I have decided (much like the New Years resolution…good luck!) to try and write a somewhat longer post each Friday for the amusement of my 4 readers. So this week, I will take on the issue of “what is best” for eliminating the prostate gland. If you are pressed for time, the bottom line here is that there are lots of techniques that work but the side effects differ. Also, for those with time crunch who want to jump to the “best data”, I recommend this article written a few years back by Dr. Martin Sanda. It is the best current article I know regarding side effects of the most commonly employed treatments: surgery, external beam radiotherapy and brachytherapy.
If you think about it, the idea of getting rid of tissue in your body is relatively simple. Cut it out, or use some energy source to cook or freeze the tissue. That said, I like to point out the old aphorism, “if it wasn’t for bleeding, we’d all be surgeons.” For that matter, one could just inject a very caustic chemical, like clorox, into the tissue. The problem then becomes restricting the approach to the targeted tissue while sparing surrounding tissue. As with any other organ, the prostate lies next to some pretty important normal structures, and this is where the challenge begins. Take a look at this picture series to orient yourself to the nearby critical structures like bladder, rectum, nerves, and bone. Now look at the real thing in this video. Finally, if you want to consider getting rid of the prostate with a radiation beam, look at this image and draw a beam through the prostate from any direction you want, remembering that the radiation will affect every thing in its path.
Since you are probably already very familiar with the standard surgical approaches to losing the prostate (robotic or open surgery) as well as the standard radiation approaches (external beam versus seeds), I will turn to the evaluation of “new techniques” for the remainder of this discussion. I was prompted to do this by several patients who asked about proton beam treatment and one who asked about HIFU this week. One clue: new is not always better.
Proton beam therapy has been around for a long time starting in the 1950’s. The physics of protons are different from photons (light, x-ray, gamma ray, etc) in that they deposit their energy after being “captured” by an atom deep in the tissue. Thus, higher doses of energy can be delivered more accurately to the prostate or other targeted tissue. However, the cost of setting up a cyclotron to generate protons for therapy is huge. There are places in the body (like the neck or brain perhaps) where the better “focus” ability of protons may make a difference. However, since prostate cancer is so prevalent, the centers that are being put in place do everything they can to use proton treatments as a marketing tool. Read this WSJ article for an honest look at what is going on. Just as you are likely reading this blog on a machine with much greater computing power than the one you had 10 years ago, the computers that control “standard” radiation therapy machines have improved to the point that it is not at all clear proton beam therapy offers any advantages. There are no randomized trials suggesting improved outcomes comparing the two techniques. Expert reviews agree with my viewpoint. My bottom line: I would not travel to a proton center to receive proton therapy and I would oppose my university purchasing a proton machine unless it was tied to a huge (expensive) research program devoid of the plan to market our prostate cancer treatment center. In the era of our need to contain costs, this is one issue that the American public should join in opposing. I say restrict these expensive machines to research institutes with proven ability to do outstanding translational radiation physics research.
What about High Intensity Focused Ultrasound (HIFU)? First, it is just another way of delivering energy to the prostate gland. Second, just as 99% of prostate biopsies are done with ultrasound guidance in a urology office, the urologist is the one who might purchase and use this machine. Now suppose you are a patient who has heart disease or other medical problems that might make you not a good surgical candidate. You have a small tumor that may not need to be treated at all. But you want some sort of treatment. What gets set up with this scenario is that a patient might logically believe HIFU is “new and better”, while a urologist or urology center in the U.S. or elsewhere can do something other than “watch and wait” or refer a patient with more aggressive disease to a radiation center. Marketing forces could easily take over medical judgment. In one review article, the authors state, “In conclusion, HIFU as primary therapy for prostate cancer is indicated in older patients (>or=70 years) with T1-T2 N0M0 disease, a Gleason score of <7, a PSA level of <15 ng/mL and a prostate volume of <40 mL. In these patients HIFU achieves short-term cancer control, as shown by a high percentage of negative biopsies and significantly reduced PSA levels.” To which I would say, “did these patients really need any treatment at all?” Although HIFU, like cryotherapy may have an interesting role in salvage treatment after radiation failure, I would not want HIFU if I had a prostate cancer that needed treatment. The standard treatments you already know about have much more data to support them in terms of side effects and long term outcomes. I regard HIFU as another area I would restrict to research only use. (Publish or perish – do not use a fancy machine for marketing).
