Prostate Cancer

Prostate cancer remains a global health issue representing the most common cancer in men and the second most cause of death related to cancer in the western world. The Prostate Cancer Foundation estimates that one in six men will get prostate cancer (PCa) in their lifetime, and that by 2013 an estimated five million men in America will be battling PCa.[1] However, the progression rate of prostate cancer is slower and as such most men diagnosed with prostate cancer will die from other causes.

In a recent publication of a long-term follow-up of men who chose watchful waiting, the prostate cancer mortality rate was 15 per 1000 person-years during the first 15 years post diagnosis of early stage prostate cancer and beyond 15 years it increased to 44 per 1000 person-years.[2] The low rate of mortality, particularly over the first 15 years, is a prime reason for why the morbidity associated with a treatment along with life expectancy plays a critical role in the choice of treatment for an individual.

The epidemiological surveillance of prostate cancer since the popularity of PSA screening and early detection, along with a longer living population, the large Baby Boomer generation and the fact that the median age of time to diagnosis has gotten younger, has resulted in an increased number of men requiring therapy. In general, men are overwhelmed with the variety of treatment options, but clearly want longer and healthier lives without the inconvenient and sometimes painful side effects of other treatments that previous generations accepted in silence. They are looking for alternatives to radical surgery or radiation. They are demanding more effective minimally invasive treatments with less risk of adverse events that may compromise quality of life.

The wide spread impact of this disease has drawn major attention and controversy to the long list of treatment options. The ideal treatment for localized prostate cancer would be: complete elimination of the prostate, no preoperative complications or blood transfusion, rapid convalescence, and complete recovery of baseline sexual, urinary and bowel function. Achieving all parameters is rare, regardless of treatment.[3] The extent of harmful outcomes depends on the type of treatment and associated collateral damage to surrounding tissues, i.e. (urinary sphincter, neurovascular bundles) and other related morbidity’s. Refinements of radical surgical techniques, as well as other less invasive procedures, such as Cryosurgery or Image Guided Radiotherapy, have had little impact on related morbidity’s. [4]

Nerve Sparing Radical prostatectomy: The gold standard, OVER 25 Years Later
It has now been over 25 years since Patrick Walsh first described nerve sparing radical prostatectomy, a procedure that still remains the gold standard for many urologists and revolutionized how we treat prostate cancer.[5] It was his unprecedented research that paved the way for the preservation of the neurovascular bundle and erectile function. Yet, what was ushered in as the modern era of the ideal treatment for localized prostate cancer has proved to be controversial and is still associated with significant morbidity? Few surgeons have been able to achieve the rate of voiding and erectile function preservation, and often at the expense of higher incidence of positive margins and recurrence.[6] More recent data reflects that many patients who undergo a nerve sparing prostatectomy and have negative margins may still show progression of disease, despite undergoing complete resection of organ confined disease.[7]

Yet, the incidence of recurrence, independent of the status of surgical margins, and after adjusting for PSA, Gleason score, and/or Tumor Volume remains unacceptably high.[8] Therefore, suggesting a more complex interplay of biologic behavior is in place- independent of the surgeon’s skills, and of the status of margin free disease.

Current mainstream PCa treatment options – radical, laparoscopic and robotic surgery, Brachytherapy, external beam radiation, and cryosurgery – have shown no significant differences in long-term outcomes.[9] A large percentage of men diagnosed with PCa will choose no treatment and will opt for a “watchful waiting” or expectant management, an approach that calls for active monitoring of the course of the disease with an expectation to intervene if the cancer progresses.[10] An incredulous decision by cancer victims willing to forgo treatment altogether, and risk progression of disease. The fact is that two separate American Urologic Association (AUA) panels on the “Guidelines for the treatment of localized prostate cancer,” reviewed data dating back to 1989 -reported in 1995, and then again as the most recent 2007 report, have failed to identify optimal treatment.[11]

