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How Has Imaging Impacted Treatment?

Shore_001Dr. Neal Shore comments on this month’s discussion of the ways imaging has impacted prostate cancer treatment.

Imaging is important for newly diagnosed prostate cancer patients who may or may not have localized disease, and it’s especially important for advanced prostate cancer patients, whether they continue to be androgen sensitive or have developed some level of androgen resistance. For earlier stages of disease, there has been a lot of interest regarding multiparametric MRI. Nonetheless, the efficacy of multiparametric MRI is limited by the expertise of the interpreting radiologist. The fusion technology software championed by several of the academic centers has been rolled out without consistency within the community. For some practices, it was adopted due to marketplace competition and the device developers’ promotions. Companies that develop multiparametric fusion technology have not made a significant contribution to the advancement of urologic and radiologic educational needs. That said, some groups incorporated dedicated specialists within their practice to train for high-quality multiparametric fusion-based biopsies. Purchasing the newest promising technology without ensuring a framework to optimize clinical results will lead to poor implementation. In the United States, MRI is still mostly recommended for patients who have had a negative prostate biopsy, but due to age, PSA kinetics, or rectal examination, there is still a concern of possible malignant disease that was missed on the first biopsy. MRI is most uniformly accepted for additional information when evaluating patients for the need for a second biopsy. MRI will no doubt have an ongoing role in the active surveillance population. MRI will no doubt have an eventual role in decision making for possible first biopsies.

 

There has been a lot of very good, evidence-based literature coming from European countries that suggests that whole-body MRI, with the right software protocol, is exceptionally helpful in evaluating metastatic disease. Unfortunately, in the United States, this protocol takes 45 to 60 minutes to accomplish, and unfortunately, translates to a challenging economic utility model for the MRI efficiency from an administrator perspective. There are many interesting and promising blood-, tissue, and urine-based markers, genomic assays, and additional imaging techniques, which require ongoing trials to determine how best to use them for the most efficient value-based care model. No single test—MRI or any other blood-, tissue-, or urine-based marker—is perfect. Eventually, we will hopefully develop a cost-effective algorithm that combines a panel of all the different biomarkers. MRI is part of that discussion, but we don’t have that sorted out currently. There have been multiple PET scan technologies developed in the last several years that have been assessed for improved potential sensitivity and specificity, and ultimately, to improve the accuracy of the data that shows cancer spread and its location. MRI and Axumin PET scanshave been approved for advanced prostate cancer patients. There have been other PET scans such as FDG, C-11 Acetate, C-11 Choline, sodium fluoride, which have not received widespread reimbursement approvals nor widespread accessibility. There is also no consensus recommendation for these technologies.


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Living With Erectile Dysfunction After Prostate Cancer

Tim M. had a Gleason 9 prostate cancer removed by his urologist. He spoke with Prostatepedia about his struggles with ED posttreatment.

How did you find out you had prostate cancer?

Tim M: I had the typical issues that people talk about: urination and a PSA that was increasing a little bit. I had a phenomenal general practitioner, a doctor who really cared. He wanted me to do a biopsy. I was resistant. I said, “Oh, come on, Doc. This must be an infection or something.” Unfortunately, I resisted for about six or seven months, maybe even longer.

Finally, he said, “No, you’ve got to go for the biopsy.” So I went to a top doctor in my area. He did a check and said, “I don’t really think there’s going to be a problem, but let’s do the biopsy.” So I did it. He called and said he was surprised to say that I had aggressive cancer.

What kinds of treatment did you have?

Tim M: I really didn’t have much of a choice. My doctor said I needed surgery right away. He was a leading surgeon with a phenomenal reputation. I had the surgery two years ago.

Did the urologist talk to you before surgery about the potential for erectile dysfunction (ED) after treatment?

Tim M: Not really. He did not really touch on it. We asked him about it at one of the interviews. If we hadn’t asked him, I don’t think he would have really talked about it. I’ll never forget his answer. He said it was 50/50 whether or not I’d get ED.

What happened after the surgery?

Tim M: The surgeon completely removed the prostate. The cancer had gotten out of the capsule, but he thought he got it all because my margins were clean. I was very lucky. He was comfortable that we had it all. I didn’t have any problems with urination. The catheter clogged up one time, which was actually one of my biggest fears, believe it or not.

The catheter?

Tim M: When I was about 17, I went to see a friend who was in the hospital. He had a catheter and he explained to me what they had done to him. It left a burning impression in my mind. There’s a tube where? That kind of stuck with me. That was one of my concerns. I did have some issues with the catheter, but after that, everything was fine except for the erectile dysfunction.

Can you talk a bit about that?

Tim M: Nothing seems to really work anymore.

