About Prostate Cancer
Prostate cancer is a disease in which malignant (cancer) cells form in the tissues of the prostate. The prostate is a gland in the male reproductive system located just below the bladder and in front of the rectum. It is about the size of a walnut and surrounds the urethra (the tube that empties urine from the bladder). The prostate gland produces fluid that is one of the components of semen. 1
Prostate cancer is among the most common cancers diagnosed in men. In the US, one in six men will be diagnosed in his lifetimes. 2 While no one will say facing prostate cancer is easy, the good news is with increased awareness and screening, more men are diagnosed early. That means most cancers are found while still localized in the prostate before the cancer has spread.
Prostate cancer is the most common non-skin malignancy in men 3 and is responsible for more deaths than any other cancer, except for lung cancer. However, microscopic evidence of prostate cancer is found during autopsies in many if not most men. The American Cancer Society (ACS) estimated that about 186,320 new cases of prostate cancer were diagnosed in the United States during 2008. About 1 man in 6 will be diagnosed with prostate cancer during his lifetime, but only 1 man in 34 will die of it. A little over 1.8 million men in the United States are survivors of prostate cancer. 4
Prognosis & Treatment
Treatment options and prognosis depend on the stage of the cancer, the Gleason score 5 , and the patient’s age and general health. With greater public awareness, early detection is on the rise and mortality rates are declining. Additionally, new advances in medical technology are enabling cancer patients to return to active and productive lives after their treatment.
When prostate cancer is believed to be localized, there are five common treatment options available to a patient:
Removal of the cancerous prostate (radical prostatectomy)
Radiation of the cancerous prostate, through either external
radiation or radioactive seed implants (radiation therapy or brachytherapy, respectively)
Freezing of the cancerous prostate (cryotherapy)
Hormonal therapy, which is non-curative and often done in conjunction with radiation therapy or cryotherapy
Observation (watchful waiting )
1. Surgery to Remove Prostate Cancer
For localized prostate cancer, radical prostatectomy (removal of the prostate gland and some tissue around it) is considered the definitive way to treat the cancer, by removing it. An estimated 91% of prostate cancer cases diagnosed in the U.S. are localized, which means many men are potential candidates for cancer removal. But, patients should discuss the advantages and disadvantages of each treatment approach with their doctor.
Surgically removing the cancerous prostate lets your doctor see how aggressive the tumor is and whether it has spread. This step can be critical since 35% of tumors are under-graded to a clinically significant extent. That means the cancer is more aggressive than the pre-surgery assessment and biopsy results indicated. 8
Choosing surgery over radiation can make it easier for your doctor to detect a cancer recurrence, through careful PSA monitoring, after a radical prostatectomy than after radiation therapy. 9 It can also help preserve your options if your cancer should return. After radiation therapy, there may be damage to the tissue surrounding the prostate. If you have tissue damage, nerve-sparing surgery may no longer be an option if your cancer returns. But, radiation usually remains an option for patients who have had surgical treatment of their prostate cancer. 10
With any cancer treatment, the first priority is survival. Several large studies suggest there is a greater chance of long-term survival for patients undergoing surgery over other potential treatments. Patients undergoing radical prostatectomy had a 40% lower risk of death from prostate cancer than radiation patients 15 years after treatment. 11 (According to a study of 3,159 men adjusted for age at diagnosis, race, socioeconomic status, Gleason score, biopsy grade of tumor and year of diagnosis.)
da Vinci Prostatectomy
da Vinci Prostatectomy is the #1 choice for treatment of localized prostate cancer in the United States.
Thanks to a breakthrough surgical technology, surgeons now widely offer a minimally invasive option for prostatectomy, the da Vinci Prostatectomy.
Imagine major surgery performed through the smallest of incisions. Imagine having the benefits of a definitive treatment but with the potential for significantly less pain, a shorter hospital stay, faster return to normal daily activities – as well as the potential for better clinical outcomes.
In prostate cancer treatment, millimeters matter. Nerve fibers and blood vessels are attached to the prostate gland. To spare these nerves, they must be delicately and precisely separated from the prostate before its removal. Surgeons use the precision, vision and control provided by da Vinci to assist them in removal of the cancerous prostate while preserving important nerves and blood vessels.
In terms of cancer control, in several large published studies, da Vinci Prostatectomy has shown equal or lower rates of positive surgical margins (meaning margins with cancer cells left behind) than large studies of other forms of surgery.
Urinary continence and sexual function after treatment are also of concern for prostate cancer patients. Studies show patients who undergo a da Vinci Prostatectomy may experience a faster return of urinary continence following surgery and lower rates of urinary pain than radiation (brachytherapy) patients. Several studies also show patients who are potent prior to surgery recover their sexual function (defined as an erection for intercourse) within a year following da Vinci Surgery. Talk to your surgeon about reasonable expectations for recovery of sexual function and a rehabilitation program that may include exercises and drug therapy.
It is important to know that da Vinci Surgery does not place a robot at the controls; your surgeon is always in control of every aspect of the surgery with the assistance of the da Vinci robotic surgical system platform.
Radiation therapy uses high-energy x-rays, either beamed from a machine or emitted by radioactive seeds implanted in the prostate, to kill cancer cells. When prostate cancer is localized, radiation therapy serves as an alternative to surgery. External beam radiation therapy is also commonly used to treat men with regional disease, whose cancers have spread too widely in the pelvis to be removed surgically, but who have no evidence of spreading to the lymph nodes. In men with advanced disease, radiation therapy can help to shrink tumors and relieve pain.
It is important to be aware that radiation can cause long-term damage to the nerves and important structures involved in sexual function. Many patients undergoing brachytherapy or external beam radiation treatment develop erectile dysfunction (as many as 50% in several studies.) 12, 13 Many radiation patients are also placed on hormone therapy, which has an immediate negative impact on sexual function.
