Prostate Cancer Treatment Options: Ask an Expert
June 25, 2013
Prostate cancer is the most common cancer in men, and the second leading cause of cancer deaths among men in the U.S. Every year, about 185,000 new cases of prostate cancer will be diagnosed in the United States.
Prostate cancer is a malignant tumor that usually begins in the outer part of the prostate. In most men, the cancer grows very slowly. In fact, many men with the disease will never know they had the condition. Early prostate cancer is confined to the prostate gland itself, and the majority of patients with this type of cancer can live for years with no problems.
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 Speaker
David Levy, MD is a staff physician in Cleveland Clinic’s Department of Urology, Glickman Urological and Kidney Institute, and is board certified in urology. He sees patients at Cleveland Clinic Cancer Center at Fairview Hospital and Richard E. Jacobs Health Center, in Avon.
Dr. Levy completed his fellowship in urologic oncology at University of Texas M.D. Anderson Cancer Center, in Houston, following his residency in urology and internship in general surgery at University Hospitals of Cleveland. He graduated from medical school at The University of Health Sciences/The Chicago Medical School, North Chicago, Ill.
Dr. Levy specializes in urologic oncology, oncology, prostate cancer, kidney cancer and bladder cancer.
Let’s Chat About Prostate Cancer Treatment Options: Ask an Expert
Atypical Small Acinar Proliferation (ASAP) Diagnosis
Peter1: I have just had my second biopsy of my prostate. The first one was done in January. Of 12 samples. 11 came back o.k., but one was ASAP (atypical small acinar proliferation). What is the likelihood that the second biopsy will come back positive for cancer given the initial ASAP finding?
David_Levy,_MD: ASAP can be considered as follows: There is cancer in the gland, but it is not on the pathology slide. A repeat biopsy is mandatory, and is 40 percent likely to reveal the cancer. It should include 18 to 20 needle cores.
Risk Factors for Prostate Cancer
pilatesgirl: Do you have any thoughts on the contributory causes of prostate cancer?
David_Levy,_MD: It seems as though environmental factors such as diet have a role in prostate cancer incidence. The typical American diet seems to be a high-risk factor compared to the typical Japanese diet for example.
mcduff1: At what point should I be concerned with my Gleason score? Two years ago, my biopsy indicated a Gleason score of 4 with a somewhat enlarged prostate. In February 2013, another biopsy indicated a Gleason score of 6: My urologist said many of those findings are subjective and is not necessarily concerned. I am 70 years old, and I work every day as a courier. I am in otherwise excellent health. My father died at 87 years old with prostate cancer, and my brother died at 69 years old with esophageal cancer. My mother is 93 years old and in excellent health. I don't want to wait until it is too late. If I need to have the prostate removed, I want to be in good health at that time. Or, is ‘watchful waiting’ sufficient?
David_Levy,_MD: With your biopsy history the relative risk of disease progression to a serious situation for you is very small. PSA levels at six-month intervals are reasonable. Your lifetime risk of dying from the disease is no more than 11 percent.
Moviejunky: I am about to undergo the radical route. I am 52 years old with a Gleason score of 6 and a PSA of 5.8 found in one core sample out of 12. What can I expect my recovery time to be, and how soon can I get back to work.
David_Levy,_MD: Your PSA is high for your age, but the Gleason score is unconcerning as is the amount of disease in the gland. There are a number of experts across the U.S. who no longer believe that Gleason 6 cancer requires any type of treatment. We would offer you a confirmation biopsy and perhaps active surveillance instead of aggressive therapy at this time.
turnips8: Weighing the risks, my urologist says he wants to do an ultrasound with biopsy since my PSA has risen to 3.0 after being in the mid-to-high two range for several years, although there is likely only about a 20 percent chance that I really have any prostate cancer. My primary care physician agrees. Why, with such a low probability of cancer, should I submit myself to the possible complications of the biopsy? I have type 1 diabetes, but I am otherwise in excellent health at 58 years old. I swim 900 meters and walk three times per week. Is this the best initial path to follow?
David_Levy,_MD: The normal upper limit for PSA in a man aged 50 to 59 years old is 3.5 ng/ml. The PSA velocity—the rate of change per year—should not exceed 0.75 ng/ml. Based on the information you provided I would not be thinking about a biopsy at this time.
