SURVIVING
PROSTATE CANCER
WITHOUT SURGERY

Introduction by Don Kaltenbach

If you are reading this book, chances are that you or someone in your life has been diagnosed with prostate cancer. The first thing you should know is that the situation is not as dire as it might seem. There is no reason for panic. Because this form of cancer is usually slow-growing, you have time to learn about the disease and fully assess your treatment options. The good news is that there are a number of effective treatments available and most men can now survive prostate cancer without having to undergo major surgery.

As a prostate cancer survivor and as director of one of the country’s premier institutions for prostate cancer research and treatment, I encourage patients to work closely with their doctors and to learn all they can before deciding on treatment. Since I was treated in 1990, dramatic progress has been made in diagnosing and curing the disease. In fact, this field of medicine has changed so rapidly that most books on the subject, even those published within the past few years, are woefully out of date. This is partly due to the fact that most books about prostate cancer have been written primarily from a surgical perspective. By contrast, the authors of this book are all involved with state-of-the-art radiation therapy, which according to the most recent Medicare data, has now surpassed surgery as the mainstream treatment of choice.

Why the trend away from surgery? The PSA blood test has transformed the entire field of prostate cancer research by enabling doctors not only to diagnose the disease earlier, but to more accurately determine the cure rates for each type of treatment. Back in the 1990’s, most men with early stage prostate cancer were advised to have their prostates removed by the surgical procedure known as radical prostatectomy. At that time, surgery was considered the “gold standard” treatment. But more recently, the majority of patients have been choosing to avoid the knife, opting instead for sophisticated forms of radiation therapy, such as radioactive seed implants or brachytherapy (pronounced brăk-ē-therapy) and Intensity Modulated Radiation Therapy (IMRT). These combined therapies are proving superior both in terms of cure rates and preserving quality of life.

Over the past decade, I have had a special interest in seeding because this was the form of treatment that I chose for myself when it was still investigational, before ten and twelve year studies demonstrated its advantages over surgery.
The purpose of this book is to provide you with the most reliable and up to date information to guide you from diagnosis to recovery. Before making any decisions about treatment, you should fully investigate the pros and cons of each form of therapy -- the likelihood of cure and the risk of long-term side effects that may alter your quality of life. Taking into account your age, your overall health, and the extent of the cancer, you will want to find a balance between treatment effectiveness and side effects – a balance with which you are comfortable, that you can live with both before and after treatment. Regardless of which type of therapy you may decide is right for you, knowing what to expect is one of the keys to fighting this disease.

You should also be aware from the outset that doctors continue to disagree about which treatment is best and whether treatment is necessary. There are many conflicting viewpoints and many misconceptions that find their way into the media. Therefore, it is often wise to obtain second opinions from one or more specialists within the field. Like all of us, doctors have biases. They tend to recommend what they know how to do: urologists tend to recommend surgery; radiation oncologists tend to favor radiation. If you have received advice from a surgeon, then you should do yourself the favor of seeking an opinion from a radiation oncologist, and vice versa. Each of these specialists will be better able to explain how and why he does what he does. The data and quality of life issues, however, will ultimately speak for themselves as you do your own research and compare the results for each type of treatment for which you may be eligible. This book will emphasize radiation as the newly emergent gold standard therapy and give you additional guidance as you make your way through what can sometimes seem like a bewildering maze of options.

Treating prostate cancer successfully requires the combined efforts of doctors, nurses and patients, and each of those three essential points of view will be offered in the pages ahead. The authors are experienced healthcare professionals associated with the Dattoli Cancer Center in Sarasota, Florida. The three of us, each working from a different vantage, are dedicated to the treatment of prostate cancer. Dr. Michael Dattoli is one of the country’s leading radiation oncologists and brachytherapists, with numerous published studies to his credit and one of the highest cure rates in the field. In the first part of the book, he will explain his cutting edge approach to diagnosis and treatment, offering the same practical advice he gives to his own patients. Jennifer Cash is an Advanced Registered Nurse Practitioner (ARNP) who specializes in the care of prostate cancer patients who receive radiation therapy. In the second part of the book, she will explain in common sense terms how you can prepare yourself for treatment and what you can anticipate after being treated.