3. Freezing the Cancer Prostate (Cryotherapy)
Cryosurgery uses liquid nitrogen to freeze and kill prostate cancer cells. The doctor places needles in preselected locations in the prostate gland. The needle tracks are dilated for the thin metal cryo probes to be inserted through the skin of the perineum into the prostate. Liquid nitrogen in the cryo probes forms an ice ball that freezes the prostate cancer cells; as the cells thaw, they rupture. The procedure takes about 2 hours, requires anesthesia (either general or spinal), and requires 1 or 2 days in the hospital. 14
4. Hormonal Therapy
Hormonal therapy combats prostate cancer by cutting off the supply of male hormones (androgens) such as testosterone that encourage prostate cancer growth. Hormonal control can be achieved by surgery to remove the testicles (the main source of testosterone) or by drugs.
Hormonal therapy targets cancer that has spread beyond the prostate gland and is thus beyond the reach of local treatments such as surgery or radiation therapy. Hormonal therapy is also helpful in alleviating the painful and distressing symptoms of advanced disease. Further, it is being investigated as a way to arrest cancer before it has a chance to metastasize. Although hormonal therapy cannot cure, it will usually shrink or halt the advance of disease, often for years. 15
5. Watchful Waiting
Watchful waiting refers to closely monitoring a patient’s condition without giving any treatment until symptoms appear or change. This is usually used in older men with other medical problems and early-stage disease. Watchful waiting is based on the premise that localized prostate cancers may advance so slowly that they are unlikely to cause men—especially older men—any problems during their lifetimes. 17 Some men who opt for watchful waiting, also known as “observation” or “surveillance,” have no active treatment unless symptoms appear. They are often asked to schedule regular medical checkups and to report any new symptoms to the doctor immediately.
Experimental / Out-of-Country Treatments
When faced with serious illness, many people explore alternative or experimental treatment options with the goal of easing their symptoms and controlling or eliminating the disease.
A treatment option for prostate cancer currently available outside the United States is High-Intensity Focused Ultrasound (HIFU). HIFU treatment uses the principle of ultrasound energy to destroy cancer cells. To treat prostate cancer, t he energy is delivered to the patient using a transrectal probe under general or regional anesthesia. Current studies show HIFU has significant complication rates and failure rates in effectively treating cancer in both initial and recurrent prostate cancer cases. As a result, some leading urologists have suspended their use of HIFU pending further evidence of its safety and effectiveness. 16
“General Information about Prostate Cancer,” National Cancer Institute, www.cancer.gov .
“Prostate Cancer: Guideline for the Management of Clinically Localized Prostate Cancer”:2007 Update. American
“ What are the Key Statistics About Prostate Cancer?,” National Cancer Institute, www.cancer.gov .
American Cancer Society 2008 Cancer Facts and Figures
“The Prostate Cancer Outcomes Study: Fact Sheet,” National Cancer Institute, www.cancer.gov .
Gleason score: A system of grading prostate cancer tissue based on how it looks under a microscope. Gleason scores range from 2 to 10 and indicate how likely it is that a tumor will spread.. National Cancer Institute, http://www.cancer.gov
Prostate Cancer Clinical Guideline Update Panel. Guideline for the management of clinically localized prostate cancer: 2007 update. Linthicum (MD): American Urological Association Education and Research, Inc.; 2007. 82 p.
King CR, Patterns of Prostate Cancer Biopsy Grading: Trends and Clinical Implications. Int J. Cancer (Radiat. Oncol. Invest): 90,305-311(2000).
Di Blasio, C. J., A. C. Rhee, et al. Predicting clinical end points: treatment nomograms in prostate cancer. Semin Oncol. 2005; 30(5):567-86.
Carlucci JR, Nabizada-Pace F, Samadi DB. Organ-confined prostate cancer and the emergence of robotic prostatectomy: What primary care physicians and geriatricians need to know. Geriatrics. 2009; 64(2):8-14.
Tewari A, Raman JD, Chang P, Rao S, Divine G, Menon M.Long-term survival probability in men with clinically localized prostate cancer treated either conservatively or with definitive treatment (radiotherapy or radical prostatectomy). Urology. 2006 Dec; 68(6):1268-74.
Zelefsky M, Chan H, Hunt M, Yamada Y, Shippy A, Amols H. Long-term outcome of high dose intensity modulated radiation therapy for patients with clinically localized prostate cancer. journal of urology.2006; 176 (4): 1415-1419
Merrick G. Erectile function after prostate brachytherapy. Int J Radiat Oncol Biol Phys. 2005 Jun; 62(2): 437-47
“Detailed Guide: Prostate Cancer – Cryosurgery,” American Cancer Society, . URL: http://www.cancer.org/docroot/CRI/content/CRI_2_4_4x_Cryosurgery_36.asp?rnav=cri
“Hormone (Androgen Deprivation) Therapy,” American Cancer Society, . URL: http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_Androgen_Suppression_Hormone_Therapy_36.asp
Benjamin J. Challacombe, Declan G. Murphy, Rhana Zakri and Declan J. Cahill, The Urology Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK, Accepted for publication 21 October 2008
“Prostate Cancer Treatment: Treatment Option Overview,” National Cancer Institute, . URL: http://www.cancer.gov/cancertopics/pdq/treatment/prostate/Patient/page4
While clinical studies support the effectiveness of the da Vinci® System when used in minimally invasive surgery, individual results may vary. Surgery with the da Vinci Surgical System may not be appropriate for every individual. Always ask your doctor about all treatment options, as well as their risks and benefits.