Have you been able to talk to your urologist about it?

Tim M: He gave me some pills—Cialis (tadalafil) and the other pills. It didn’t help. Then he said to try the injections, which seemed to help a little bit, but not really. He wanted me to increase the dose, but I really didn’t want to do that because of all the warnings: if something goes wrong, get to a hospital right away. The whole deal with the needle and the possibilities of side effects put a damper on things.

Did you talk to him about any other options?

Tim M: He went through all the options with me, including the vacuum and an implant and none of them seemed too attractive to me.

How do you feel about all that?

Tim M: Pretty bad. But you know, as you get older, you begin to accept things a little bit more. I guess you have to. I wasn’t happy about the cancer to begin with. All I can do is do what I can do.

I just turned 70 this month. I also have some cardiovascular issues. I go to the gym. I try to do what I have to do to keep conditions under control as best I can.

My doctor called me at 8:30 the night of my diagnosis and said, “I have to tell you you’ve got an aggressive cancer. It has to come out right away.” There was no light discussion. It’s not like I had a choice. If I had let it go, I would have died.

He was so focused on your cancer that he wasn’t really even thinking about potential ED?

Tim M: Yes, I believe so. That was the priority.

Did you have any problems with incontinence after the surgery?

Tim M: A little bit. I still wear pads, but I barely need them. I just got used to them.

He had suggested that I do Kegel exercises. But it’s weird. Because of my cardio situation, I wind up going to the gym and working like a fool for hours a week, but I just couldn’t get into those exercises. The pads were just too convenient, but that’s pretty much dried up at this point. The only time I have a problem is with stress if I’m exercising or something like that.

Do you have any advice for other men about to have prostate cancer treatment?

Tim M: You have to do what you have to do and deal with what you have to deal with. What you have to deal with might not be too good. There is nothing good about it in my view. My advice is to consider that ED is going to be an issue.

Do you think that more men are suffering from ED than surgeons think?

Tim M: Yes. I do absolutely think that. I’ll tell you something else. It’s a little bit sensitive to talk about, but I’ll just come out and say it. How do you define erectile dysfunction? You know what I’m saying? There are different levels of an erection. Obviously, when you are younger, it’s one way. My question is, where is the threshold? What if you end up with a three-quarter situation? My doctor told me 50% of men have ED, but of the other 50% what in the hell was the quality of what they had left?

Was the erection like what they had before or was it just enough so that they could use it?

Tim M: Yeah, just enough to use. I mean if you’re not going to be able to perform to some degree of quality, why bother?

Also, there’s a secondary problem, which is a psychological issue. When you ejaculate, there’s nothing there.

That must be a bit demoralizing.

Tim M: That was very demoralizing. Some people say, “What’s the difference?” There is a difference. It’s a mental thing. To tell you the truth, my first thought was: “Have I become like a woman? Is this an orgasm that a woman would have?” The physical aspect is not the big thing. It’s how you’re interpreting it and what’s going on inside your mind that’s the major thing.

It changes the whole experience.

Tim M: Thank God this didn’t happen when I was in my forties.

It might be worth going to see an expert in ED.

Tim M: Well, I know all the possibilities. It’s the shots. It’s the vacuum. It’s the operations.

From age 15 to 68, it was all just a natural happening. And now, you’re talking about mechanisms and devices and shots and operations and you have to push a button?

It sort of takes you out of the moment.

Tim M: It puts a whole different perspective on the deal. Men should definitely be prepared for what’s going to happen. I do think more information needs to be out there.

The more men know about what may happen the better they can prepare themselves?

Tim M: Yes. I think where doctors make a mistake, at least in everything I’ve seen and read and everything that the doctor has said to me, is that this is not a binary A or B thing. Do you have ED or don’t you? It’s not like that. It’s more like: do you have no dysfunction or do you have some? Is it the same as before or not? That’s important. My guess is that the vast majority of guys are going to say no.


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Surgery For Metastatic and High-Risk PCa

Edward Schaeffer, MD, PhD, Urology

Edward Schaeffer, MD, PhD, Urology

Dr. Edward Schaeffer is the Chair of the departments of Urology a Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital.

In July, Prostatepedia spoke with him about the advances in urology. Subscribe to read the entire conversation.

What are the current thoughts on the role of surgery for recurrent oligometastatic disease? [Oligometastatic disease means you only have three to five metastatic lesions outside of the prostate gland.]

