Aug. 18--An increase in cutting-edge procedures to fight prostate cancer has made curing or managing the disease long-term a lot easier, doctors say.
"Sometimes what we did in 2005 is different from what's available in 2011," said Dr. Arnold Bullock, a urologist with the Center for Advanced Medicine at Barnes-Jewish Hospital. "It means that what we believed for 40 years has changed. Nothing is simply 'This is what we do for prostate cancer,' any longer; we have therapies that are appropriate to the individuals."
The major changes have been in the area of treatment. The surgery no longer leaves men disabled for weeks and sorry they had surgery or treatment, doctors say. The rate of after-effects has diminished to where 80 percent to 90 percent of men can expect to be back to normal after prostate cancer, doctors say.
Dr. Gerald Andriole, director of the Prostate Study Center at Barnes-Jewish Hospital, said doctors have learned better ways to read prostate-specific antigen screening tests.
The test is famous for false positives that lead to unnecessary biopsies.
The new way to do it, said Andriole, is to read the rate of increase in the test results. "So a PSA reading of 10 may not be as important as a PSA that rises from 0.5 to 2.5 very rapidly," he said. The rapid rise may help distinguish a non-cancer problem in the prostate gland from cancer, he said.
That's important because PSA numbers can be affected by prostate problems that aren't cancer, said Dr. Mark Clanton, chief medical officer High Plains Division American Cancer Society in Austin, Texas. "A high PSA can be from an enlarged prostate or something else. Right now, we have no definitive test to detect prostate cancer."
Still, proponents of screenings cite a 2008 statistic from the National Cancer Institute that since the adoption of the test in the early 1990s, deaths from prostate cancer have dropped 37 percent.
The American Cancer Society expects about 250,000 men to be diagnosed with prostate cancer this year and 33,700 men to die from the disease this year.
But in the case of early detection, Bullock said, biopsies that confirm cancer are much kinder.
"We administer anesthetic, we use smaller needles and the results are quite accurate," he said.
Doctors can create a three-dimensional map of a tumor, Andriole said. That has been difficult until recently because cancer tissue and healthy prostate gland tissue are indistinguishable to anyone other than a pathologist. And the ability to map tumors has led to a number of other therapies, including:
Cryosurgery -- Some refer to this as a male lumpectomy. It kills tumors by freezing the inside of the prostate gland. It saves the gland and the patient from the after-effects of surgery such as incontinence and erectile dysfunction.
Con -- It may not get all of the cancer, but practitioners say they get enough that smaller bits can be monitored and removed later.
Robotic surgery -- Removing the prostate gland if the cancer is contained in the gland remains the only therapy that leaves men cancer-free. This adds the precision of a robot guided by a surgeon.
Cons -- Although practitioners tout the DaVinci surgical system as better able to save nerves and blood vessels, and the minimal cutting shortens times for recuperation incontinence and erectile dysfunction, skeptics say they haven't seen the evidence to back up the claims. Still practitioners and skeptics agree the experience and skill of the surgeon is more important than the machine.
Laparoscopic surgery -- Doctor works through a few small punctures, the surgery is less invasive and generally reduces the risk and length of incontinence and erectile dysfunction.
Cons -- Seen as a favorable method by doctors.
Radiation -- New machines can focus radiation beams at the cancer and avoid nearby tissue. Also, doctors can insert radioactive pellets into the prostate gland, reducing the need for regular radiation treatments.
Cons -- Skeptics say the ability to map a cancer is at best in its infancy and the method is oversold; it's still radiation.
Provenge -- This is a new, last-resort vaccine purported to halt and reverse the spread of late-stage cancer, but not in everyone.
Cons -- This argument is more political and moral than medical. The doctors expect to see the debate over is it worth $90,000 or more to prolong a man's life an extra six months?
DEBATE ABOUT PROCEDURES
The cutting-edge developments have opened a debate -- albeit friendly and courteous -- between doctors who are in private practice and those who are in academic research hospitals.
Clanton of the Cancer Society, said private practitioners treat about 70 percent of prostate cancer cases; researchers in academic hospitals treat about 30 percent. Private practitioners tend to be more conservative and cautious.
"We have to feel that these new procedures are safe," Dr. Sameer Siddiqui, a urologist with St. Anthony's Medical Center in south St. Louis County and a practitioner of robotic surgery. "In (many) cases, there's no published evidence about long-term effects."
Even after FDA approval for procedures and new tools, "I want to see these (therapies) 10 years out," said Dr. John Bedwinek,a radiation oncologist with the SSM hospital system in St. Charles County. "We still don't know about the (after-effects) and complications that can arise years after the treatment."
For example, cryosurgery, "Leaves behind (very small) cancer tissues," Bedwinek said. "What happens years down the road? There's no evidence yet."
Bullock disagreed.
"This is evidence-based medicine," Bullock said. "Some men can live with a slow-growing cancer; others want to know it's over and done with."
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