Significant advancements in the detection and treatment of prostate cancer — the second-most common cause of cancer death in men behind lung cancer — means prostate cancer doesn’t have to be a death sentence or the end of your sex life.
Screenings of the prostate, a walnut-sized portion of a man’s reproductive system that wraps around the urethra, the tube that carries urine out of the body, have improved. More information on prevention is available as are considerably more options — from monitoring to surgery with robotics.
“We understand this cancer much better than we did 10 years ago. We now know that not every man diagnosed is going to die from it and a lot of these men have the very viable option of active surveillance,” said Dr. Dipen Parekh, professor and chairman of the department of urology and director of robotic surgery at the University of Miami Miller School of Medicine.
“Now, hope is a matter of choice, not chance,” Parekh said. “The focus on prostate cancer is not just the cure but, in addition, to get back the quality of life a man enjoyed before he got cancer.”
That point is important because prostate cancer comes with a host of psychological issues given that post-surgical side effects include incontinence, as well as sexual dysfunction or inability to achieve and maintain an erection.
“Good sexual function and continence control, we’re doing much better than we did 10 years back, but by no means are we at optimal level. There are still several layers of improvements where we can make quality of life even better,” Parekh said.
According to the Centers for Disease Control and Prevention, in the United States in 2009, the year with the most recent figures, about 200,000 men were diagnosed, and about 30,000 died from cancer of the prostate.
And while “one in six men may be diagnosed with prostate cancer” at some point in their lifetime, “only one in 35 will die from it,” said Dr. Sri Sundararaman, medical director of radiation oncology for Memorial Cancer Institute in Hollywood. “It doesn’t immediately bring up the connotation of having less than a year to live. Millions are living with prostate cancer under watchful waiting.”
In fact, most older men who have prostate cancer die from heart attacks, strokes or old age, rather than from the cancer.
Given that most men don’t die from prostate cancer and that blood tests, like the PSA, can result in unnecessary surgeries, which contain a host of risks, the U.S. Prevention Services Task Force recommended against routine screening for prostate cancer in 2012. That recommendation proved controversial among urologists.
“There have been conflicts in the media, even in medical literature, ‘Why do we care about prostate cancer, it doesn’t kill many people and most of the time it’s benign and most men die with prostate cancer?’ But we are still dealing with tens of thousands of men dealing with prostate cancer and annually die from it,” Sundararaman said. “What we want to do, from start to finish, we want to make sure a patient understands that they can empower themselves about their situation. Not knowing, not checking is not an appropriate way to deal with this.
“If you are talking about a man, 40 to 50, a rectal exam goes hand in hand with a blood test. Start checking by 50. Start earlier if you have younger family members affected by prostate cancer.”
Should cancer be detected, a patient, in consultation with his doctor, can decide to monitor, rather than surgically remove, a cancerous prostate.
“Nowadays, you receive a diagnosis and the first question is, ‘Does the cancer need to be treated or not?’ It’s not a knee-jerk reaction to treatment,” said urologist Dr. Fernando Bianco, a surgeon in robotics for Doctors Hospital in Coral Gables. “Factors come into consideration: the biology of the tumor with a Gleason score, PSA level, then whether the patient has high blood pressure or diabetes, also an evaluation of urinary and sexual function. Can they have erections and how important is this for them? Same goes for urinary function, whether the stream or flow is strong or weak. You want to determine all those things to come up with a comprehensive plan for that patient.”
Means of observance include a prostate-specific antigen (PSA) blood test to measure the cancer’s concentration in the blood or a biopsy of the prostate. If the cancer shows signs of growth or stands poised to spread via a Gleason test grade, then a choice of surgeries can be considered. These can include radiation therapy or brachytherapy, which uses radioactive seeds to kill cancer cells; radical prostatectomy, the removal of the cancerous prostate and surrounding tissue; and robotic-assisted laparoscopic prostatectomy, the next wave, according to Sundararaman.
Other means include proton-therapy radiation to kill the cancer cells and hormone therapy if the cancer has spread. All of these options are dependent on a patient’s age and condition.
Rene Suarez, a retired law enforcement who lives in Coral Gables, began PSA screenings of his prostate six years ago at age 45 thanks to an aggressive doctor, he said. He was diagnosed with prostate cancer about two years later despite having no symptoms — which can include difficulty in passing urine and erectile dysfunction. His prostate also was normal in size, not enlarged, which can be another symptom.
Doctors gave Suarez two options: Wait a year and see what happens or undergo surgery.
“I opted to go with surgery,” said Suarez, 51.
Dr. Akshay Bhandari, assistant professor of urology at Columbia University Division of Urology at Mount Sinai Medical Center, performed the robotic surgery.
But initially Suarez, who is in a relationship, had to deal with the myriad thoughts men struggle with when talk turns toward the prostate and sexual and bodily function health.
“Psychologically, it’s a major player. Not only with erectile problems but leakage. You can be on Pampers the rest of your life. There are a lot of things one has to go through psychologically,” Suarez said.
The upshot for Suarez post-surgery? Minimal pain. Four small incisions.
“No side effects. Everything is normal,” Suarez reports. “They recommended Cialis and I took it for a month, but I went off of it and I haven’t had any problems. The only problem, and it’s not based on surgery, is my sex drive is less, but that might be based on hormones or testosterone.”
Suarez’s positive outcome is not unusual, his doctor says.
“He’s a textbook case, one of those guys who was healthy to begin with,” Bhandari said. “He was relatively young to get prostate cancer. They do have short-lived incontinence, but if you take the same person who is 70 or 65 with hypertension, diabetes and they are needing medication to get erections, they don’t do as well. It can take up to a year to get their erections back and even if they do, they would need medications and are less likely to get back to baseline. That’s the main counseling I do.”
Most patients who opt for robotic surgery can go home within a day or two with a catheter to drain the bladder until the sutures heal. The catheter is used for about a week. Normal continence usually resumes for 95 percent of patients within the first six months.
Robotic surgery is the preferred surgery because blood loss is minimized as is the risk of damaging blood vessels and nerve bundles that are responsible for blood flow to the penis. Infrared vision helps guide the surgeon.
“We give a dye to the patient and that dye gets lit by the infrared light so every blood vessel looks green, like rivers, so we can separate out the nerves responsible for erections. That’s why the robot separates the nerves more efficiently,” said Bianco of Doctors Hospital.
“Image-guided surgery is a significant advancement since the 1990s,” Sundararaman said.
And, sorry men, despite what you may have heard, masturbation and frequent sexual activity, a flushing of the pipes as it were, is not likely going to prevent you from developing prostate cancer, Bianco said.
“There’s nothing there, it’s not associated with sexual frequency. There was also the theory that if you have a vasectomy it would increase your risk. This is not true.”
The take-away message: “In 2013, if someone comes in with symptoms we’ve done a disservice somewhere,” Sundararaman said. “Ninety-nine percent of them should have been diagnosed with a PSA.”
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