Genitourinary Cancer – 7
(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Thank you Chiragbhai for several interesting points about prostate cancer diagnosis and treatment. 1. Biopsy technique is different compared to most cancers, requiring multiple cores from different areas of prostate. 2. Grade derived from multiple areas is known as Gleason score. This score is integral part of making treatment decisions. 3. PSA alone is not sufficient for making diagnosis. Small rise in PSA is frequent in benign prostatic hyperplasia. Very High PSA may be seen in urine infection or prostatitis. 4. Most patients with low PSA, low Gleason score do not need CT/PET scan etc imaging. 5. Treatment decisions are based primarily on stage, Gleason score, and PSA level. Patient choice, comorbidities are additional factors. Chiragbhai, we left discussion at this last point, about confusion in patient’s mind. On one hand you have test i.e. PSA for early diagnosis. On the other hand, medical science tells us that most early stage patients especially older ones can be left without any treatment, as majority will never develop symptomatic or life threatening stage of cancer. and that is why mass screening of asymptomatic men is not a good idea.
Answer: Agree. That is the main learning for us in India, from decades of experience in Western countries. Otherwise we will face the same problem.
Let us continue our discussion related to treatment of early prostate cancer. Options include:
1. Radical prostatectomy (RP)
2. Radiotherapy: a. External beam b. Brachytherapy
3. Other local therapy options: High Intensity Focused Ultrasound (HIFU), Cryosurgical ablation – These are not widely available, not studied on large scale, but can be used in selected cases. For example, HIFU is available in Gujarat and few of my patients underwent this therapy for early prostate cancer, with very old age or major comorbidities. These are patients not suitable for surgery due to age/comorbidities and were not willing for radiotherapy.
4. Active surveillance: for patients with “very low or low risk” prostate cancer, favorable features, and life expectancy less than 10 years in general. Patients with higher life expectancy may also take this option after understanding pros and cons. Also, patients in higher risk category, especially with life expectancy less than 10 years, may choose this option. This option is generally not offered to high risk or very high risk category.
We also need to understand concept of Risk Categories before we discuss more details of above options. Treatment options are generally planned for an individual patient based on their risk category. Broadly there are six categories of localized disease: low, intermediate, high risk (each subdivided in two). Tumors of T1-T2a, Gleason score 6 or less, PSA <10 are in low risk. With increasing stage of tumor, Gleason score and PSA level risk category increases.
Additionally, any regional lymph nodes involved is Seventh category.
Treatment options do overlap, as the risk categories are based on a continuum of risk factors, and experts may differ somewhat.
Que: This makes more sense now. You have already explained about options 3 and 4. How about first two options? How do you choose between them?
Ans: Choosing between Surgery and Radiotherapy has been a long debate. Several review articles and guidelines have discussed this at great length. However, broadly you can conclude following:
1.Both options are essentially equal in terms of cancer control rate.
2.Choice depends on patient to a large extent, as both therapies have distinct advantages and disadvantages. In USA, patients are generally advised to meet both surgeon and radiation oncologist before taking decision.
3.Choice also depends to some extent on other factors. Such as availability of local expertise. Since both treatment are complex and require considerable expertise (and good equipment and team in case of radiotherapy), referring doctor should take this into account first while communicating with patient. Additionally, older age, especially over 70-75 is a relative contraindication for surgery, more so if there are significant comorbidities which increase anesthesia risk.
4.With increasing risk category, radiotherapy preference increases. Such as in high or very high risk category, several experts prefer radiotherapy over surgery. In very early or early stage, Brachytherapy alone is also an option.
April 15th 2018.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org