Prostate Cancer's Prognosis

New Therapies Exist, But Men Still Face a Tough Call: Get Treated Now, or Wait

By Adam Voiland

By the time Jim Hurley, 54, learned last year that he had early-stage prostate cancer, the disease had already killed his father and struck two brothers. With that family history, the plaster artisan from Springfield, N.J., wasn't about to take chances. For two months, he pored over scientific studies, books, and websites about the cancer. He discussed his situation with doctors, his brothers, and other survivors. A surgeon recommended surgery. A radiation oncologist advocated a form of radiation therapy. But Hurley, concerned that either could leave him impotent or incontinent, settled on a novel technique that attacks cancer with sound waves. He had to drop $23,500 and fly to Toronto to get treated with high-intensity focused ultrasound, or HIFU. (Health officials in Canada and Mexico permit the procedure, but U.S. regulators haven't made a decision on it.) So far, he's pleased with the results.

Hurley may be in the vanguard of a new generation of prostate cancer patients, who are seizing on novel medical options in order to confront the disease without sacrificing quality of life. "Prostate cancer can totally decimate your masculinity," says Jim Kiefert, chairman of the executive committee of Us TOO International, a prostate cancer support and education group, and a survivor of the disease. "For every treatment, you run the risk of impotence and incontinence." To minimize the chances of such problems, some patients are now opting for high-tech therapies such as HIFU and robot-assisted surgery. Others are choosing to forgo curative treatment, instead taking a calculated gamble that they can hold out against the disease.

For some men, trying to hold out is an option because the cancer often isn't lethal. About 1 in 6 American men will be diagnosed with prostate cancer at some point, but only about 1 in 35 men will die of it, according to the American Cancer Society. Other men never suffer symptoms: Between 30 and 40 percent of men who die of causes unrelated to cancer turn out to harbor undiagnosed—and effectively harmless—prostate tumors, autopsy results show.

In a study published in May 2005, more than 90 percent of men with low-grade tumors—those with a so-called Gleason score of less than 5—had not died of prostate cancer within 20 years of diagnosis, despite going untreated. "Because prostate cancer usually grows so slowly, many tiny cancers probably do not need treatment," says study coauthor Peter Albertsen of the University of Connecticut Health Center in Farmington. "These are the men who should consider active surveillance." That treatment strategy, also sometimes called watchful waiting, involves close monitoring of the tumor and a treatment intervention if troubling signs emerge.

Some experts argue that watchful waiting is too often overlooked. "All the evidence points to the fact that many men get treatment they don't need," says Laurence Klotz, chief of urology at Sunnybrook Health Science Centre in Toronto.

Nevertheless, plenty of patients fall into a gray area in which surgery or radiation therapy is potentially lifesaving. A Scandinavian study published the same month found that 8.6 percent of patients who received surgery died from prostate cancer within 10 years, compared with 14.4 percent of those who pursued watchful waiting. (Death rates for men diagnosed today may be lower than those in published studies because screening methods have improved.) A 2006 trial also observed a higher death rate among men who went untreated. "Not all cases of prostate cancer are created equal," says Yu-Ning Wong, a medical oncologist at the Fox Chase Cancer Center in Philadelphia. "Patients with more aggressive [tumors] are at a higher risk of developing metastatic disease and really should strongly consider treatment."

Some men fall on the cusp—and aren't willing to jeopardize quality of life in order to get cured. When Leonard Norwitz of San Jose, Calif., was diagnosed nine years ago, a urologist had strongly recommended surgery. "He thought we ought to get it when it was small," the clinical social worker recalls. But second opinions convinced Norwitz, now 65, that treatment wasn't imperative. Instead, he joined a clinical trial in which he's using lifestyle changes to attempt to control his tumor's growth. He also gets regular follow-up tests. If one raises a red flag, he plans to receive radiation therapy.