Lastly for today: Cryotherapy. I guess you could properly think of this as a way of removing energy from the prostate to the point the cells can survive. More simply, if you form ice crystals in a cell, bad things happen. Do it at least 3 times, and the cell will die. At our institution, the most frequent use of this has been in the area of salvage treatment for radiation therapy failure. Here, I think it is an advance over the much more difficult old efforts to remove a radiated prostate gland from the fibrotic tissue that results from modern radiation therapy techniques. In the old days, you could pretty much count on this kind of surgery resulting in 100% impotence and very high rates of incontinence. Now, with the more modern probes, the incontinence rates are much lower, and some patients can be salvaged with much less morbidity (although impotence rates are still nearly 100%). In addition, cryoprobes can be used to treat just part of the prostate, leading to our own institution’s interest in targeted focal therapy. I will deal with this in some future post, but suffice it to say, that you can stick a probe or two into a small tumor in the kidney, liver, or really any organ, freeze the tumor, and it will cure some of the patients. There is an excellent professionally done video of how our institution approaches this put together and posted by Mike Landess. Much research remains to be done in this area. However, as to use of cryotherapy for the initial treatment of the whole prostate gland, I would again stay away from that. My view is that the standard treatments (you already know about) have a better chance of controlling your prostate cancer. If you are not a good candidate for surgery, then I would recommend radiation therapy rather than having a urologist utilize cryotherapy – not enough long term followup data for me to be confident in this approach for “whole gland treatment”.
I hope you have a great weekend, and please feel free to comment and subscribe to this blog if you want it to continue!
prost8blog 
Outstanding piece, Mike – very informative and perfect level of detail. Thank you!
As one of your four readers from the other site I am glad that you are staying with it for our benefit. Thanks
Ray
Dr. Glode,
I think we must be readers #5 and #6! Thank you for taking the time out of your busy schedule to clarify these different treatments, their history, and how they work on the body (good and bad). Thank you also for writing in non-medicalese for those of us who are not medically trained. How you present the information is very clear and understandable. Also just read yesterday’s (March 19) blog, which was also very important reading material for us even at this stage (IV) of the condition. We appreciate this information!
Andrea (Aria) and Barry
Dr. Glode,
I think we must be readers #5 and #6! Thank you for taking the time out of your busy schedule to clarify these different treatments, their history, and how they work on the body (good and bad). Thank you also for writing in non-medicalese for those of us who are not medically trained. How you present the information is very clear and understandable. Also just read yesterday’s (March 19) blog, which was also very important reading material for us even at this stage (IV) of the condition. We appreciate this information!
Dr. Glode,
I think we must be readers #5 and #6! Thank you for taking the time out of your busy schedule to clarify these different treatments, their history, and how they work on the body (good and bad). Thank you also for writing in non-medicalese for those of us who are not medically trained. How you present the information is very clear and understandable. Also just read yesterday’s (March 19) blog, which was also very important reading material for us even at this stage of the condition. We appreciate this information!
Hello Dr. Glode,
My husband has an appointment with you next week. He was referred by Dr. Edward Eigner. He is newly diagnosed with very early stage and hopefully small prostate cancer, and we’re investigating his treatment options.
We’re very interested in the NanoKnife procedure done by Dr. Jaime Wong at the Malizia Clinic in Atlanta. It’s pretty new for prostate cancer, and we’re wondering if you have an opinion on it.
Love your blog and look forward to meeting you next week!
Vickie – as a matter of practice, I never comment on personal issues in the public forum. Thanks for your kind words regarding the blog and I look forward to meeting you. Perhaps I will blog about gamma knife, tomotherapy, nanoknife, etc in a future post. I have been on a panel with Gary Onik who has personal experience with this device as outlined in this article:
http://online.wsj.com/article/SB10001424052748704029304575525832837346848.html
Dr. Glode,
I thought over the last 5 years ,I’d read everything on the internet about prostate cancer. I had seen that article in the WSJ, but I’ve never heard of tomotherapy! I’m burning up the web right now researching it!
