Prostate Cancer

Patients with prostate cancer have many options — from watchful waiting to robotic surgery, immunotherapy to physical therapy

 

One out of seven men nationwide will be diagnosed with prostate cancer, though only one out of 36 will die from the disease. Advancements in detection and treatment have improved considerably.

Prostate cancer symptoms

Cancer Treatment Centers of America has identified the following symptoms related to prostate cancer:

Burning or pain during urination.

Difficulty urinating, or trouble starting and stopping flow, or decreased flow or velocity.

More frequent urges to urinate at night.

Loss of bladder control.

Blood in urine or semen.

Erectile dysfunction.

Painful ejaculation.

Swelling in legs or pelvic area.

The ‘21’ study

Can frequent sexual release reduce the risk of prostate cancer? In 1992, a study of 30,000 predominantly white men who did not initially have prostate cancer, led by epidemiologist Michael Leitzmann at Harvard, suggested that men who reported 21 or more ejaculations per month had two-thirds the lifetime risk of prostate cancer compared to men who reported fewer ejaculations (four to seven) per month. Of these men in the the eight-year study, about 1,500 developed prostate cancer.

The debate remains.

Dr. Michael Cusnir, an oncologist with Mount Sinai Medical Center, believes the self-reported study, published in the April 2004 The Journal of the American Medical Association (JAMA), which reported that ejaculation frequency is not related to increased risk for prostate cancer, “appears to be credible.”

Dr. Dipen Parekh, a professor of uroglogy and director of robotic surgery at the University of Miami’s Miller School of Medicine, gives less credence to the study. “There a huge difference between observational and association cause-and-effect.”

HOWARD COHEN


hcohen@MiamiHerald.com

The detection and treatment of prostate cancer is getting high tech.

New sophisticated screenings, better tests for evaluating biopsied tissue and use of MRI-ultrasound fusion to accurately map prostate cancer are the latest advancements in detecting and treating the disease.

“These are the things that are new and exciting,” 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. “If you do get a diagnosis of prostate cancer, if you seek out treatment with the right people, and you are in the right hands, you should expect an excellent future course.”

In addition, robotic-assisted laparoscopic prostatetectomy continues to advance as a surgical tool, along with radiation therapy or brachytherapy, which uses radioactive seeds to kill cancer cells. Still others undergo a radical prostatectomy, the removal of a cancerous prostate and its surrounding tissue.

Pre- and post-surgical pelvic floor physical therapy, a series of exercises under the guidance of a therapist, can also strengthen pelvic areas to end incontinence, said Louise Gleason, a physical therapist with South Miami Hospital’s Pelvic Floor Center.

And, for those for whom prostate cancer has become too advanced and who are not candidates for surgery, Provenge, a restorative treatment of cellular immunotherapy, made from a patient’s own immune cells, can stimulate a patient’s immune system to identify and target prostate cancer cells, thus prolonging life, said Dr. Michael Cusnir, an oncologist at Mount Sinai Medical Center in Miami Beach.

Guidelines

Guidelines for 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 changed since May 2013.

“Instead of every man over 40 getting a PSA (prostate-specific antigen blood test), now it’s more focused on screening for patients with a high risk for prostate cancer, those who have a family history, or who are African American,” said Parekh.

MRI-ultrasound fusion, adopted early by UM’s Sylvester Comprehensive Cancer Center, can result in more accurate prostate biopsies than ultrasound alone or digital rectal exams.

The American Cancer Society recommends that at age 50, men who are at an average risk of prostate cancer have a discussion about the risks and potential benefits of a screening with their doctor.

The screening discussion can start at 45 for men at higher risk of developing prostate cancer, which, according to the American Cancer Society, will impact one out of seven men in the United States — though only one out of 36 will die from the disease. Most older men who have been diagnosed with prostate cancer will die from other causes before succumbing to the cancer.

At-risk men would include African Americans, who have a higher instance of prostate cancer compared with their white and Hispanic counterparts, or men who have an immediate relative such as a father, brother or son who was diagnosed with prostate cancer before age 65.

Those who have had more than one immediate relative with the disease at an early age should begin discussions with their doctors even earlier, at age 40.

Prostate cancer is the second most common cause of cancer death in men, behind lung cancer and ahead of colon cancer.