As a former patient, I can tell you that in addition to the physical side of the disease, prostate cancer is an emotional journey. The prospect of having to cope with any life-threatening disease can be harrowing. It is not just the medical tests and wading through statistics. Prostate cancer affects us on the deepest gut levels. Developing a positive mental outlook can make a world of difference in the long run. While every individual case is unique, there are challenging aspects of this disease that all of us experience. I will discuss these areas in the third part of this book, from the vantage of my having already made the passage and lived through what you are likely to be going through.

As a lawyer, I also want to make you aware of your rights as a patient. Our shared goal with this book is to help you make informed decisions about your treatment. Don’t delegate that decision to someone else. After all, it’s your body and your health that are at stake. As you gather information, always consider the source and use your own judgment about your needs. You will know best what is right for you.

Don’t be afraid to voice your concerns to your doctor and don’t hesitate to ask questions – you have every right to know the answers and to expect a standard of care with which you are satisfied. It is my dearest hope that those of us who have made this journey before you can help you find your way more readily, that the path will be easier for you, and your destination all the more sure.

TABLE OF CONTENTS

Introduction by Don Kaltenbach

Part One by Michael Dattoli, M.D.
The Non-Surgical Approach to Diagnosis and Treatment

Chapter 1: The Basics of Prostate Cancer
Chapter 2: The Diagnostic Tests for Prostate Cancer
Chapter 3: Considerations Prior to Treatment
Chapter 4: Treatment Options
Chapter 5: Radical Surgery
Chapter 6: Radiation Therapy
Chapter 7: Cryosurgery
Chapter 8: Treating Metastatic Disease

Part Two by Don Kaltenbach
The Patient’s Point of View

Chapter 9: One Patient’s Journey
Chapter 10:The Emotional Burden of Prostate Cancer
Chapter 11: The Financial Side of Prostate Cancer

Part Three by Jennifer Cash, ARNP, MS, OCN®
Post-treatment Care and Lifestyle Changes

Chapter 12: Coping with Side Effects
Chapter 13: Diet and Nutrition Guidelines

Appendix A: Where To Get Help
Appendix B: Glossary of Medical Terms
Appendix C: Questions To Ask Your Doctor
Appendix D: References
Appendix E: Charting Your Progress



PART ONE BY MICHAEL J. DATTOLI, M.D.

THE NON-SURGICAL APPROACH TO DIAGNOSIS AND TREATMENT

The entire field of prostate cancer diagnosis and treatment has undergone a revolution during the past few decades, in part brought about by widespread screening with the PSA blood test, which has allowed for earlier diagnosis of the disease. We have also seen dramatic technological progress in each of the medical specialties that are involved in the field. All of these changes have improved the prognosis for most patients regardless of their age and the stage of their cancers.

Recent advances in the delivery of high energy photons, ultrasound imaging, and computerized treatment planning have essentially turned the tide against what was previously thought to be a disease most effectively treated by means of radical surgery. At this time, an overview of prostate cancer care and treatment from a non-surgical perspective, as presented in this book, is crucial for every patient wishing to receive the highest standard of care. The discussion that follows is intended to provide the latest data and essential knowledge to prepare patients to make fully informed decisions about their treatment options with their doctors.

EXCERPTS FROM CHAPTERS 5 AND 6: RADIATION VS. SURGERY

Why is surgery no longer the treatment of choice for most patients?

Historically, radical prostatectomy was for many years the primary treatment for early stage prostate cancer and most urologists regarded it as the "gold standard" treatment (and most still hang on to that belief despite data to the contrary). Since urologists are the specialists who see most prostate cancer patients after diagnosis, it is not surprising that they recommend their specialty and that in the past most patients chose the surgical option. That situation has changed in recent years with advances in alternative, non-surgical treatments such as radiation therapy. With more men being diagnosed earlier thanks to PSA screening and patients doing more research prior to embarking on a treatment course, the number of radical prostatectomies has fallen dramatically since the early 1990s. That trend is likely to continue as more patients opt for non-surgical treatments with comparable or superior cure rates and a lower risk of complications.

What cure rates have been reported by the premier surgeons?

When comparing radical surgery with other treatment options in the PSA era, findings have been consistent when grouping patients in low, intermediate and high risk categories. With a follow-up of ten years or longer, prostatectomy appears to be effective in 80% to 90% of patients, as reported by teams from the leading specialty centers, but this success rate applies only to patients with low risk, favorable tumors (PSA < 10, Gleason score = 6, clinical stage T2a or less).

