Prostate Cancer: Exploring the Options for Treatment

Steve Clinton

Approximately 180,000 American men will receive a new diagnosis of prostate cancer in the coming year, according to the National Cancer Institute (NCI).

Many of these men, particularly those diagnosed with early-stage prostate cancer, will be faced with a difficult decision: Should I opt for active surveillance, or elect to have my cancer treated with surgery (a radical prostatectomy), radiation, cryotherapy, hormone therapy, or a combination of more than one of these options?

“I wish I could do a consult for every man diagnosed with prostate cancer, but obviously I can’t,” said Steven K. Clinton, MD, PhD, Director of Prostate and Genitourinary Oncology at The Ohio State University Comprehensive Cancer Center – James Cancer Hospital and Solove Research Institute (OSUCCC – James).

Here’s what Dr. Clinton and his team tell the thousands of prostate cancer patients they see at the OSUCCC – James Multidisciplinary Prostate Cancer Clinic:

“Throughout history, and until more recent years, it was deeply ingrained in the minds of doctors and patients that if you have a cancer diagnosis, the goal is to immediately eliminate the cancer, through radiation, surgery or drugs,” Dr. Clinton said. “It’s a mindset hard to change.”

This mindset led many to opt for surgery or radiation to eliminate their prostate cancer. However, there can be risks associated with these treatments, including urinary incontinence and erectile dysfunction, as well as other injuries to the bladder and rectum.

The introduction of the prostate-specific antigen (PSA) test more than two decades ago has led to earlier diagnosis of prostate cancer, often while it is still localized and has not metastasized and spread to other parts of the body, “which has improved our opportunity to cure the disease in many men,” Dr. Clinton said. “But, we now are fully aware that we also detect many cancers that we believe are more indolent and may not warrant aggressive therapy.” 

Advancements in molecular testing of biopsy samples enable physicians to detect — along with traditional biopsies — not just the prostate cancers that are aggressive and potentially lethal, but also the slower-growing and more indolent types of prostate cancer.

“The dilemma is there are no perfect tests that can precisely define the difference between the more aggressive prostate cancers that warrant treatment immediately and the cancers that, if left alone, may never bother the patient,” Dr. Clinton said. Research at the OSUCCC – James and other national cancer centers is leading to advances in identifying the novel biomarkers that differentiate more aggressive forms of prostate cancer from less aggressive forms.

What is Active Surveillance?

“It’s a term that should be in capital letters,” Dr. Clinton said. “And it’s not sending the patient home and waiting for something to happen. It requires careful monitoring.”

Active surveillance at the OSUCCC – James utilizes PSA tests and digital rectal exams (DREs) three or four times a year. Dr. Clinton and the team of urologists also have patients undergo a second biopsy within a year of their first biopsy “to eliminate the possibility of what we call a sampling error, which is missing something that would impact your treatment decision.”

For many men, active surveillance works well particularly if the exams provide good results, but men get anxious when they come in for their regular PSA and DRE tests.

“Many men initially like the idea, but as the months go on they become anxious, and it impacts the quality of their lives and may at some point change their minds about active surveillance,” Dr. Clinton said. “Other men are able to compartmentalize the cancer in their mind and not worry too much, which is why communication and education are so important.”

Some of the factors that determine whether active surveillance or treatment is warranted include the age of the patient and an estimate of their overall health and lifespan. Prostate cancer occurs more frequently with aging, with the average age at the time of diagnosis being 65. About 26,000 patients died from prostate cancer in 2016, according to the NCI, making it the second most common cause of cancer death in men, behind lung cancer. Yet more than 2 million men are living with the disease today in therapy and monitoring.

“If the patient is older, has other health issues and may not live more than a few years, we’d lean toward active surveillance,” Dr. Clinton said. “If the patient is younger and healthy and has decades to live, you may be more aggressive in your recommendation.”

Again, Dr. Clinton cautions that there is no magic formula to determine the course of treatment for prostate cancers that physicians believe are non-aggressive and slow growing.

“You’re weighing what the cancer looks like on the biopsy, the changes in PSA, and the digital rectal exam of the prostate, integrated with imaging and new molecular tools that are being developed. The situation during active surveillance may change over time,” Dr. Clinton said. “And you balance that with the health and life expectancy of the patient … and how important is sexual function and bladder leakage and what are their major anxieties about the treatments for prostate cancer.”

Research indicates that for many decades too many men with indolent forms of prostate cancer were having surgery and other forms of treatment that result in acute and potentially long lasting side effects.

The bottom line is there is no routine cancer and there are no “one size fits all” answers to treatment.

“I think that every man newly diagnosed with prostate cancer should seek a second opinion and have more than one set of eyes review their case and help them make a decision on what to do,” Dr. Clinton said.

Every patient should spend a significant amount of time with their medical team to learn about and understand their cancer and their range of treatment options.

“It’s up to each physician working with their patient to make this assessment,” Dr. Clinton explained.

The OSUCCC – James Multidisciplinary Prostate Cancer Clinic provides the expertise needed to help patients decide how to proceed.

“We hold the clinic every Wednesday,” Dr. Clinton said. “Patients newly diagnosed with prostate cancer will see a medical oncologist, a urologist, a radiation therapy specialist, everyone they need to see, all in one day. And we have the pathology from their biopsy and specialized prostate pathologists at Ohio State review the case.”

If you have been diagnosed with prostate cancer and would like a second opinion or to speak with a prostate cancer specialist at the OSUCCC – James Multidisciplinary Prostate Cancer Clinic, please call The James Line at 800-293-5066 or 614-293-5066 to make an appointment.

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