By Tom Mullaney
It seems inconceivable that a small, walnut-sized gland lying just below the bladder could be the vicious killer of about 28,000 American men this year. Yet, that is the devastating toll inflicted by prostate cancer.
Until quite recently, urologists had a limited, unreliable arsenal to screen for the disease, namely the prostate-specific antigen blood test (PSA) and a digital rectal exam. Speaking with a number of medical urologists and urologic surgeons at leading Chicago facilities, Chicago Health learned how new, promising research and treatment options are offering better diagnostic and surgical outcomes.
The PSA is not a diagnostic test, but simply a blood test that is prone to false positive readings. PSA levels are correlated with risk of prostate cancer. There are not reliable normal or abnormal levels, and patients are often faced with a diagnostic gray zone. In these situations, urologists have struggled with whether to recommend biopsies.
“If a man is diagnosed with prostate cancer, many management options exist, which can range from active surveillance to surgery to radiation to androgen deprivation (hormonal therapy) or a combination of treatments,” says Scott Eggener, MD, co-director of the Prostate Cancer Program at University of Chicago Medicine and president of the Chicago Urological Society. “Today, new tests, such as the 4K Score (OPKO) and Prostate Health Index (PHI), Polaris and Oncotype, have been shown to outperform the traditional PSA test. Multiple published articles have shown these tests to more reliably identify high-grade prostate cancers on biopsy while minimizing the total number of men requiring a biopsy. They’re giving doctors a better assessment of risk.”
Eggener says that improved diagnostics can now help physicians reduce the number of biopsies doctors perform and offer a more tailored approach for men diagnosed with prostate cancer. For many of these men, active surveillance is an attractive option since many small cancers neither grow rapidly nor escape the prostate wall and can be closely monitored over time without resorting, as before, to radiation or surgery.
When a biopsy is warranted, physicians typically insert a needle through the rectum and probe 12 areas of the prostate. Yet, this method often misses hidden tumors, resulting in undertreatment. A 12-core biopsy only samples 1 percent of the prostate surface, according to Gopal Gupta, MD, prostate cancer surgeon at Loyola University Health System.
A new technology, UroNav, is giving urologic oncologists higher precision and detection capabilities for prostate biopsies. The software fuses images from MRIs with ultrasound to create a three-dimensional view of the prostate. Ultrasound determines the prostate’s size while the MRI guides the biopsy needle via GPS-style technology to lesions it has detected. This improves tumor detection and the degree of aggressiveness—vital biomarkers that guide better treatment options.
This technology is allowing surgeons to achieve a more targeted biopsy, says Gupta. Loyola was the first medical center in Illinois to install this new technology that now can be found in other major hospitals. Gupta says the new technology is “the hottest topic of discussion and excitement at medical conferences.” The goal is to detect even more microscopic tumors that previously went undiscovered.
Should all of the available information suggest that the cancer has not escaped the prostate wall nor entered the patient’s lymph nodes and/or bones, new treatment options can be considered. Eggener practices a procedure titled Focal Therapy (focal laser ablation), which pairs MRI with a pinpoint laser to ablate—vaporize—a prostate’s cancerous cells using high heat.
In surgery, urologists are turning to robotic surgery with its minimally invasive incisions and faster recovery times. Vishal Bhalani, MD, a urologic surgeon and chair of the Robotics Steering Committee at Weiss Memorial Hospital, has performed close to 200 operations with the da Vinci Surgery robotic platform.
Joe Murphy, a business owner from Aurora, was referred to Bhalani last summer. He showed none of the normal prostate symptoms, yet his PSA test score was quite high. The biopsy revealed a prostate, not walnut-sized, but as big as an orange. “I was shocked when they told me,” Murphy says.
Murphy says Bhalani made five small cuts in his abdomen. The robot was used to remove the prostate and reconnect the bladder to the urethra. Murphy left the hospital two-and-a-half days after surgery and is amazed at his rapid recovery.
“I couldn’t lift anything for a week. [Bhalani] took the [catheter] out a week later, and then I could do pretty much anything. I drove my car and went to the store. I just couldn’t do any heavy lifting for three weeks,” Murphy says. He has had three blood tests over the past nine months; all have shown no sign of any cancerous activity. He praised his surgeon’s “incredible patience” with all his concerns.
Bhalani is excited by current prostate cancer research focusing on lifestyle (smoking and exercise) and nutrition. Eggener heads a clinical trial based on these factors for the National Cancer Institute, further exploring whether dietary modifications (more fruits and vegetables, less red meat) can slow the growth of this silent but deadly cancer.
As long as physicians continue improving their approaches to prostate cancer faster than the cancer can grow and spread, the future of prostate health is looking good.