Decision Making Tools for Prostate Cancer
Moritz Hansen, MD
The "good news" about a diagnosis of prostate cancer is that most men have time to do their research and choose the treatment that's best for them. Here are a few tools to help men make their decision.Download podcast (.mp3)
Dr. Moritz Hansen (Guest): Well, there are a range of symptoms extending all the way from no symptoms all the way to significant symptoms when somebody has metastatic disease. Often, patients will be identified with prostate cancer before they have symptoms. That is a group of patients who often have localized disease that has not spread. Symptoms suggesting that it has spread include blood in the urine, urinary difficulties, or even bone pain.
Melanie: There are so many treatment options out there today, with different kinds of radiation and seed and all these terms people hear. Tell us about some of the treatments for prostate cancer that are giving such hope to men that are diagnosed with it.
Dr. Hansen: Again, there are a range of treatments. Starting at the most simple, there are many men who are identified with prostate cancer that is very low risk, and with the appropriate support structure, these men can often be followed with active surveillance where they are closely monitored for progression of disease and then treated when and if that disease progresses. Other men who don’t have low risk—let’s say more intermediary or higher risk disease—are candidates for treatment, and at that point, a decision is often made together with the patient whether to proceed with either surgery, or as you mentioned, radiation therapy, or even there are some treatments that involve freezing of the prostate. This is a difficult process oftentimes for patients to understand the differences between these treatments, the differences in potential side effects, and effect on quality of life. If you start taking the broad view then, surgery is performed either in an open fashion or, more recently, through a less invasive laparoscopic robotic approach, where the prostate is removed as well as the surrounding lymph nodes. Radiation therapy can involve seed placement or external beam treatment or even proton beam treatment. As you mentioned, I think it does become somewhat difficult and there’s not one best treatment for each patient. There has to be a process by which the patient and the physician get together. They really review the options and try to tailor the treatment option that both is best for the patient in terms of available evidence, but also what is best for the patient in terms of their preferences.
Melanie: Dr. Hansen, certainly depending on the diagnosis that a man receives, whether he decides external beam radiation or this implanted seeds, tell us a little bit about what they can expect with some of these treatments. Let’s start with radiation. Is this a simple or is this a long-term kind of procedure for men to go through?
Dr. Hansen: Seed placement is often an outpatient or overnight procedure for the patient and is a one-time treatment. External beam therapy for the prostate is often a daily treatment and can extend out to many weeks to even a month or two. Often, patients who have either seed placement or external beam can experience some fatigue and perhaps need a nap in the afternoon during the treatments. They can also develop irritation to the urinary tract and have urinary urgency or frequency, as well as perhaps some irritation in the area of the rectum. At the completion of the treatment, many of these effects resolve, but again, it can take a month or two or even out towards several months to resolve. Longer term side effects of radiation therapy can also include progressive erectile dysfunction, but that may not be recognized for perhaps a year or two after treatment.
Melanie: What do you tell a man about that, Dr. Hansen? Because I think that for men, they hear that and they hear about it in commercials and all around, and that’s very scary for them. What do you tell them to kind of give them some hope that after treatment, the erectile dysfunction can be dealt with?
Dr. Hansen: Well, I think that is a very important part of the counseling process, and as a urologist, I see men with erectile dysfunction, even who have not had treatment for prostate cancer. They do have a number of options. These range all the way from medications, which can help men achieve erections. I think the most commonly one is something like Viagra and that often is used following the treatment for prostate cancer, either with surgery or radiation, but again, there are a number of options to achieve an erection. I think that the good news for men is that sensation is often, if not the same, and quite similar to prior to treatment and that orgasm is achievable. It is more an issue of achieving erection, and again, there are treatments such as medications. There are injections that can allow men to have a [ridge] erection, and also there are prosthetics that can be placed that can give a man a very natural erection. These are options down the road for men who really are having difficulty with this after treatment.
Melanie: Speak about some of the other treatments that are out there, immunotherapy and you even mentioned freezing prostate tissue. Speak about those, are they new? Are these new advancements something that can help men?
Dr. Hansen: Freezing the prostate, something also called cryosurgery, has been around for probably 20 years or so. The more recent advancements surrounding cryosurgery are that the surrounding tissues are not affected as much as they were in the past. The one thing I will say regarding cryosurgery is that it does have a very high impotence rate and that for men who are sexually active before and hope to maintain that, it may not be the best treatment for them. Oftentimes, cryosurgery is used in patients who have perhaps failed radiation, who cannot get any more radiation to the prostate, and cryosurgery or freezing of the prostate has been shown to be effective in treating those patients. That’s the area where, perhaps, has its greatest utility rather than primary treatment for prostate cancer, though it can also be used as a primary treatment for prostate cancer.
Melanie: What’s on the horizon for men with prostate cancer, something very exciting that you’re reading about or studying about, doing clinical research about?
Dr. Hansen: I think the most exciting thing right now, and this is not just for prostate cancer but I think all cancers, is really trying to identify who we should treat and who we should not treat. These are genetic tests that are becoming available that can profile patients and look at not just their overall health status or projected longevity or perhaps just the stage and grade of the cancer, but really looking at their genetic risk. There are a number of companies that are getting to provide this and I think within the near future, I would say, that these will be the type of risk profiling that is often done in breast cancer and in other cancers where we can try to target and figure out who it is that is at the greatest risk. I think that we certainly are managing more patients with surveillance, but we don’t know perhaps the ones that are going to be progressing. I think genetic profiling will help with that and really treat them earlier. Perhaps there are men that we are treating currently that would have a very low risk for either progression or death from the disease and it may save them treatment. I think these are some things that are the most exciting about what’s coming up in the future.
Melanie: Dr. Hansen, you’ve given us such great decision-making tools for men suffering with prostate cancer and for their loved ones who shove them into the doctor in the first place. In just the last minute, if you would, please tell us why they should come to Maine Medical Center for their urologic care.
Dr. Hansen: Well, thanks again. I think one of the things that we try to do at Maine Medical Center is we utilize what we call clinical prediction models and we also use a clinical navigator model to help patients. What that means is that we are able to use the available risk prediction models that are out there. Some of these are available online, some of them that we have that have been developed here at Maine Medical Center. We can individualize patient’s risk, but then we also have narrowed the process where patients can sit down, use these tools as openers to a conversation and then together with the physician as well as our nurse navigator, who specializes in prostate cancer, have a conversation about how the patient views these risks, what they would prefer, and really have a sort of a holistic and inclusive discussion that involves both the care provider and the patient in deciding what to do.
Melanie: Thank you so much. You’re listening to MMC Radio. For more information, you can go to mainemedicalcenter.org. That’s mainemedicalcenter.org, mmc.org. This is Melanie Cole. Thank you so much for listening.