Prostate Cancer Treatment Update (cont.)

MEMBER QUESTION:
I've read that the best candidates for surgical removal of the prostate are men under 70 years of age. Is the surgery less likely to be effective for men over 70, or more likely to have serious complications? Why are men over 70 less likely to be good candidates for surgical removal?

OH:
In general, men over the age of 70 have an increased risk of complications related to surgeries compared to men under 70. The recommendation of 70 as a general cutoff for surgery stems from two points: The first is that very effective alternatives are available to men of all ages that would represent a very suitable alternative to surgery and the second is the increasing risk of complications in the older men.

That said, many urologists will operate on men over the age of 70 if they are otherwise in good health. But, it should be clear to patients that surgery has not been clearly proven to be superior to treatment such as radiation or seeds in all situations.

MEMBER QUESTION:
At what point in time after removing the prostate, and for the past two years of "excellent" follow-up results, is a person safe from having the cancer again?

OH:
That's a good question. Prostate cancer has a very long natural history. In this regard, that means that it takes many years from the treatment to be certain that the cancer will never recur. Generally, with each passing year, and at 5 and 10 years, a person who has no evidence of recurrence measured after surgery, such as a PSA that's undetectable, should be increasingly confident he's been cured. However, the greatest certainty really comes out after 10 to 15 years of follow-up.

MEMBER QUESTION:
What is your opinion of cryoablation for primary or recurring treatment?

OH:
Cryosurgery has had an up-and-down history in terms of the evidence for its benefit, and like the other treatments for prostate cancer, has never been compared to a treatment such as surgery or seed implants in such a way that we know whether it's better, worse, or the same. Therefore, it's very hard to comment on advantages and disadvantages compared to those treatments.

Generally there has been less data in the use of cryosurgery as primary treatment, but single institution studies have shown this treatment can effectively treat localized prostate cancer. We just don't know if it's as good as or less effective than other options. In the area of recurrent disease, there has been more enthusiasm for cryosurgery as an option. However, these remain relatively small studies of selected patients in a small number of centers around the country.

As discussed earlier in the context of surgical intervention after radiation, there may be a role for cryosurgery in some patients with local recurrence after more standard options such as radical prostatectomy or seed implantation.

"A recent study in hormone refractory disease was presented at a prostate cancer meeting in Florida that suggested that a vaccine called Provenge improved survival in patients who received this compared to a placebo."

MEMBER QUESTION:
I was diagnosed seven years ago. I had been responding well to hormones, despite some of their issues, but my PSAs had risen during my last visit. I am discussing options with my urologist and others who have been where I am. Is the change in how hormones had been helping a sign of changes, and what are my options?

OH:
A rising PSA in the setting of hormonal treatment can be a sign of what we call hormone refractory or resistant disease. This situation requires that a testosterone blood level be checked to be certain that the hormone shots are effectively suppressing testosterone. If this is the case, or if the hormone treatment was surgical castration, then options at this point include the use of secondary hormonal treatments and chemotherapy.

It would be considered premature at this point, in my opinion, to use chemotherapy if the only sign of this refractory cancer is a rising PSA. That said; the goal of treatment here is to try to suppress and delay the cancer from growing in this hormone refractory state.

Secondary hormone treatments include high dose Casodex, ketoconazole, and estrogen type treatments. These are generally best discussed with a medical oncologist, and I might suggest a consultation with a medical oncologist be conducted in the near future to review these choices.

The good news is there is a lot of research going on in this area, in addition to these standard options I mentioned. For instance, a recent study in hormone refractory disease was presented at a prostate cancer meeting in Florida that suggested that a vaccine called Provenge improved survival in patients who received this compared to a placebo. This vaccine is not commercially available and there are ongoing studies, but it points out that promising new treatments are on the horizon.

MEMBER QUESTION:
Can you say with absolute certainty that a biopsy needle will never deposit a cancer cell into healthy tissue as it is withdrawn from a cancerous prostate?

OH:
Of course we can never say with absolute certainty that biopsy procedures don't "spread" cancer. That said, it is highly unlikely that needle biopsies have any impact on promoting cancer spread. Why is this so? Millions of men get biopsies and are diagnosed with cancer that has been completely cured with treatments such as surgery or radiation. If biopsy did have a significant risk of spreading cancer beyond the organ, then one would suspect cure would be unlikely or otherwise compromised.

So in my opinion, I do not believe men should be overly concerned that biopsies spread cancer. In fact, cancers spread themselves, and this is the greatest concern of all.

"I have great optimism for the future and hope our efforts will have a meaningful impact on patients' lives in the near future."