend a repeat biopsy confirming favorable biopsy features before committing to surveillance.
Medical Treatment of Prostate Cancer
donnarush: At what point do you recommend an active 87 year old to seek alternative treatments after a six-year diagnosis of prostate cancer? My father has been on Casodex® with Lupron Depot® for 10 months and his PSA is rising again. What is a good option for him?
Dr_Stephenson: In general, among older patients, primary hormone therapy has fallen out of favor due to long-term side effects. We tend to watch these patients closely or consider them for aggressive treatments. A rising PSA on hormone therapy is often an indicator that the cancer has 'learned' to grow and thrive despite hormone therapy. The first step would be to verify that the testosterone levels are appropriately being suppressed (<50 ng/dL). Depending on the PSA level, it may be reasonable to get a bone scan and/or CT to make sure the cancer has not spread. If there is evidence of metastasis to the lymph nodes or bone, your father would be a candidate for treatments such as docetaxel, abiraterone acetate, sipuleucel-T, and enzalutamide—to name a few.
Sy: What are the near-term and long-term side effects of various prostate cancer treatments, in particular, cryotherapy? How about success of cure?
Dr_Stephenson: All men are impotent after cryotherapy. Cryotherapy also can only be done on men with small glands (<40 cc). Those are the major disadvantages to cryotherapy. The chances of voiding problems, incontinence and rectal symptoms after cryotherapy are very low. Serious complications from cryotherapy are also much less than in the past due to improvement in the technology and delivery system.
Sy: Dr. David Levy of Cleveland Clinic apparently has done cryotherapy successfully. Is that better than prostectomy or radiation therapy?
Dr_Stephenson: No treatment has been proven to be superior to others in terms of quantity and quality of life. There are advantages and disadvantages to all of the treatment options.
Sy: Cleveland Clinic seems to have had good success with cryotherapy. Would you recommend it to someone over 65 years old with intermediate stage cancer?
Dr_Stephenson: Cryotherapy would be a very reasonable strategy to pursue in a man with intermediate-risk prostate cancer who is older than 65. Make sure the physician who performs the procedure has a proven track record of success!
cincytau: How do you measure the effectiveness of beam radiation therapy?
Dr_Stephenson: The PSA (prostate specific antigen) level after radiation is the best measure of success, at least early on. The problem is that hormone therapy will cause the PSA level to also decline, but this may not necessarily indicate the cancer is cured. Likewise, many normal prostate tissue cells survive after radiation and continue to make PSA. Stable PSA at low levels is a good indicator that the treatment was successful.
brookjax: After prostate removal, at what level of PSA (prostate specific antigen) should one consider using radiation to remove residual cancer cells, and would this radiation permanently affect libido or cause ED (erectile dysfunction)?
Dr_Stephenson: There is no defined, pre-set level when one should or should not receive radiation after surgery for a rising PSA. The best time to administer radiation therapy is when the clinicians feels the rising PSA is indicative of recurrent prostate cancer, and whether the he or she believes radiation therapy will benefit the patient. There are many patients for whom radiation therapy is not beneficial for a rising PSA. The rising PSA may not represent cancer. The rising PSA may represent an indolent, slow-growing cancer that may pose a minimal threat to a man's well-being and longevity. The rising PSA may be indicative of metastatic disease for which radiation therapy is not helpful. In my experience based on patients that I have treated who have PSA levels drawn in our laboratory, rising PSA levels on at least two measurements for a man with adverse risk factors (high Gleason grade, extraprostatic disease and seminal vesicle invasion) as low as 0.06 to 0.10 mg/ml may be indicative of recurrent cancer. However, the significance of a rising PSA level depends on the PSA assay used to measure it, evidence of a rising versus bouncing PSA pattern, and the clinical and pathological features of a man's cancer. Radiation therapy after surgery may significantly impair the recovery of sexual function.
Bmccloy: Is the procedure sometimes referred to as ‘GPS’ external beam radiation’ as god or better than ‘proton treatment’ as found at Loma Linda University in California?
Dr_Stephenson: I think you're referring to image-guided radiation therapy. This has become the standard of care in the eyes of many radiation oncologists. Intuitively, it makes sense, but I have yet to see convincing data to prove its safety and efficacy.
Proton beam therapy is promoted as a better treatment approach involving radiation therapy for prostate cancer. This is purely speculative. There really is not evidence at this point to support this notion. Much of the virtues of proton beam therapy in mainstream media is more promotional than factual!
parwez: I’m age 62, with a Gleason score of 8, and radical prostatectomy in April 2012. The margins were positive and the lymph nodes negative.
