Genitourinary Cancer – 9
(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Thank you Chiragbhai for several interesting points about treatment of localized prostate cancer. 1. Apart from surgery and radiotherapy, few other options exist for selected cases, most importantly only monitoring (active surveillance without treatment). 2. We also discussed concept of risk categories. 3. Pros and cons of surgery or radiotherapy discussed. Mainly surgery is a short treatment but has risk of incontinence and impotence. Both improve over time in majority, but not all. Risk is lower with newer techniques. 4. Radiotherapy on the other hand requires no hospitalization, can be done in older or sicker patients as well (surgery over age 70-75 generally not preferred). Side effect is short term local issues due to irritation of bladder and bowel, but in long term about 50% develop impotence.
Answer: Right. A lot of research has happened in field of localized prostate cancer. Few other important points worth knowing are:
1. Active surveillance i.e. monitoring without treatment involves PSA every six months, digital examination every year. And most importantly repeated prostate biopsies, initially more frequent such as every year, and then 3-5 yearly. If any major change in Gleason score, PSA or examination, treatment may be required.
2. For early risk categories, treatment is generally either surgery or radiotherapy. However, with increasing risk categories, other treatments may be added. For example, ADT i.e. androgen deprivation therapy is added to radiotherapy for higher risk categories. This is hormonal therapy with a goal of reducing testosterone production, injection given subcutaneous or intramuscular every one to three months. Duration is six months to 2-3 years in various studies and risk categories. Some experts start ADT few months before starting radiotherapy. ADT is generally not added to surgery.
3. In high or very high risk categories, there is now some data from large studies to suggest potential role for even chemotherapy (in addition to ADT) after radiotherapy i.e. Docetaxel. However this is not considered absolute standard of care. Similarly there is also data for adding abiraterone in this setting.
4. Post surgery some patients may need additional radiotherapy, such as those with positive margin, spread outside of prostate, seminal vesicle invasion, lymph node involvement.
5. Some patients have low rising PSA post surgery with no evidence of disease on whole body imaging i.e. no metastatic disease, frequently referred to as biochemical relapse. Such patients are thought to have recurrence in prostatic bed from very small amount of microscopic disease. These patients are also treated with radiotherapy to prostatic bed.
6. NEW Surgical techniques like Robotic surgery have reduced complications somewhat, but main advantage is a shorter hospital stay post surgery, rather than a marked reduction in complications. There is no improvement in cure rate with Robotic surgery.
7. NEW Radiotherapy techniques such as IMRT, IGRT again reduce complications but no major change in cure rates.
Que: It is good to know about so many advances in treatment of localized prostate cancer of various risk categories, and for different age groups or fitness levels. However in India we see a large number of cases diagnosed late, in fourth stage i.e. with metastatic disease. How do you evaluate and treat these patients?
Ans: Agree. Since we don’t have large scale PSA screening, a large number of our patients are not in very early stage. They are detected when they have symptoms, such as with local advance disease or with stage four disease. Most patients in stage 4 present with either symptoms of prostate enlargement and on evaluation found to have bone metastases OR they present with bone pain (frequently severe), weakness, general symptoms and on evaluation diagnosed to have prostate cancer. Initial evaluation is most commonly a PSA, routine blood work, abdominal sonography. A bone scan is added if PSA is very high, such as over 20 or symptoms suggestive of bone spread or high alkaline phosphatase. More recently PET-CT scan has also been used for staging. PSMA PET scan is even more sensitive and uses a special dye that is more sensitive for detection of prostate cancer cells. Most common initial site of spread is bones. Later it can spread to other sites like lymph nodes, liver, lungs etc.
June 9th 2018.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org