With intermediate and high risk patients (PSA greater than 10, Gleason 7 to 10, clinical state equal to or greater than T2b), the data shows that these patients have a high risk for biochemical failure after radical prostatectomy. Indeed, it is with the higher risk groups that the results obtained with surgery have deteriorated to the point of being woefully unacceptable. The lack of any plateau in the disease-free survival curves of surgery patients with a pre-treatment PSA above 10 and/or a Gleason score of 7 or higher is especially striking coming from a leading institution like Johns Hopkins (see Figures 8-9). Note that these researchers defined biochemical disease-free survival after surgery as having an undetectable PSA.

Figure 8: Likelihood of biochemical failure (rising PSA) by pre-operative serum PSA (Khan MA, Partin AW, The Oncologist, Vol. 8, No. 3, 259-269, June 2003). Data derived from the series by Dr. Patrick Walsh, Johns Hopkins Hospital, 1982-2001 (Figures 8-9).

Figure 9: The likelihood of biochemical failure (rising PSA) by pre-operative biopsy Gleason score (A) and by pathologic Gleason score (B).


What misleading arguments are used to promote surgery?

While legitimate arguments can be made for and against each type of treatment, a number of misleading arguments are often made in favor of the use of surgery over radiation. The common sense notion of "cutting the cancer out" is used to imply that a radical prostatectomy is the most effective therapy. But the fact is that 50% or more of patients with intermediate or high risk cancers will fail after surgery.

Another argument often used to promote surgery over radiation is the assertion that if a patient undergoes radiation and it fails, then surgery as a salvage treatment will not be an option. In fact, this is not the case. Many experienced surgeons will perform a prostatectomy at this point, albeit the operation is more difficult, as tissue that has been irradiated becomes more fragile. Depending on the institution reporting, between 10% and 50% of these patients can be cured by a salvage prostatectomy. Complications such as incontinence and erectile dysfunction increase somewhat, and the surgeons appear to be far more willing to disclose these complications which they can attribute to the radiation. Complication rates are relatively high according to a National Cancer Institute investigation of patients treated primarily with radical surgery (without receiving radiation), although the surgeons appear to be less forthcoming in this regard.

Treatment options for patients who have failed radiation are actually quite numerous. In addition to a salvage prostatectomy, they may include salvage brachytherapy, Intensity Modulated Radiation Therapy and brachytherapy (combined), and cryosurgery (all of which are discussed in greater detail below). It is the flip side of the coin that is actually more troublesome - the patient who has had surgery and fails. At this point, it is often unclear whether the PSA is rising due to local recurrence, or distant relapse (which may be microscopic and not detected by bone scans, CT scans, MRI, etc.) or both. In this situation, only salvage radiation is an option for potential cure, and recent studies demonstrate that only 10% to 30% of patients can be successfully salvaged (rescued).

Why are more patients choosing to combine seed implants with IMRT?

Over the past decade I have seen the pendulum swing dramatically from patients in the past who strongly desired to undergo seed implantations alone to more recent patients who desire the combination method of IMRT and brachytherapy. This trend is probably due to a number of factors. These days many patients do extensive research and find that there is always a real risk of having extracapsular disease extension, which is more effectively treated by integrating seed implants with IMRT (or 3D-CRT). Many patients now understand that with IMRT they are afforded the added security of covering possible extracapsular extension while experiencing little to no additional side effects.

What is the likelihood of cure with brachytherapy and IMRT?

The 10-year and 12-year cure rates for brachytherapy or combination therapy using brachytherapy and external radiation (3D-CRT or IMRT) are as good as or better than results achieved with other treatment modalities, including surgical removal of the prostate. Freedom from biochemical failure is typically 90% or higher for low risk patients receiving brachytherapy, while even high risk patients may enjoy an approximate 80% freedom from biochemical failure when brachytherapy is combined with external radiation.

The criteria used at my institution for biochemical disease-free survival is quite rigorous. Only patients who achieve and maintain a PSA nadir of 0.2 or less are considered disease-free. After seed implants and external radiation, the prostate is left in place and any remaining normal prostate cells will secrete PSA, so there will be a certain baseline PSA level. I have patients with PSA levels as high as 3.0 that over time have never shown any PSA velocity. Their PSA readings have been stable and not rising for a decade or more; however, when using strict criteria, they are technically not cured, even though most of these patients will probably never have symptoms or die from prostate cancer. As such, the actual cure rate may be somewhat higher than that reported.