Dr_Stephenson: If the PSA level is undetectable, you could consider adjuvant radiotherapy or close observation with radiation therapy at the time the PSA (prostate specific antigen) starts to rise. If the PSA is rising now, the benefit of radiation therapy would depend on the PSA level and how quickly it is increasing. For monitoring, I would have the PSA checked three to four times annually.
Intermediate-Stage Prostate Cancer Treatment
Sy: What is your recommendation for treatment of intermediate-stage prostate cancer for someone over 65 years old?
Dr_Stephenson: Not all intermediate cancers are created equally! A man with a life expectancy of more than 10 years who has a large nodule on his prostate (clinical stage T2B) or multiple cores showing Gleason 3+4, 4+3, or PSA >10 ng/mL, which the physician believes to be related to prostate cancer (as opposed to benign enlargement), should consider pursuing aggressive therapy. On the other end of the spectrum, active surveillance may be a very reasonable strategy for a man with a life expectancy of less than 10 years or a man who has low-volume, Gleason 3+4 disease in a few cores. For the man who falls in between these extremes, radical therapy or surveillance may be reasonable options depending on the patient's treatment goals, life expectancy, associated medical problems and cancer features. In the past, active surveillance was not considered an appropriate option for men with intermediate-risk cancer who had a life expectancy of more than 10 years. We now know that many of these cancers are associated with a low risk of causing problems or a man's demise. Active surveillance is a very reasonable strategy for many of these men.
dliving41: In December 2010, a biopsy found cancer in one of 12 core samples of 5 percent with a Gleason score of 3+3. In December 2011, a repeat biopsy had similar results, but this time a core sample of 5 percent, had a Gleason score of 3+4. My last PSA was 3, and it had been as high as 5. Would you recommend another biopsy this year?
Dr_Stephenson: If you are in your 50s (with a life expectancy of more than 20 years), I would tend to favor aggressive treatment for low-volume Gleason 3+4. For a man in his 60s or older (with a life expectancy of 10 to 20 years), active surveillance may be a reasonable option. If you chose active surveillance, I would highly recommend a repeat biopsy before committing to this option to be sure we are not under-appreciating the grade and volume of cancer.
Erectile Dysfunction Treatment
brookjax: If Viagra® or Cialis® are not sufficient, would you recommend using Bi-Mix or Tri-Mix as a next step for erectile dysfunction? If not, why?
Dr_Stephenson: The options for a man with erectile dysfunction after treatment who do not respond to Viagra® or Cialis® depend on the time course after treatment. If he is very early in his recovery after treatment (i.e., less than six months), one could simply be patient and waiting for the natural recovery process to take place. He could re-try these medications at a later point in time. For a man who desires to be sexually active now, the options are injection therapy or a vacuum pump (the choice is really up to patient preference). For a man with permanent erectile dysfunction (defined as absence of erections for more than one year after completion of therapy), one may consider a penile prosthesis.
gypsy1213: Would you discuss HIFU (high-intensity focused ultrasound) as a new procedure that is being done in Europe for prostate cancer—its cost, insurance coverage, effect on potency, and bowel and urinary tract side effects? Is there any radiation or chemotherapy treatments required after the HIFU procedure?
Dr_Stephenson: HIFU is not approved for use in the U.S. I cannot comment on the reasons why it is not approved. HIFU uses thermal energy (heat) from high-intensity, focused ultrasound waves to destroy prostate tissue—and prostate cancer—in the process. It is not considered a standard treatment option for localized prostate cancer—even in countries where it is approved such as Canada—because there is not sufficient data to support its safety and efficacy relative to other treatment options. Thus, it is still considered experimental. Any literature (electronic or print media) you may have read suggesting that it is a widely accepted approach with results equivalent to the standard options is promotional and not evidenced-based. I am not suggesting that it is not as good as the other options. The truth is that we just don't have sufficient data at this point in time to make an accurate assessment. There is great appeal to the procedure as it is a minimally invasive option. There are concerns about important morbidity and efficacy. There are also concerns that it may burn a therapeutic bridge (surgery and radiation therapy, for example) should the initial HIFU treatment fail.
jaffa: Is focal point therapy recommended for low-risk prostate cancer?
Dr_Stephenson: Focal therapy is an area of active investigation, but currently is still considered experimental. The problem with focal therapy is that we know many men may be appropriate candidates for this procedure, but it is difficult to identify them at the time of diagnosis. Another concern about focal therapy is that it may make subsequent therapy more difficult and less successful if the focal therapy treatment does not cure you. Focal therapy is theoretically associated with a lower risk of treatment side effects, although this has yet to be proven.
Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic expert Andrew Stephenson, MD is now over. Thank you Dr. Stephenson for taking your time to answer our questions today about Prostate Cancer.
Dr_Stephenson: Thank you for all the questions. Hopefully, you found my responses helpful.
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