But putting off therapy as Norwitz has done can take nerves of steel. At the Brady Urological Institute at Johns Hopkins University, says research director Robert Getzenberg, about 1 patient in 10 who initially declines curative treatment eventually changes his mind, not for any medical reason but rather to rid himself of the psychological burden of carrying cancer. (An additional 2 of every 10 ultimately get surgery or radiation because their cancer seems to be advancing.)

Watchful ways. Better tests for monitoring tumors might help patients feel more secure in their decisions. Researchers are studying numerous genes and proteins that could become useful biomarkers of a tumor's status. Long-standing clinical tools are also undergoing refinement. For example, for almost two decades doctors have used patients' blood concentrations of a protein called prostate specific antigen to screen for cancer. More recently, they've found that a significant increase over time, or upward velocity, in a cancer patient's PSA hints that his tumor may be growing quickly and becoming more apt to metastasize. PSA velocity is now increasingly being used to differentiate between aggressive and indolent tumors—and to guide treatment decisions accordingly. The National Comprehensive Cancer Network, an alliance of cancer centers, recently decided to include PSA velocity in its clinical guidelines, says radiation oncologist Anthony D'Amico of Brigham and Women's Hospital in Boston. The measurement's emerging importance gives healthy men a reason to have their PSA tested, as the American Urological Association recommends that whites over 50 and African-Americans over 40 do annually. If cancer eventually develops, having a pre-existing record of PSA levels could help a man and his doctor gauge the magnitude of the threat, D'Amico says.

Other variables also factor in treatment decisions. Chiledum Ahaghotu, a urologist at Howard University in Washington, D.C., generally recommends surgery or another aggressive therapy to relatively young and healthy patients, while he would consider watchful waiting an option only for men who have a life expectancy of less than 10 years, because of age or illness.

Robots. Meanwhile, new technologies might trim complication rates, tilting the scales toward treatment. One advance, the robotic surgery system dubbed da Vinci, has taken hospitals by storm. Within the past two years, the number of hospitals worldwide using the $1.5 million device has ballooned from 328 to 656, according to Intuitive Surgical, its California-based manufacturer. Some surgeons favor the new system, which gives them fine control. Using joysticks and a live video feed, they guide the robotic arms through dime-size incisions. Accumulating evidence suggests that robotic surgery, with the right person at the controls, is at least as good as the conventional technique. A review of the scientific evidence, published in February in the International Journal of Clinical Practice, suggests that robotic surgery results in less blood loss, shorter hospital stays, and slightly less post-surgical incontinence than the conventional operation. So far, it has resulted in impotence rates and apparent cure rates similar to those of standard surgery. "We have not been able to identify any disadvantages," says Joseph Smith, a urologist at Vanderbilt University Medical Center in Nashville who has performed some 1,500 robotic prostatectomies and 3,000 standard ones. But the skill of the surgeon is more important than the type of procedure, he adds. He recommends that men find an experienced surgeon they trust and let that doctor decide whether to do the procedure robotically.

Like surgery, radiation treatments such as brachytherapy may improve with technology's advance. For example, D'Amico and his colleagues have pioneered the use of magnetic resonance imaging in the or to guide doctors as they insert radioactive seeds into cancerous portions of the prostate. Compared with ultrasound guidance, which is widely used, mri guidance has reduced urinary complications, they've found.

HIFU, the sound-wave treatment that Jim Hurley received, is another emerging option. During the operation, doctors insert an ultrasound transducer into the rectum and bombard the prostate with sound waves that heat and kill tumor cells. At this point, though, HIFU is available only at clinics abroad or in one of three ongoing U.S. trials. Two of those trials, which are using different devices and running in a total of 11 states and the nation's capital, are comparing HIFU with another relatively new technique, cryotherapy. That approach, which attempts to kill tumor cells by freezing them, also may minimize urinary complications. But skeptics caution that HIFU and cryotherapy may not permanently eliminate all tumors.

Hurley has no residual problems to remind him of the cancer, and he's glad he took the time to find the treatment that suited him best. Other men also stand to gain by exploring their choices, doctors say. "Get as much information as possible," says Getzenberg. "Get second opinions. Step back a little bit, take a deep breath, and look at your options."

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