Prostate cancer is one of the most commonly diagnosed cancers in men and the second most common cause of cancer death. Approximately 180,000 men are diagnosed each year with prostate cancer and approximately 27,000 men of the disease. Dying from prostate cancer is something we don't want for anyone. Because prostate cancer is such a variable cancer, we don't have to treat all men the same way. Many men don't need to be treated at all.
To have the full range of treatment options, it's important to diagnose prostate cancer in its early stages. Early stage prostate cancer is silent, meaning it doesn't have symptoms. Prostate cancer symptoms are produced by advanced prostate cancer and metastases (the spread of a disease from the primary site of disease to another part of the body).
Prostate cancer symptoms include significant difficulty urinating and bone pain. If prostate cancer is diagnosed because of symptoms, it's usually late stage disease with few treatment options. To diagnose early stage prostate cancer, which does not produce symptoms, we must look for it. We look for it with PSA testing.
Prostate Specific Antigen (PSA) Testing
PSA is a normal, harmless protein that's specific to the prostate. Only the prostate makes this protein and leaks it into the bloodstream where it can be measured. It's not cancer specific. However, we interpret PSA test results in the context of other risk factors such as family history and ethnicity to estimate a man's risk for prostate cancer.
Investigating Elevated PSA
If a man is thought to be at sufficient risk for having prostate cancer based on his PSA test results and other risk factors, he will need further evaluation. This has historically been done with ultrasound guided biopsy of the prostate. Ultrasound guided biopsy may identify prostate cancers not likely to grow or spread, leading to over diagnosis.
It may also miss clinically important prostate cancers, or those that are at risk to spread. Recent advances in MRI evaluation of the prostate has allowed for a better way to investigate risk for prostate cancer. It typically identifies clinically important prostate cancers and can be used for a targeted biopsy, greatly reducing the risk of missing a prostate cancer. It's also useful for staging prostate cancer and helping to guide recommendations for managing the disease.
Making Management Decisions for Prostate Cancer
Prostate cancer is a highly variable cancer. Not all prostate cancers behave the same and not all are associated with the same level of risk of progression. Most prostate cancers progress slowly. When making recommendations for managing prostate cancer, it's important to know what its risk of progression is and look at the risk in the context of a man's life expectancy.
Then recommendations are made for managing that risk of progression for that man's life expectancy with one goal in mind - that no man die from prostate cancer. Each man receives a customized treatment plan to manage and effectively treat the condition.
The Gleason score is one way we learn about a prostate cancer's risk for progression. This is a number between 6 and 10 assigned to the cancer by the pathologist based on the appearance of the cells when examined under the microscope. Dr. Gleason described 5 different patterns and suggested that we might be able to estimate a cancers risk for progression based on the patterns that are present.
The cells that form into patterns one and two are indolent or idle and are no longer identified. The cells that form into patterns 3 through 5 are considered important. The pathologist identifies a primary and secondary pattern in the biopsy tissue and adds the two numbers to provide a sum or score from 6 to 10. We use PSA and Gleason score to assign men to a category of risk for progression and manage each category differently.
Understanding Your Risk
The categories of risk of progression are very low risk, low risk, low intermediate risk, high intermediate risk and high risk.
Men at very low risk of progression have low volume Gleason 6 prostate cancer. Men at low risk have high volume Gleason 6 prostate cancer. These men typically don't receive treatment. The management strategy most appropriate for them is active surveillance - including regular PSA testing and MRI surveillance or follow up biopsies.
Men with Gleason 7 prostate cancers are in the category of intermediate risk for progression. These are considered clinically important cancers and are typically treated to prevent them from progressing, although some are candidates for active surveillance. The choice of management strategies is surgical management or definitive radiation often with a period of hormonal deprivation. This choice is usually based on life expectancy and patient preference.
Men with Gleason 8 to 10 prostate cancer are at high risk for progression. These are considered lethal prostate cancers and typically require further evaluation with MRI and bone scan for staging. Most of these men will benefit from a combination of treatment. This may be surgery followed by radiation and hormonal therapy or radiation and hormonal therapy alone.
Surgery for Prostate Cancer
If surgery is the appropriate and preferred strategy for treating intermediate or high risk prostate cancer, it's done laparoscopically using robotic technology. The procedure is called a Robotic Assisted Laparoscopic Prostatectomy. The most obvious advantage to this approach is a quicker and easier recovery.
The goals of surgical management are cure, complete recovery of urinary control, and preservation of sexual function. Because it's essential to have a good cancer outcome along with the recovery of these very important quality of life issues, the experience of the surgeon is especially important. Dr. Jackson has performed more than 1,500 robotic prostatectomies. His practice is devoted entirely and only to the management of prostate cancer.
This commitment and specialization provides a predictable recovery for most men. Reasonable expectations for recovery include one night in the hospital with discharge at about noon the following day. Men are sent home with a catheter for eight days. Most men feel well enough to return to work in a couple of weeks depending on the demands of their job.
Seventy-five percent of men will recover urinary control within three months. Another 10 percent will regain control will within four months, and 10 to 12 percent will take six months. Three percent will always need to wear some protection after surgery, but approximately 97 percent will be pad free. Sexual function takes much longer to recover, typically 12-24 months. It's directly related to patient age and function prior to surgery. Disease free status is confirmed with PSA surveillance every three to six months. PSA after surgery should be undetectable.
Prostate cancer symptoms are produced by advanced or metastatic prostate cancer and have few treatment options. To have effective treatment choices, prostate cancer must be found early. Early prostate cancers do not produce prostate cancer symptoms. It's a silent disease, so we must look for it. We look for it with PSA testing.
PSA test results are interpreted in the context of other risk factors to estimate a man's risk for prostate cancer. That risk is investigated with an MRI and possible MRI targeted biopsy. Microscopic examination of the biopsy tissue informs us of the risk of prostate cancer progression and guides recommendations for treatment strategies.