Prostate Cancer Genetic Markers
decmly: OPKO Health, Inc. offers a 4Kscore™ Prostate Cancer Test that can predict indolent versus aggressive prostate cancer. ‘A panel combining our PSA test and our novel kallikrein markers could create a diagnostic test able to accurately predict prostate cancer-positive biopsies this could lead to a 50 percent decrease in unnecessary prostate biopsies.’ Kallikrein markers have been tested in over 10,000 patients. The kallikrein panel predicts biopsy results in previously unscreened men with elevated PSA. This company is in Europe. Has anyone heard of this test, and what are the chances of it coming to the U.S. for a clinical trial? The website is: www.opko.com/products/point-of-care-diagnostics/4kscore-next-generation-prostate-cancer-diagnostics/.
David_Levy,_MD: Through extensive efforts primarily led by our Glickman Urological and Kidney Institute Chairman Eric Klein, MD, there is a genetic marker test now commercially available that is being used on prostate biopsy cores to help predict the aggressiveness of the disease. This is not a 100 percent accurate predictor of disease behavior, but will likely factor into clinical decision making for select patients. More details are available through the Glickman Urological and Kidney Institute at Cleveland Clinic.
‘Watchful Waiting’ vs. Active Surveillance
russb: What is Cleveland Clinic's experience with active surveillance? Have you seen any cases where the cancer has spread beyond the prostate while a patient has been actively monitored.
David_Levy,_MD: Our approach to active surveillance (AS) is a Gleason score of 6 or less in no more than three cores positive with a confirmation biopsy that reveals no increased amount of disease. If these criteria are met, then serial PSA testing at six-month intervals should be done. Provided there is no PSA progression, surveillance should be continued. To date I have not seen anyone progress to a non-treatable situation.
jmneub: What is your protocol for active surveillance in a 65 year old with stable PSAs between 8 and 9, a Gleason score of 7, tumor confined to the prostate per CT and normal rectal exam? No treatment was elected by the patient at this time. The PSAs are quarterly, and started out at about 6 three years ago.
BigMike50: What are your thoughts regarding the advisability of active surveillance? If chosen, what is the recommended follow-up for a 50-year-old man meeting all of the National Comprehensive Cancer Network standards for very low recurrence risk (PSA = 4.16, Gleason 3+3 = 6, PSA density = 0.13 and biopsy two cores (11 percent and 17 percent) of 12 positive with both from the same area?
David_Levy,_MD: By definition you do not qualify for active surveillance (AS) based on the Gleason score. Active surveillance is specific for a Gleason score of 6 or less, with no more than three cores involved with disease on confirmatory biopsy. What you have chosen is ‘watchful waiting.’ My approach to such is PSA at six-month intervals. If the PSA is rising, then treatment can be offered.
CLSkipper: I am 58 years old, and I was diagnosed in October 2012 with prostate cancer after a PSA of 13 and a biopsy. Ten samples were taken with one showing four percent cancerous cells. My Gleason score was 6. I have benign prostatic hyperplasia. I have chosen active surveillance. Since my diagnosis my three-month follow-up PSAs have 6.7 and 8.1 and I am scheduled for another biopsy in October. My question is if my PSA bounces around between 6 and 13, am I facing a biopsy every year?
David_Levy,_MD: To qualify for active surveillance a second confirmation biopsy should be done and should be no less than 18 needle cores. If that second biopsy shows no more than three needle cores positive and Gleason is less than in any positive core, then you are a candidate for surveillance. Annual biopsy is currently the protocol with PSA testing at six-month intervals. More frequent biopsies would be offered only if there is clear PSA progression, but not for erratic elevations in PSA.
prostatepete: I also have Gleason 7 and a stable 9.9. I have no symptoms, and I have been just getting tests.
David_Levy,_MD: By definition you do not qualify for active surveillance (AS) based on the Gleason score. Active surveillance is specific for a Gleason score of 6 or less, and no more than three cores involved with disease on confirmatory biopsy. What you have chosen is ‘watchful waiting.’ My approach is PSA at six-month intervals. If the PSA is rising, then I would offer treatment.
grandpa43: I was diagnosed with low-grade prostate cancer in late 2004. In early 2005 I opted for brachytherapy. All went well and my PSA numbers remained below1.0 for about five years. Suddenly the number began to increase slightly over a period of months and years. My urologist suggested that I have a biopsy, CAT scan, etc. Eighteen samples were taken, and all of the results were negative. This same procedure was repeated last December with the same negative results. A checkup in May showed the PSA rising to 2.9 from 2.1 from about five months prior. Do you have any suggestions?