About 233,000 new cases of prostate cancer will be diagnosed nationwide in 2014, and 29,480 men will eventually die from it, according to the American Cancer Society. The upshot: More than 2.5 million men in the United States who have been diagnosed with prostate cancer at some point — the average age at the time of diagnosis is 66 — are still alive. Active surveillance, or monitoring the disease with doctor and patient working in tandem, can also improve quality of life.

Success story

Jesse Diner, a litigator who lives in Plantation, advocates for PSA testing after he underwent treatment for prostate cancer last summer with Parekh at UM. Diner, 67, lost his father to prostate cancer in 1987. His uncles, on both sides of his family, also had prostate cancer. He has had routine PSA tests for years.

“My attitude is if one person can benefit from early detection, then it is worth it to share my story,” he said. “I consider myself so lucky by being detected early and having great robotic surgery.”

Detection, and treatment, “is not as draconian as it used to be when I think of my father’s diagnoses in the ’80s. Mine wasn’t noticeable from a physical exam,” he said.

In January 2013, after returning home from a visit to Vermont, Diner’s PSA test was high and he went to a local urologist. A second PSA test was not as high as the first but still not where it should have been, he said. A biopsy revealed cancer.

“Given my family history, this was something I didn’t want to fool around with,” Diner said.

Diner did some research, contacted an uncle who teaches at UM, and came into contact with Parekh. “With prostate cancer it’s not something that grows fast so you have an opportunity to check things out.”

Diner and Parekh opted for robotic surgery in July.

Robotic surgery, guided by infrared vision, is preferred 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 that allows a man to achieve an erection. The image-guided surgery is also less traumatic.

Most patients go home within a day or two with a catheter, for about a week, to help drain the bladder until the sutures heal. Normal continence resumes for 95 percent of patients within the first six months.

Diner was back at work in 10 days. No complications. He said he had no need to take the prescribed pain medication.

“Surgery went well, the pathology came back great, everything was contained, it was no place else. They monitor me every three months to make sure everything’s OK. I’m grateful to get this behind me and [regain] my normal life and my work and not miss a beat,” Diner said.

Physical therapy

For patients who need help dealing with issues of incontinence, which can occur before or after prostate cancer surgery, or from an enlarged prostate as a man gets older, therapeutic exercises can be a remedy.

The Pelvic Floor Center at South Miami Hospital focuses on a ring of bones that includes the sacrum at the bottom of the spinal column and the pelvic bone on either side. At the base of that bone structure lies muscles that hang like a hammock from the tailbone to the pubic bone, supporting the pelvis. These muscles are voluntarily controlled, like the biceps or triceps, and are used to control the passage of waste from the body.

“I gear my physical therapy toward the muscles and bones of the pelvis to see if we can help patients restore that function after whatever procedure they have,” Gleason said. “When these muscles are weak, or not working properly, they can’t close that urethra to hold that urine back and that’s where I come in. I assign people exercises based on the strength they already have so as to maximize their improvement,” she said.

In general, it takes about a month before a patient will see real strengthening, Gleason said.

Typical sessions run once a week for about six to eight weeks with home exercises suggested afterward. A simple exercise might go like this: Recline on the floor with knees bent, a hand on the belly, another on a leg. Tighten up around the anal area as if holding back gas. Release and repeat.

“The first goal is to isolate the pelvic floor and be able to recognize when they are using it,” Gleason said. “From there, you can begin to exercise because you are using the correct muscle.”

Still other therapies can utilize electrodes placed on the skin to measure activity in the muscles to train the muscles to contract and strengthen. If the incontinence or sexual dysfunction is muscular related, these exercise combinations can be effective, Gleason said.

Immunotherapy

In some cases, prostate cancer has advanced beyond surgical solutions. Provenge, a therapeutic class of cellular immunotherapies, was first used in South Florida at Mount Sinai Medical Center in 2011 and has been adopted at about 50 other institutions around the country, including at UM. The process is not curative. But this non-surgical alternative to prostate cancer treatment can improve the survival rate of patients for months or years.

Patients’ cells are collected, infused with an antigen that helps activate the patient’s T-cells to help fight the cancer cells, and then placed back into the patient’s body intravenously.

“Almost like a blood transfusion,” explains Mount Sinai’s Cusnir. “We almost train the patient’s own immune system to recognize the cancer cells and fight them on their own.”

The process is repeated three times in two-week intervals.

“We’re still looking for a big change,” Cusnir said about the treatment of prostate cancer, “but at least we keep improving survival.”

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