If you do decide to write about the nanoknife, there’s a guy in Denver who had it done at the Malizia Clinic. He’s eager to share his experience on it. If you’re interested, I can leave a phone message at your office with his Contact info.
Thank you so much for the time you spent with us today.
Vickie
In regards to proton treatment, your reservations seem to be based on it being more expensive and not more effective than other forms of radiation treatment. These are good points. However, it ignores the question of reduced side effects touted for proton therapy.
As an engineer, I appreciate the benifits of a more readily ‘focused’ (or targeted) energy source, but I have yet to find a peer reviewed comparison (at least, not written by a stake holder). Do you have any articles on proton therapy side effects?
I am unaware of any randomized prospective trials that compare proton beam therapy to conventional photons. The side effect profile for photons is very acceptable in my view using standard IMRT techniques. There is a nice review of the side effect profiles of “modern” surgery, brachytherapy, and IMRT published in the NEJM three years ago. If you look at figure 1 you can see the time course of side effects.
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This is a really great piece. However, I wouldn’t write HIFU off just because it’s new. This treatment has really made some strides, it seems, in the past few years in clinical trials, etc. It is also a really good option if you are older and probably couldn’t handle the physical stress of a surgery and recovery. Don’t forget that everyone with prostate cancer is in a different position, age, PSA score, etc. Plus, if this type of treatment could be refined it would be a really great alternative to traditional surgeries. I have a buddy with prostate cancer and am helping him do some research. Anyone know anything about this- called “Sonatherm”? http://www.prnewswire.com/news-releases/sonacare-medical-to-launch-fda-cleared-sonatherm-hifu-surgical-ablation-system-at-american-urology-association-aua-annual-meeting-205782311.html
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With havin so much content and articles do you ever
run into any issues of plagorism or copyright infringement?
My site has a lot of unique content I’ve either created myself or outsourced but it appears a lot of it is popping it up all over the internet without my agreement. Do you know any techniques to help stop content from being ripped off? I’d
certainly appreciate it.
I have tried to always put in quotes or direct attributes via links. As for copyright issues, I am not sure they apply, but who knows. My suspicion is that there isn’t much risk, since there is no commercial intent, unlike Google which seems to be able to surf the world and bring us “all the news that’s fit to print” – all generated by the entities who actually pay the reporters.
I’m extremely impressed with your writing skills and also with the layout on your blog. Is this a paid theme or did you modify it yourself? Anyway keep up the excellent quality writing, it is rare to see a nice blog like this one these days.
You are very kind. I am happy it is of interest to a few folks out there. The format is stock from WordPress, and I pay for the annual subscription so that I can avoid annoying ads which were the bane of my former blog.
You listed most of the PCa commonly employed treatments: surgery, external beam radiotherapy, Toma Therapy, Proton therapy, brachytherapy etc along with some potential side effects. I think the other 6 readers of your blog would like to see your research on the odds of each treatment as related to possible stopping the spread of PCa cells before they go CTC’s, (Circulating Tumor Cells) and have to spend the next 10 years at attempting to save ones life. Each treatment has “odds” of capturing the PCa cells in the prostate before they escape. Let’s use an average example of a man just diagnosed with PCa , Gleason of 7 and a T-2 score? He has all the treatments available…… What are his odds for ea. treatment for a possible total remission?
Craig
While there are no randomized controlled trials to answer your question, as a general phenomenon, it seems that most approaches have roughly the same chance of curing a patient. The side effect profiles can differ and should be carefully considered and discussed with a physician who has a broad perspective and isn’t wedded to one approach over another in my view. The specifics of odds for progression (psa) free survival can be estimated for each stage of prostate cancer (including the T2/Gleason 7 suggestion) by the Kattan nomograms among others.
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Fantastic post but I was wanting to know if you could write a litte more on this
subject? I’d be very thankful if you could elaborate a little bit
further. Bless you!
Happy to elaborate but need to know which issue you would like to expand
Well, I have been doubting benefits of cryotherapy until I tried it first time. It’s amazing, anyone (of curse pregnant women shouldn’t do that) should try it!
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