Prostate Cancer: Treatment of Prostate Cancer, Part I

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Guest: Thomas E. Keane – Urology

Host: Dr. Linda Austin – Psychiatry

Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. Thomas E. Keane, who is Professor and Chairman of the Urology at MUSC. Dr. Keane, we have been talking about the diagnosis of prostate cancer. Let’s move on now and talk about the treatment of prostate cancer. I would imagine that depends on how serious the case appears to be, is that correct?

Dr. Thomas E. Keane: That’s correct and there are some options, which are most suitable for localized prostate cancer and there are other options, which are suitable for advance disease. One of the biggest problems that we have in the management of prostate cancer is staging that disease accurately. Typically, when patients first get a diagnosis of prostate cancer, all they hear is the word cancer and the next 25 to 50 minutes conversation passes straight over their head and they end up at the end of the interview when the physician thinks, he has done a great job in education, but the patient hasn’t listened to a word that is said because they have been so stunned by this diagnosis that you really need to get them back at second time and go over everything. Now, there are five options for the treatment of prostate cancer. If there was one that was better than all the rest, there would be only one option for the treatment of prostate cancer, but there are five. So, we need to get that straight at the start. In terms of the options, you have observation, which is now called active observation; you have radical surgery, radiation therapy, freezing, and hormones.

Dr. Linda Austin: So, let’s take those one at a time. In what situation would you use active observation?

Dr. Thomas E. Keane: Active observation is typically most suitable for a man, who has significant comorbidities, meaning he has other illnesses, which are likely to take him away just as quickly as the prostate cancers are. There is also the elderly patient, who if he lives 10 years will be doing very well. There is also the patient who makes the decision that he is not prepared to put at risk his quality of life or his life by having the other treatments and he chooses to see how things go in terms of his prostate cancer. This is all dependent upon the aggressiveness of the prostate cancer that he has. For instance, if you have a Gleason VI (3+3) prostate cancer, which is the kind most commonly diagnosed with a PSA below 10, your chances of dying of prostate cancer in the next 15 to 20 years is approximately 20% to 25%. So, you have to weigh that risk again somebody, who comes and say 300 pounds in weight, smoking three packs of cigarettes a day, having had two MIs already, and continuing in that lifestyle then my advice to that patient would be don’t waste your time treating your prostate cancer because you are going to be dead before you know.

Dr. Linda Austin: I believe you said the second option was radical surgery.

Dr. Thomas E. Keane: And again, yes. Radical surgery is certainly an option, but also has its prime candidates and then patients, who may not be so suitable. If you are over 70 years of age, you probably may not have to have the surgery. Number one, you have a limited life expectancy left over 70, although most people who are over 70 would disagree with me over saying that. Nonetheless, if you get 15 years, you are doing well and if you get 20, you are doing very well. In terms of the surgery, the mortality from a radical prostatectomy is 0.2%. So, it is unlikely that the operation is going to kill you. It is also likely that hopefully if it’s done confidently and that you didn’t have too aggressive disease that we can cure the prostate cancer. So, you may ask why not do surgery on everybody? Well, the reason is quality of life. Your potency and continence are certainly at risk when you have a radical prostatectomy. Again, it depends on age. In our hands here at MUSC, if you are under 65 years of age and you are potent before the operation, you have about a 70% chance of remaining potent with the use of 5-phosphodiesterases inhibitor such as Viagra, or Levitra, or Cialis. Now, it may take up to 3 to 5 months for your potency to return and a lot of men will tell you they are potent before the operation when in fact they are not.

Dr. Linda Austin: So, you need to ask their wives?

Dr. Thomas E. Keane: You need to make sure the wife is sitting about a foot behind and just look at her when you ask that question because that’s where the truth will come from. The second thing to say about this is that removing the prostate is not going to make your potency any better. So, if you are already having some trouble then the chances are, you will have trouble afterwards, but it’s most important that the patient understand, being impotent purely means that you cannot generate a spontaneous erection. It does not mean you cannot generate an erection, it does not mean you can never be intermittent, and it does not mean you can never have intercourse. It means, you will have to do something to produce that erection and as men age, many of them still with an intact prostate have the same problem and use a means to achieve an erection. So, a lot of the concerns that people have about loss of potency are due to a lack of understanding of what it actually means. The second biggest problem is incontinence and that’s leakage of urine. It’s the fact that if you cough or sneeze, you may squirt a bit of urine. That can happen; it happens to men who still have the prostates in place. Most men will find that if they use a small pad that takes care of the problem. Again, with our own results from MUSC, 90% of our patients at two years are fully 05:15 and the last 300 patients, we had 30 patients who had some continence difficulties; two of those patients required a second operation to make them dry. We had information out of the other 28, around 22 of those patients and 17 of them used just one pad a day, which is frequently not wet. So, in answer to your question about surgery, yes, it is certainly an option for a lot of men. There are some complications or quality of life issues, which if they are addressed upfront can be dealt with very efficiently and the patients need to be reassured that what’s important when they decide on a surgical approach is not necessarily a mechanism by which the prostate is taken out meaning, is it robotic, is it laparoscopic, is it retropubic, or is it perineal because all of those options are available. What’s important is the experience of the surgeon and the number of operations they do? Because basically today, there has been really no difference shown in the outcomes depending on which approach you use. So, whatever your surgeon is most familiar and most effective with, is the option you should have.

Dr. Linda Austin: We have three more methods to talk about. Let’s talk about those in a separate Podcast. Thanks a lot Dr. Keane.

Dr. Thomas E. Keane:You are welcome.

Dr. Linda Austin: If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection at 1-843-792-1414

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