Common side effects of mainstream PCa treatments include deterioration or compromise of urinary, sexual and bowel functions.[12] The extent of harmful outcome depends on the type of treatment and the damage to tissues other than the prostate gland, i.e., the external sphincter, neurovascular bundles and rectum. The mechanism of injury with surgery is a result of inability to identify and preserve these structures. In the process of cryosurgery there is leaking of Argon gas and lethal freezing of adjacent tissue. With radiotherapy, it is the result of ionizing radiation emitted to intervening and/or surrounding tissue. Furthermore, there is a documented increase incidence of Rectal Cancer associated with radiotherapy of the prostate, in which the most recent study reported a 70 % greater incidence in patients that received radiation versus patients who underwent a prostatectomy.[13] Even with the most recent refinements to radical surgery and radiation therapy have had little effect on the key treatment related morbidity[14]

The fact is there lacks a universal opinion of what is the optimal treatment for localized prostate cancer. however, High Intensity Focus Ultrasound (HIFU) has evolved into and acceptable alternative with comparable clinical outcomes, but with less risks of urinary incontinence, bowel function and erectile dysfunction.

[1] Prostate Cancer Foundation: About Cancer 2007

[2] Bill-Axelson A, Holmberg L, Ruutu M et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N. Engl. J. Med. 352(19), 1977-1984 (2005).

[3] Saranchuk J, Touijer AK, Kattan MW. Et al: Achieving optimal outcomes after radical prostatectomy. J Urol. Suppl. 171:213,807, 2004.

[4] Khoo VS. Radio therapeutic techniques for prostate cancer, dose escalation and brachytherapy. Clin. Oncol. R. Coll. Radiol. 17(7), 560-571 (2005). , Hoznek A, Nenard Y, Salomon L, Abbou CC. Update on Laparoscopic and robotic radical prostatectomy. Curr. Opin. Urol. 15(3), 173-180 (2005).

[5] Walsh PC, Partin AW, and Epstein JI: Cancer control and quality of life following anatomical radical retro pubic prostatectomy: results at 10 years. J Urol 152: 1831-1836, 1994.

[6] Augustin H, Hammerer P, Greafen M, et al: Intraoperative and preoperative morbidity of contemporary radical prostatectomy in a consecutive series of 1243 patients: results of a single center between 1999 and 2002. Eur Urol 43: 113-118, 2003.

[7] Wieger JA and Soloway: Incidence, etiology, location, prevention and treatment of positive surgical margins after radical prostatectomy for prostate cancer. J. Urol, 100:299, 1998. Ward JF, Zinck H, Bergstralh ET, Slezak JM et al. The impact of surgical approach (nerve bundle preservation versus wide local extension) on surgical margins and biochemical resources following radical prostatectomy. J Urol.172:1328, 2004

[8] Cheng L, Daron MF, Bergstralh EJ, et al. Correlations of margin status and extra prostatic extension with progressions of prostate carcinoma. Cancer, 86:1775, 1999.Lerner SE, Blute ML, Bergstralh, et al. Analyisand risk factors for progression in patients with pathologic confined prostate cancers after radical prostatectomy. Jurol 156; 157.1996. Kassabian US, Bothles K, Weaver R et al. Possible mechanism for seedind tumors during radical prostatectomy. J Urol 150:1169, 1993.

[9] 10th Conference on Clinical Practice Guidelines and Outcomes Data in Oncology: National Comprehensive Cancer Network 2005.

[10] Bill-Axelson A, Holmberg L, Ruutu M et al. Radical prostatectomy versus watchful waiting in early prostate cancer.

[11] AUA Best Practice Guidelines available @

[12] Steinbeck G, Helgesen F, Adolfsson J et al. Quality of life after radical prostatectomy or watchful waiting. N. Engl. J. Med. 347(11), 790-796 (2002). Penson DF, McLerran D, Feng Z et al. 5-year urinary and sexual outcomes after radical prostatectomy: results from the prostate cancer outcomes study. J. Urol. 173(5), 1701-1705 (2005)

[13] Baxter NN, Tepper JE, Durham SB, et al. Increased risk of rectal cancer after radiation: a population-based study. Gastroenterology, 2005; 128:819-824

[14] Khoo VS. Radiotherapeutic techniques for prostate cancer, dose escalation and brachytherapy. Clin. Oncol. R. Coll. Radiol. Hoznek A, Nenard Y, Salomon L, Abbou CC. Update on Laparoscopic and robotic radical prostatectomy.