How do brachytherapy and IMRT compare with surgery?

As discussed earlier, treatments can be compared in terms of cure rates and complication rates by evaluating the results obtained at premier medical centers for each treatment specialty. For low risk patients, brachytherapy with or without supplemental IMRT (or 3D-CRT) appears to be comparable to surgery as far as likelihood of cure, but with less risk of serious, long-term complications. For intermediate and high risk patients, a number of recent studies have shown brachytherapy and supplemental IMRT (or 3D-CRT) to be significantly more effective at curing prostate cancer than surgery (Figures 12-13).

Figure 12: Biochemical disease free survival (bNED) for prostatectomy (Pound et al) and brachytherapy published studies (Blasko et al, Merrick et al), with patients stratified by pretreatment PSA level (J of Brachy Int., Vol. 17, July-Sept. 2001, 193).

Figure 13: Biochemical disease-free survival (bNED) for prostatectomy (Pound et al) and brachytherapy published studies (Blasko et al, Merrick et al) with patients stratified by Gleason scores of at least 5 (J of Brachy Int., Vol. 17, July-Sept. 2001, 193).

The results of my own published studies are consistent with those reported by the brachytherapy teams described above, showing a similar plateau in the disease-free curve (Figure 14). My personal series dates from 1991 with Pd-103 seed implantation and supplemental external radiation, utilizing 3D-CRT and more recently IMRT for the treatment of intermediate and high risk patients. The overall actuarial freedom from biochemical failure at 10 years was 79% in patients having locally advanced, high risk prostate cancer. That number is actually improving to more than 80% with patients who have now been followed for 12 years or more. Meanwhile, morbidity has been limited to temporary urinary symptoms, similar to those that occur with seed implants alone.

A note of caution should be added with regard to seed implants as monotherapy. Back in the 1990's, intermediate risk patients were commonly treated with seeds alone, and now we are seeing a small percentage of these patients experiencing biochemical failure beyond 8 years. This would indicate that the combined approach of seed implants with supplemental external radiation is a more effective protocol for patients at the intermediate risk level.

Our success with higher risk patients is indicative of an important area where brachytherapy and IMRT offer significant advantages over surgery. From a surgical perspective, it's very difficult if not impossible to cure stage T3 malignancies, and it's very difficult to cure patients having Gleason scores in the 7 to 10 range and PSA's greater than 10. But we have had a very successful run using external radiation for about four to five weeks, and then adding the implant boost using Pd-103 brachytherapy about four weeks later. This integrated approach has been able to cure some cancers which were formerly deemed to be incurable with surgery or any other treatment option.

Figure 14: Biochemical disease-free survival at 10 years as indicated by PSA = 0.2 for 161 intermediate and high risk patients treated with brachytherapy and external radiation (Dattoli et al, Cancer, Vol. 97, 2003).

As mentioned, even patients who have evidence of lymph node involvement are now being treated. This group of patients is also treated with hormonal agents. Combined hormone blockade is followed by IMRT to target not only the prostate but also the periprostatic tissues and the lymph node bearing sites. Then finally the seeds are implanted where most of the tumor volume is, namely in the prostate itself. Having treated patients with lymph node cancer successfully, we are moving up the ladder in terms of the stage of the disease that can be conquered.

EXCERPT FROM CHAPTER 1:

THE BASICS OF PROSTATE CANCER

What is prostate cancer?

Prostate cancer (PCa) is the most commonly diagnosed cancer in men. Since the advent of screening with the PSA blood test in the late 1980’s, prostate cancer has been diagnosed more frequently, reaching epidemic proportions during the last decade. It is second only to lung cancer as a leading cause of cancer death in the male population. That grim statistic, however, is likely to change as the disease is increasingly diagnosed earlier when it is more treatable.

Where is the prostate gland located and what is its function?

The prostate is a walnut-size gland located at the bottom of the pelvis, just beneath the bladder and in front of the rectum (see Figure 2). Found only in men, the prostate gland surrounds an inch-long segment of the urethra, the channel through which urine exits the bladder and passes out of the body. The primary function of the prostate is to produce some of the seminal fluid, which flows into the urethra at the time of orgasm. The fluid allows for nourishment and transport of the sperm at ejaculation. The seminal vesicles are two sac-like structures that are attached to the back of the prostate and produce additional seminal fluid that passes through the gland.

