February 19, 2015 | by Bertram Yuh M.D.
For men walking out of the doctor’s office after a diagnosis of cancer, the reality can hit like a ton of bricks. The words echo: “Prostate cancer” ... “Aggressive prostate cancer.” The initial feelings of grief, denial and anger are mixed with many thoughts: How much time do I have left? What else do I want to accomplish? What about my family, job and retirement plans?
Prostate cancer is the most common cancer in men – and the second-leading cause of cancer death – and a diagnosis of aggressive disease is often life-changing. As a urological oncology expert, I see men face the ups and downs of their diagnosis.
Although slow-growing cancers take decades to cause serious problems, fast-growing, or high-risk, cancer has the potential to quickly spread to other parts of the body. These tumors occur in up to 25 percent of men with prostate cancer, encompassing cancers of high Gleason grade, high levels of prostate specific antigen (PSA) or extremely abnormal prostates on physical exam.
Even if tests indicate that the cancer is only in the prostate, the prospect of cancer spreading or leading to death is anxiety-provoking and intimidating. Once men are able to reach the acceptance phase, the primary question becomes: What are my treatment options?
At City of Hope, our multidisciplinary team manages aggressive prostate cancer and the circumstances in which men need multiple forms of treatment. We not only have a proven track record in surgery for high-risk cancer, we also provide extended lymph node dissection, which offers extremely accurate assessment of the cancer’s spread.
Robotic surgery is currently the most common operation for prostate cancer, and is increasingly being used for aggressive disease. Men should consider this option when making a decision about treatment.
An evolution in treatment
For years, the preferred treatment for high-risk cancers was a combination of radiation and hormone therapy. But with this type of treatment, the grade and stage of cancer is only an estimate, sometimes leading to an underestimation or overestimation of the disease, causing false hope or despair in patients. Surgical treatment for high-risk prostate cancer has not only been shown to be possible, but also safe. In fact, surgical treatment offers several benefits over traditional radiation therapy.
The first benefit is the ability to accurately determine the severity of the cancer. By examining the removed prostate after surgery, doctors can know precisely how far along the cancer is. They can determine whether the cancer is confined to the prostate, growing just outside the prostate or in the lymph nodes – or of higher or lower grade than previously thought – and is vital for patient counseling and determining the prognosis.
The second benefit of surgical treatment is that it can make other therapies unnecessary. The majority of men who choose surgery can avoid hormone therapy treatment, which is associated with many side effects including osteoporosis, decreased sexual drive and erections, hot flashes, fracture risk and potential heart disease. However, up to 50 percent of men with high-risk prostate disease will still need additional therapy at some point after initial treatment.
Third, if men undergo surgery first, radiation therapy afterward is quite safe. When radiation therapy is given first and then surgery after, many men experience significant side effects such as high rates of urinary leakage, erectile dysfunction or abnormal connections between the intestine and bladder.
A fourth advantage of surgery is the significance of an undetectable PSA. PSA is widely used as a marker for remaining or recurring cancer after treatment. After surgery, the PSA is expected to decrease to an undetectable level, which occurs uncommonly after radiation therapy. With an undetectable PSA, any type of increase will be easily detected, leading to earlier intervention and improved outcomes.
Talk with your doctor
The take-home message is that surgical treatment is an effective option for most aggressive prostate cancers, and can be done safely on its own or prior to radiation therapy. Men diagnosed with aggressive prostate cancer should talk with their doctor about the best options for them. A second opinion might also help men understand all possible treatments and their pros and cons.
Cancer is individual; cancer treatment should be, too.
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Learn more about becoming a patient or getting a second opinion by visiting our website or by calling 800-826-HOPE (4673). City of Hope staff will explain what's required for a consult at City of Hope and help you determine, before you come in, whether or not your insurance will pay for the appointment.