Dr. Edward Schaeffer: Many surgeons and patients are enthusiastic about aggressively treating oligometastatic prostate cancer. I’m also enthusiastic about the possibility that this approach could help patients. But I think it is very important for patients reading this interview to understand that these kinds of studies are totally experimental; we do not know yet if these approaches will benefit men. Although I’m personally enthusiastic about these kinds of approaches—and am the principal investigator on a study exploring this called the TED trial. (TED stands for Trimodal Elimination of Disease and uses surgery, radiation, and systemic [chemo-hormonal] therapy to eliminate all visible evidence of prostate cancer.) However, I really only recommend that the average patient seek treatment for their oligometastatic or recurrent prostate cancer in the setting of a clinical trial. This is really experimental. We don’t know if it helps and it may actually hurt people—this is why it needs to be done as a trial.

Is there any controversy over surgically treating the primary tumor when a man’s cancer has already spread outside the prostate gland?

Dr. Schaeffer: No, I don’t think there is any controversy in that. If you mean is there controversy in over-treating the prostate if a man has ogliometastatic disease, then yes, that is controversial. But in my mind, surgery benefits most men with large bulky high-grade cancers. Radiation is less effective in those cases.

In the last three to four years in my practice, I’ve seen more and more men with more advanced high-grade bulky cancers. I believe, although this hasn’t been shown in a randomized clinical trial, that the best way to manage these cancers is the way we manage many other cancers: a multimodal approach of surgery followed by radiation and potentially chemotherapy.

Why do you think more and more people are being diagnosed with bulky high-grade disease?

Dr. Schaeffer: Several reasons. One, the United States Preventive Services Task Force (USPSTF) changed their recommendations in 2008 for men over 75 and in 2012 for men under 75 for PSA screening. It’s well documented that there have been relaxations in PSA screening and that relaxations in PSA screening have resulted in fewer biopsies.

Think about the natural history of prostate cancer: if you had an aggressive localized cancer and left it alone for five to seven years, it would come back as a bulky aggressive cancer most probably involving the lymph nodes or beyond.

And that is exactly what we’ve seen. Dr. Jim Hu published that exact observation in JAMA Oncology in December 2016. Unfortunately, we’ve now proved that what we thought would happen did in fact happen. The screening recommendations are not to the benefit of the patient. Fortunately, the USPSTF recently revised their recommendations and now suggest that PSA screening is something that physicians should bring up and discuss with their patients. This is a big step in the right direction.


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Advances in Urology

Edward Schaeffer, MD, PhD, Urology

 

 

Dr. Edward Schaeffer is the Chair of the departments of Urology a Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital.

In July, Prostatepedia spoke with him about the advances in urology. Subscribe to read the entire conversation.

 

What are the current points of controversy in the world of prostate cancer surgery—both for men who have been newly diagnosed and for those facing recurrence?

Dr. Schaeffer: Surgery for prostate cancer remains the gold standard, the best way to c

ure the disease. It is also the oldest treatment. Prostate cancer surgery was first performed in 1904; it’s withstood the test of time.

The big hurdle for prostate cancer surgery has always been maintaining its outstanding cure rates while continuing to minimize postsurgical toxicity and side effects.

The operation has certainly evolved over the last 30 years. Dr. Patrick Walsh at Johns Hopkins University was my mentor. He perfected the open radical prostatectomy. Many Johns Hopkins alumni have now brought minimally invasive laparoscopic robotic prostatectomy online.

Today, for almost all cases, the laparoscopic robotic prostatectomy offers a state-of-the-art approach. Still, it is important for a man considering surgery for prostate cancer to find the most experienced surgeon he can. Ultimately, experience trumps approach.

You need to find a surgeon you like, because you’re going to have your surgeon for the rest of your life.

You need someone who has enough experience to give you a good outcome. Patients ask, “Should I come to you?” I say, “I’m confident I can help you, but we need to have a great relationship as I’m going to take care of you for the next 30 years…”

Is there a learning curve for robotic prostate cancer surgery?

Dr. Schaeffer: There is a learning curve to prostate surgery, period. Prostate surgery is incredibly complex. In an average surgeon’s hands, it is a four-hour operation. The surgery requires an intense knowledge base. It’s difficult whether you choose an open approach or a laparoscopic robotic approach.

I believe there are some subtle things about a robotic approach that an experienced surgeon can translate into better outcomes for patients. Ultimately, an open operation is not that different from a laparoscopic approach. But, yes, there is a very steep learning curve to robotic prostatectomy.

My other general philosophy is that I don’t consider myself to be a technician—a robotic surgeon. Rather, I proudly consider myself to be a physician who takes care of men with prostate cancer. One of my skillsets is that I’m able to perform prostate cancer surgery well. I do both open and laparoscopic approaches in my practice, though I favor the robotic approach. Ultimately, though, I consider myself to be an expert in prostate cancer who offers patients a good understanding of which treatment approach may be right for them. That may be surgery or radiation or surveillance.

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