The prostate gland contains many hundreds of tiny passageways lined with cells that produce seminal fluid. Normally, these lining cells reproduce slowly, at about the same rate that cells die. But with cancer, some of these cells become abnormal and reproduce at an uncontrollable rate. Although several other cell types are found in the prostate, more than 99% of prostate cancers develop from the glandular cells. The medical term for cancer that starts in glandular cells like these is adenocarcinoma. Over time, the build-up of cancerous cells in the gland produces a lump or “tumor.” Not all tumors are cancerous. Benign tumors can be caused by infections, bruising and other nonmalignant medical conditions.

It should be noted that prostate cancer is not contagious. Nor can it be sexually transmitted. Because prostate cancer grows so slowly, it often causes no symptoms in the early stages. When symptoms do occur, they usually take the form of difficult or frequent urination, a slow or weak urine stream and/or urination during the night (nocturia). These same symptoms, however, are more often caused by an overgrowth of normal prostate tissue that commonly occurs with aging. This non-cancerous condition is known as benign prostatic hypertrophy, or BPH.

Although many men with BPH never experience serious problems due to the condition, with sufficient time, symptoms will begin to manifest. As the prostate gland enlarges, BPH tissue may constrict the urethra. There are a variety of medications that can be used to treat the symptoms of BPH. These include alpha blockers like Hytrin® and Flomax®, and other agents such as Proscar® and Avodart®. With advanced BPH, surgery may be necessary. The most common surgical approach to BPH is called a transurethral resection of the prostate (TURP). For this procedure, the surgeon uses an instrument called a resectoscope to remove excess BPH tissue. In some cases when the prostate gland is very enlarged due to BPH, an open surgical procedure known as a simple prostatectomy may be performed. Other treatment methods take advantage of the fact that heat (thermopathy) eradicates benign cells (e.g. the indigo laser or theTargis™ microwave system).

How Common is Prostate Cancer?

According to the American Cancer Society, more than 230,000 men will be diagnosed with prostate cancer in 2004, and approximately 29,900 men will die from the disease. 1 out of 6 men will be diagnosed with prostate cancer during his lifetime, but only 1 out of 32 men will die from it. Prostate cancer becomes more prevalent with age. More than 70% of all prostate cancer cases are diagnosed in patients over age 65. Because the U.S. has a rapidly aging population, the problem is on the rise. Many physicians are also seeing a growing number of younger patients, from 30 to 65. Whether this is due to earlier screening and detection or disease migration to younger individuals is currently unknown.

What Causes Prostate Cancer?

The exact causes of prostate cancer are unknown, but a combination of genetic and environmental factors, including certain aspects of the lifestyle in western countries, probably contributes to the progression of the disease. Researchers have identified several inherited genes that appear to increase the risk of prostate cancer. We know that at least 10% of prostate cancers are inherited directly from parents, while most prostate cancers appear to be acquired because of the way we live and what we are exposed to in the environment. These non-genetic factors may include diet, smoking, industrial pollution, excessive alcohol consumption, stress, and so forth.

Autopsy studies have shown that in men over the age of 30, about a third will have microscopic prostate cancer regardless of their geographical location. Yet there is a gross discrepancy between the high rate of clinical prostate cancer in the U.S. and Western Europe compared to that in Asian countries like Japan. So it would seem there is something that keeps the microscopic cancer localized in Asian men, while the cancer is not contained in western men. This finding is strengthened by studies showing that for Asian men who migrate to the U.S., the incidence of clinical prostate cancer increases up to seven times in one generation. One factor that researchers believe may account for the geographical discrepancy with prostate cancer is diet, especially, the higher intake of saturated fat and red meat in the U.S. and Western Europe compared to Asia.

Who is Most at Risk for Prostate Cancer?

Age, race and family history are the most important risk factors for prostate cancer. Those men who are most at risk are those with a positive family history, Caucasians 50 years of age or older, and African American males over 40 years of age. Prostate cancer occurs almost 70% more often in African-American men than it does in white American men, and African Americans have the highest prostate cancer mortality rates of any ethnic group.

Studies also indicate that men with a family history of the disease are two or three times more likely to get prostate cancer. The likelihood that a man will inherit the disease increases if 1) two generations of his family have had prostate cancer, 2) two or more immediate relatives have had prostate cancer (brothers and/or father), and 3) one or more relatives are diagnosed before the age of 55. Men who have a strong family history of prostate cancer should begin yearly monitoring (with the PSA test and digital rectal exam) as early as age 35.

