Options for treating prostate cancer

Prostate cancer is the second most common malignancy, second only to skin cancer.

More than 240,000 men are diagnosed with the disease every year, translating into one in every six men being affected by prostate cancer. Being diagnosed with cancer usually sets off a cascade of emotions, making patients feel confused, anxious, and at times even hopeless. All too often this is compounded by the challenges of determining a plan to treat ones disease.

Following diagnosis, patients are flooded by information and trying to make sense of the different treatment options can make even the most educated patient uncertain. While the Internet contains many valuable resources, advertisements are often cloaked as educational tools, and patients should be cautious. I believe it is important to be educated regarding ones disease, however going to Google is not always the best first step. Talk with your physician and ask for recommended resources, this provides a much more reliable way to start your education.

Traditionally, for prostate cancer, patients had two main treatment options: surgery or radiation. Based on a patient’s goals, disease state, and health an appropriate treatment plan would be made. However, over the past decade the market place has become flooded with new technologies. Patients are relying less on their physician to make the decision for them and are taking an active role. As newer therapies are introduced, patients are not always equipped to untangle marketing from medical facts.

Robotics is one such technology that has been quickly embraced and adapted to medical therapy. In the case of robotic prostate surgery, the robot builds on concrete oncologic principals. Early on it was shown that removal of cancerous tissue, in this case the prostate, results in improved survival. Robotic surgery increases the magnification and visualization of the surgical field while allowing for precise and intentional movements. As a result, in the hands of a skilled surgeon, the prostate can be removed with greater attention, resulting in improved functional outcomes, decreased blood loss, and a shorter recovery.

In my practice, I developed and employ the SMART-surgery technique. On rounds the morning following surgery, I am greeted by my patients comfortable walking about their rooms and ready to go home that afternoon. Furthermore, our research shows that at one year following surgery 85 percent of patients have erectile function and 96 percent are continent. Less than four percent of patients have any evidence of disease. In reality, the robot is only an instrument, which I have used to refine the same surgery I learned in residency, building on decades of medical evidence.

Robotic radiosurgery, or Cyberknife, is a completely different adaptation of robotic technology. First the name radio-surgery is misleading as this is not actually surgery but rather radiation therapy. In this treatment modality, a computer programmed robot is employed to reposition the radiation beam in order to deliver targeted therapy. Originally, the technology was developed for dynamic tissues, like the lung, which are in constant movement. However, studies have shown that the prostate is susceptible to subtle movement as gas moves through the bowels, and thus there is an argument for robotic targeted therapy.

While radiation therapy has been employed by oncologists for decades, the Cyberknife utilizes a dramatically different dosing regimen called hypofractionation. Traditionally, external radiation is given over approximately 40 treatments; with hypofractionation patients receive less than half the traditional radiation dose in a significantly shorter period of time.

The belief is that as the individual doses are higher, less total radiation is required to have the same oncologic effect, however the science behind this is controversial. This technique was first used in England between the 1960s and 1980s in response to economic factors which motivated the development of a more cost-effective treatment plan. Long-term follow up of these patients demonstrated sub-par survival compared to current treatment expectations. While more contemporary studies have demonstrated comparable outcomes to standard radiation protocols, these studies only provide five year follow-up, with most studies focusing on low risk patients.

As the true benefit of effective prostate cancer treatment can take years to be realized, this period of time is far too short to allow for widespread acceptance of this new technology.

Personally, I advocate for surgical therapy as it is the only treatment that allows for complete removal of the prostate and enclosed cancer. Following surgery, a pathologist examines the prostate and from this report we are able to further define the treatment plan. In radiation therapy this step is not possible as the prostate remains in the body. Furthermore, monitoring after treatment varies between the two. After surgery, ideally the prostate specific antigen (PSA) becomes undetectable and subsequent elevation indicate disease progression. Following radiation this is not the case, the PSA can remain elevated for months and patients are often left waiting to find out whether they have had an appropriate response to treatment. Lastly, for those who have a recurrence, option are much more limited following radiation therapy.

At the end of the day, the patient is the only one who knows what treatment is best in line with their personal goals and beliefs. Discussing treatment options with your general physician can provide an un-bias sounding board, however it is important to recognize that they might not be as up-to-date with the literature as the specialists. Also, when choosing a physician, I recommend asking specific questions about their experience with the procedure as it is the doctors skill, not the technology that they use, that truly will determine outcomes.

Dr. David B. Samadi is the Vice Chairman of the Department of Urology and Chief of Robotics and Minimally Invasive Surgery at the Mount Sinai School of Medicine in New York City. He is a board-certified urologist, specializing in the diagnosis and treatment of urological disease, with a focus on robotic prostate cancer treatments. To learn more please visit his websites RoboticOncology.com and SMART-surgery.com. Find Dr. Samadi on Facebook.