David_Levy,_MD: A prostate protocol MRI is the next step for you and based on these findings a saturation biopsy is indicated. There are cells somewhere in your system making PSA. The question is where, and at times we cannot find the answer.
RIVERSANTO: For the last 10 years my average PSA was 1.2 to 3.2. On March 11 it was up to 4.3, and then on March 15 it went up to 4.9. On April 11 it was 3.9, and my PSA free was 40 to 41 and greater than 23 percent, which is suggestive of a benign condition. The physician suggested a biopsy after a digital exam. I am concerned about the risk of biopsy and side effects, without having a 100 percent secured negative or positive result from biopsy.
David_Levy,_MD: Your age is an important determining factor. Your PSA velocity, rate of change over time is a bit high but erratic, which goes against a growing cancer. The age risk for disease is about 30 percent of 50-year-old men, 38 to 40 percent of 60-year-old men and about 60 percent of 70 year old men, but the lifetime risk of dying from the disease is 11 percent. I would not feel strongly about a biopsy for you, but a repeat PSA within four months is very important. Risks of the biopsy are real, but small.
Individualizing Patient Treatment
T3959: Why is it so difficult to determine which treatment option is best for a patient? All options seem to have huge disclaimers. It seems that whatever option is picked by a patient, it is a ‘roll of the dice’ as to how well it will work. Also, how is the Da Vinci® procedure different from other robotic-assisted procedures?
David_Levy,_MD: To date there is no proven superiority of one treatment option over another, but side effects can be significantly different. If we take two patients with the same biopsy score, PSA and amount of disease, the cure rates are equivalent for surgery, radiation and—as far as we can tell—cryosurgery. However, the risks of treatment-related complications are significantly different. Provider experience is critical in the choice to treatment. It is not really a ‘roll of the dice,’ but there are very real differences in risks of complications. The Da Vinci® is the robot that is used for urologic, gynecologic and other surgical procedures.
decmly: When do you suggest to a patient that he get his prostate removed? If you are just diagnosed with prostate cancer is such radical treatment advisable right away?
David_Levy,_MD: Based on published reports there is no proven superiority of surgery over radiation over cryoablation for localized disease. There are criteria that make some better candidates for the different treatments. Risks of complications are quite different based on the type of treatment provided.
Low-Volume Disease Treatment
elowery99: In December 2012 I was told that my prostate cancer size was .05 mm. My PSA was 4.30 then and has been 3.90 and 4.25 since. My main concern now is whether to choose radiation treatment or prostate removal. Which will result in fewer problems with incontinence of my bladder? I want to lose so more weight and start treatment or remove my prostate within next six months. What about my time frame; is it okay?
David_Levy,_MD: From what you have listed you have low-volume disease. The Gleason score is a critical component for decision making. To date the treatment with the lowest side effects is cryosurgery with respect to urinary incontinence and bowel and bladder dysfunction with comparable PSA results. There are a number of factors that help determine who is a candidate for this treatment option.
Focal Cryoablation Therapy
philos: What are the advantages or disadvantages of cryotherapy vs. laser treatment in focal therapy? Is a prostatectomy still an option after either procedure if they are not successful?
David_Levy,_MD: To date there is no laser treatment for prostate cancer. Focal cryotherapy is being done with increasing frequency throughout the U.S. If there is evidence of persistent or recurrent disease, patients are typically candidates for surgical removal, repeat cryoablation and even radiation therapy.
dliving41: I am a 72-year-old male with prostate cancer who is otherwise healthy. A biopsy in December 2010 had one core sample with 5 percent of the tissue with a Gleason score of 6. A repeat biopsy in December 2011 was similar (one core sample with approximately 5 percent of the surface area), but the Gleason score was 3+4=7. Should I look into the Oncotype DX® prostate cancer test just announced? My PSA remains under 4.
David_Levy,_MD: At your age the lifetime risk of dying from the disease is 11 percent. Based on the Gleason score we would offer treatment provided you are otherwise healthy. My bias would lean more towards focal therapy, i.e. focal cryoablation, if you prove to be a candidate or radiation based on very low PSA and very low amount of disease. Please realize that there is a low, but real possibility, of needing additional therapy.
regamon: I was diagnosed with prostate cancer on June 4 of this year. The Gleason Scores out of 28 cores were: six 3+3=6 and two 3+4=7. My PSA was 7.59, which was 3.7 one year ago. Is proton therapy would be suitable treatment? And what is the cure rate? How do you compare this to intensity-modulated radiation therapy (IMRT)?