What Types of Doctors Treat Prostate Cancer?

The treatment of prostate cancer is divided between several medical specialties: urologists (surgeons), radiation oncologists, and medical oncologists. Urologists are doctors who spend one year after medical school studying general surgery, and three additional years studying surgical treatment of the sexual organs and urinary tract. Radiation oncologists are doctors who spend one to three years after medical school studying general medicine and three additional years studying the use of radiation for treating all types of cancer. Medical oncologists spend three years after medical school studying internal medicine and two additional years studying the use of chemotherapy, and to a lesser degree studying hormonal therapies.

In many cases, the specialties overlap. Urologists sometimes perform radioactive seed implants, but require assistance from a qualified radiation oncologist in order to treat with radiation. Both urologists and radiation oncologists often prescribe hormonal therapy, as do medical oncologists. Most newly diagnosed patients are first referred to a urologist, and are often encouraged to have surgical treatment before they have had the opportunity to fully assess their other options. For this reason, patients are well advised not to rush into any form of treatment, to do their own research and obtain second opinions from the other specialties.

Why is the Treatment of Prostate Cancer so Controversial?

Part of the reason this field is controversial is due to the fact that regardless of which treatment is used, patients have a reasonable, short-term, disease-free prognosis, which is unlike most other cancers. This is true even for prostate cancer patients who undergo the more esoteric or investigational therapies. Even patients who choose not to be treated are most likely not going to die in the short term. In addition, when a primary therapy like radiation or surgery fails, there are other treatments like hormonal therapy or other systemic medications to fall back on. This is a different kind of situation than you find with most other diseases.

With other cancers, you're really put in a position where your back is against the wall and you're fighting for your life. As a doctor, you’re in fifteenth round, and you have to knock this cancer out, or that's it for your patient. With prostate cancer, we have a variety of specialties, all of which offer treatments that can potentially knock the cancer out at least for a while. In this situation, each type of specialist can argue that the specialty he has been trained in and practices offers the best therapy.

In order for you as a patient to find your way through these conflicting viewpoints, a careful evaluation of the latest data on cure rates and quality of life is essential to consider along with the specifics of your case and your individual needs. This is especially important since despite the relatively slow growth of most prostate cancers, relapse may follow a slow, painful course. Many doctors believe that progressive prostate cancer is the worst type of cancer because it kills you slowly!

The argument over which type of treatment is best continues because there are no prospective randomized trials that would definitively compare the various specialties and the different treatments they offer. However, what we can do is rigorously compare the results obtained by the premier treatment centers for each specialty and each type of treatment. That type of comparison is available to both doctors and patients and probably explains why the trend is away from surgery, with an increasing number of patients choosing one or more forms radiation therapy.

How do you find the doctor who is right for you?

A number of criteria can be used to help you evaluate a doctor's merit. A doctor with staff privileges at one or more hospitals will have usually demonstrated the necessary proficiency in his field to earn the respect of his or her colleagues. Review-committee membership at a respected medical institution also indicates a doctor's reputation among peers. A doctor whose practice is hospital-based or part of a group practice may be preferred, since any reputable hospital or group practice will require their physicians to undergo peer review sufficient to ensure quality care.

It is advisable to find a doctor who treats a large number of prostate cancer patients, and is therefore more familiar with the kind of care they require. Board certification will indicate that a doctor has been thoroughly examined although it cannot guarantee his competence. Certification in a specialty, especially oncology, or possession of a board fellowship are further indications of distinction. It is possible to check the credentials of a doctor with the Directory of Medical Specialists or the American Medical Directory, a copy of which can usually be found in the reference room of your local library. You might also ask a doctor for his or her curriculum vitae.

Any of these criteria will improve your chances of finding a capable physician. You might start as many patients do with a referral from a local, trusted doctor who is familiar with the reputable and respected physicians in your area. Keep in mind, however, that most general practitioners typically know very little about prostate cancer, and therefore, they usually refer prostate cancer patients to a urologist, who is likely to recommend surgical treatment rather than one of the non-surgical options.

A good physician will explain your condition in detail, taking the time to answer all of your questions and correcting any misconceptions you may have. It is your right to receive a complete description of all your options, and their advantages and disadvantages. This is vital information if you are to have a sense of control over what is happening to you. If the doctor fails to disclose this information, or does not encourage you to choose for yourself which treatment you wish to receive, find another doctor.

