For Advanced Prostate Cancer, Aggressive Treatment Is Required

As discussed in previous installments, prostate cancer diagnostics have advanced by leaps and bounds in recent years.

The precision in which skilled diagnosticians collate, synthesize and analyze data points from various sources—family history, genetic background, prostate-specific antigen (PSA) tests, magnetic resonance imaging (MRI), ultrasound scans, biopsies and more—is impressive. By the time you're looking at treatment options, you can be sure your medical team has a very clear idea of the parameters of your tumor or tumors.

One of the determinants for whether a man is a candidate for more invasive procedures versus less invasive ones is the Gleason score.

Pathologist Donald Gleason developed the scoring system in the 1960s, when he studied cancer cells and noticed they developed in five clearly delineated patterns as they morphed from normal cells into tumor cells.

Gleason graded them from 1 to 5, with grade 1 being nearly normal cells and grade 5 indicating high-grade tumor cells that are hardly recognizable as normal human cells.

The Gleason score is derived from your pathologist's assessment of your biopsy. The specialist assigns one Gleason grade to the most predominant pattern in your biopsy and a second grade to the second most predominant pattern. Thus, you might get two grades of 3 and 4, which yields a Gleason score of 7.

Pathologists today rarely assign scores between 2 and 5, so Gleason scores generally range from 6 to 10, with 6 being the lowest-grade cancer. A Gleason score of 7 would indicate an intermediate grade of cancer, while 8 to 10 represents a high-grade cancer.

Another important factor you and your medical team should consider is whether the pathologist encountered any cells rated at a Gleason grade of 5, because that would indicate a higher chance of recurrence.

Taking the data from the pathologist's reading of your biopsy or biopsies, and factoring in data points such as your age, family history, ethnic background and overall health, your medical team works with you to come up with an appropriate plan for moving forward.

"Once you've made the decision that the treatment is to be performed, then historically your backbone options are going to be surgery, radical prostatectomy or radiation, which was typically whole-gland radiation," said Aditya Bagrodia, M.D., a urologic oncologist at the University of California San Diego Health. "And those still very much comprise the bulk of what's done."

But big topics like prostate cancer surgery and radiation treatment often contain big misunderstandings.

Most men's knowledge of prostate cancer surgery is incomplete at best. There is often a dated belief that prostatectomy—the removal of all or part of the prostate gland—is an utterly devastating procedure that will lay you out flat for several days or a week.

These days, nothing could be further from the truth. In fact, the science of prostate surgery has left the 20th century behind and joined the age of robotics.

"The vast majority of prostatectomies are done robotically or laparoscopically, which means through small openings on the belly," said Petar Bajic, M.D., a men's health specialist whose urology practice is affiliated with the Cleveland Clinic. "This is about a two- to four-hour surgery in which the prostate is removed, as well as the surrounding lymph nodes. The lymph nodes are sort of the sewer system for the organs—they collect fluid and cells as they leave the organs, so if there is prostate cancer that escapes, it might be in the surrounding lymph nodes."

A laparoscopic prostatectomy and a robotically assisted prostate cancer procedure are similar in that they're both performed via one or more tiny incisions in the abdomen. Using a camera and tools that are inserted through the incisions, the surgeon removes the prostate gland and possibly the surrounding lymph nodes.

The difference between the two procedures is that with laparoscopic surgery, the doctor physically manipulates long-handled instruments that reach through the belly down to the prostate while an internal camera guides the maneuvering. With robotic assistance, the surgeon sits at a console next to the patient and operates a robotic system, one that frequently runs on what's called Da Vinci technology.

The robotic system projects a high-definition, 3-D rendering of the man's prostate and surrounding tissue on a screen in front of the doctor as the doctor's movements at the console's joystick-like interface are translated to the tiny instruments inside the man's body.

In addition to the exponentially improved precision that robotics-assisted surgery offers, modern medicine has come a long way in terms of making it easy on the patient, too.

"For instance, we have a same-day surgery program where you can come in, get your surgery and go home," Bagrodia said. "There's been some tremendous improvement in multimodal pain, optimized anesthesia, early recovery, so we can get patients in and out. Generally, with that type of approach, Tylenol or ibuprofen are going to be perfectly adequate for pain control, and you're walking the day of [surgery], eating and drinking the day of. That's very different from what a prostatectomy looked like 30 years ago."

The other major type of invasive prostate cancer intervention involves radiation therapy, a targeted attack on the tumor during a series of procedures over several weeks or months. The hope is the radiation will kill cancer cells in the prostate, as well as any that might be present in the lymph nodes.

Radiation therapy can be used for both early-stage and advanced prostate cancer, and in conjunction with hormone-deprivation therapy, to provide another vector of attack on cancer. It's also frequently employed to treat recurrent cancer after a man has had surgery.

Men may undergo one of two basic types of radiation therapy: external beam radiation or brachytherapy.

"External beam radiation delivers radiation from the outside in through a series of treatments that would be determined by the radiation oncologist who is treating it," Bajic said. "But, basically, you go through this machine that delivers this nonpainful radiation from the outside in. It's kind of like going through a CAT scan."

External beam radiation usually involves several weeks of treatment, sometimes several times per week.

Brachytherapy involves the insertion of dissolvable radioactive beads that are strategically implanted around the prostate to attack the cancer from within. These types of procedures are usually reserved for men with lower-grade prostate cancers, typically with Gleason scores of no more than 6 or 7.

"Those seeds slowly release radiation over several months, which is what we call low-dose brachytherapy," Bajic said. "There's also something called high-dose brachytherapy, where, basically, there are these temporary catheters that are put in and deliver high doses of radiation over a very short period. And then they're removed, and then the guy comes back another time for another treatment."

There are some important differences between surgery and radiation therapy for the treatment of prostate cancer.

While surgical prostate interventions have come a long way in sparing the nerves and blood vessels crucial to sexual function, there can be sexual side effects immediately following surgery, though they typically improve slowly over time. On the other hand, radiation treatments can cause damage to the prostate that results in sexual side effects that aren't present at first, but only manifest later.

Depending on the man's age and overall health, his decision will likely involve an in-depth and ongoing conversation with his medical team.

"First of all, we discuss all of the available treatment options with the patients and go into the details between surgery and radiation about expectations, relative risks and benefits to each approach," Bajic said. "And then, through kind of a shared decision-making approach, we decide what to do.

"Some people might want to do everything possible to avoid a surgery," he continued. "So, in that case, they might decide for radiation. Some people might be more interested in having the side effects now while they're younger and healthier, and not have to worry about something down the road. They might be more inclined to choose surgery."

Whether you choose radiation or surgery, just make sure you are fully engaged with the decision-making process all the way through, and understand the pros and cons of each option.

The most important detail to keep in mind is that both radiation treatment and prostatectomy offer equal chances of success.

"In general, we consider surgery and radiation to be equally effective at curing the cancer," Bajic said. "That's important to know. That's been studied extensively."