David_Levy,_MD: You have several options at this point. Without knowing your age and medical history, IMRT, radioactive seed implant or proton therapy are all forms of radiation therapy with similar outcomes, but the delivery of the radiation differs as do the potential treatment-related side effects to some degree. I suggest you discuss these various options with your radiation oncologist to get more information. There is no superiority of radiation over surgical removal of the prostate that has been demonstrated, but side effects are potentially different. Finally cryosurgery may also be an option based on your age. We offer all of these treatment options at Cleveland Clinic.
unsure: I am 47 years old and have undergone a radical prostatectomy. After surgery my PSA was 0. The cancer was found in a lymph node and outside the prostate, but not yet in the bones. I am presently doing hormone therapy and will have radiation. I have been offered chemotherapy. Do you recommend this therapy? My Gleason score is 7 (4+3).
David_Levy,_MD: Radiation therapy is an option based on the time since surgery. I do not believe that chemotherapy fits in the regimen at this time.
Da Vinci® Robotic Procedure
prostatepete: What is your opinion of the Da Vinci® robotic procedure? I have heard that unless you do 1,000 or more that the side effects are worse than if you get the old style operation.
David_Levy,_MD: Typically, across the U.S., urinary continence following the robotic procedure is worse than conventional surgical removal of the prostate. I do not believe the critical number is 1,000, but it is critical that the surgeon be very experienced with the robotic procedure.
Side Effects of Prostatectomy
eisendo1: Six months ago I underwent a radical prostatectomy. How long should I expect to experience occasional leakage, and what can I do to prevent the leakage?
David_Levy,_MD: Leakage rates from prostatectomy are as high as 60 percent across the nation, based on surgeon experience and technique used. It is impossible to predict what lies ahead for you, but many people experience improved urinary control over the course of the first year following surgical removal.
pilatesgirl: I would like to know any updates on post-surgical health for men after prostatectomy. My husband is seven years out from surgery, and has had no detectable prostate-specific antigen (PSA) for all those years. We learned that the five-year mark was the critical one to be worried about metastasis. Is that still current thinking? He is 65 years old, is in good health and is on no medications. He has no erectile function, and has full urinary continence. I wonder if there are thoughts about precautions and care we are recommended to take to do our best for his health. Is a yearly PSA frequent enough at this point to monitor? He is reluctant to have more frequent testing.
David_Levy,_MD: It sounds like your husband has done very well from the cancer perspective. Continued PSA monitoring on a yearly basis is still recommended. A healthy lifestyle is the best you can do now with no real need for precautions going forward. As for erectile function there are several options, including Viagra® (sildenafil citrate), Cialis® (tadalafil), Levitra® and Staxyn® (both vardenafil hydrochloride). Any of these oral medications can work, but none of them work 100 percent of the time. If there is no success from the pills, then a much more effective option is a medication that is injected directly into the side of the penis. This medication works over 90 percent of the time within eight minutes of administration. It results in an erection that will typically last 30 to 90 minutes with very few side effects. Other options include a vacuum pump device.
Prostate Cancer Prevention
eseme: I have enlarged prostate (50 in size) and from a biopsy result, it's benign. I am presently on Flotral® (alfuzosin) and Dutagen® (dutasteride) 0.5 mg. What steps should I take to prevent prostate cancer?
David_Levy,_MD: There is not much you can really do to prevent prostate cancer. There is no FDA-approved cancer preventive medication for prostate cancer. However, some providers use Proscar® (finasteride) in an effort to decrease the likelihood of being diagnosed with prostate cancer by 23 percent based on the published prostate cancer prevention trial that involved over 18,000 men.
Moderator: I'm sorry to say that our time with Cleveland Clinic expert Dr. David Levy is now over. Thank you, Dr. Levy, for taking your time to answer our questions today about prostate cancer.
David_Levy,_MD: Thanks for joining us. These were great questions. I’m happy to discuss these issues in more detail if some of you want to make an appointment.
If you would like to make an appointment with Dr. Levy or any of our other urologists 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 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.
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 No. 1 in the nation.
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