Throughout the period of your treatment, the physician should continue to keep you fully informed of the nature and rationale behind any tests or procedures recommended to you. Clear and concise written materials that explain the basic facts of prostate cancer, its symptoms and all of your treatment options, should also be made available to you.

A doctor who communicates concern for the patient as an individual can ease the treatment process. A physician who cares is more likely to inspire trust in his patients and help to allay their fears. But a doctor who sees each patient only as another medical condition to treat will most likely leave his patients feeling alienated, confused and anxious. Ultimately, such a doctor will impede the progress of those under his care.

In the final analysis, you need to have a comfort level with your doctor that enables to you answer the following questions affirmatively. Do you trust and have confidence in your doctor? Does he put you at ease? Are you able to talk with your doctor in a relaxed manner?

A physician may be completely suited for treating some patients and unsuited for treating others. It may be nothing more than a matter of incompatible personalities. But you will be making critical decisions with this doctor, and undergoing a treatment process that can be difficult and extend for months or even years. Is the physician only interested in treating you, or will he follow you after treatment annually or biannually? You will need a doctor you can depend on when the going gets tough. If for any reason you do not feel comfortable with your physician, you should carefully consider whether it is in your interests to find care elsewhere.

When should prostate cancer not be treated?

Studies have shown that with early stage prostate cancer patients who are not treated, the risk of dying from disease is very low for the first 10 years after diagnosis. Therefore, in the past, it was argued that prostate cancer patients with a life expectancy of less than 10 years should not be treated, because they were more likely to die from some other cause. With life expectancy increasing for the population as a whole, there are actually fewer and fewer cases of prostate cancer these days that do not call for some form of treatment, and the relatively non-invasive therapies such as brachytherapy and/or IMRT are often appropriate for older men who are otherwise in good health.

According to the most recent actuarial data, a 60-year-old man has a life expectancy of 20 years or more. He should therefore pursue some form of treatment because he will probably live long enough to die from his prostate cancer if it isn’t treated. An 80-year-old man now has a life expectancy of 9.1 years. In the case of an 80-year-old whose general health is good and who has no other serious health conditions, he too stands a good chance of living beyond 10 years and would also be wise to consider treatment. For men over 80, treatment should be determined on a case by case basis since their life expectancy begins to fall significantly below 10 years. Nonetheless, your health should be viewed as more important than age per se, since an 84 year old may actually be healthier than his 54 year old counterpart, who consumes excessive alcohol (ETOH abuse), smokes cigarettes, etc.

What is “watchful waiting” and when is it recommended?

Watchful waiting is an option for some early stage prostate cancer patients who want to try to preserve their quality of life by avoiding aggressive treatment for their cancer at least temporarily. These men may be advised to wait and monitor the progression of their cancer with periodic laboratory tests and physical examinations. Although I inform my patients of this option, I’m generally opposed to it for most men, because I don’t see much merit to the idea of waiting as cancer progresses and becomes less treatable. Nor do I see much data to support this approach. The exceptions are those patients regardless of age who have a life expectancy less than ten years because of some other medical condition, such as heart disease or another form of cancer that is likely to be a cause of death before prostate cancer. For these men, watchful waiting is a more realistic option.

Advocates of watchful waiting often correctly point out that the term is misleading and should not imply passive waiting or doing nothing. A more active program of surveillance (sometimes called “expectant management”) is intended and may include a diet and fitness regimen undertaken in consultation with a doctor and tailored to the patient’s condition. The process of waiting to see if the cancer progresses is bound to cause prolonged periods of anxiety for many men; and therefore, a strong sense of commitment and mental stamina are demanded of those who choose to wait rather than be treated.

Early proponents of watchful waiting based their argument on Swedish data, which received a great deal of publicity in the early 1990’s. The Swedish researchers argued that there was no survival benefit for patients treated versus patients who were not treated. But if we look closely at those studies, it turns out that the patients were not just undergoing watchful waiting, because when the disease started to progress in men who had not been treated, they were subjected to endocrine therapies such as hormonal therapy or orchiectomy (castration). Therefore, the Swedish data did not provide an accurate picture of watchful waiting. As discussed in the next chapter, the survival benefits of treating prostate cancer have not yet been conclusively demonstrated, but researchers have compiled enough data to establish the long term cure rates for each type of treatment.