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Sifting Through Prostate Cancer Treatment Choices

By Jerry Berger
Beth Israel Deaconess Medical Center Staff

Joel Carpenter received some bad news at the worst possible time - minutes from the close of business on a Friday afternoon. The answers to his questions about his Stage One prostate cancer diagnosis would have to wait. But not that long.

A post 5 p.m. call was returned at 8:05 a.m. the following Monday and Carpenter sat down with Beth Israel Deaconess Medical Center Prostate Care Center surgeon Dr. Martin Sanda, later that week.

"When you find out that you have a disease like this you want to get to the expert as quickly as you can because you have a thirst for knowledge," says Carpenter, 50, who underwent a successful prostatectomy in May and was back to work 2 ½ weeks later. "There's a whole bunch of things you don't know."

And that is precisely the goal of the Prostate Care Center, says Dr. Glenn Bubley, a medical oncologist and - along with Sanda and radiation oncologist Dr. Irving Kaplan - one of the center's three co-directors. "The Prostate Care Center is set up to help patients who are newly diagnosed get through the morass of decision-making," says Dr. Bubley. "The anxiety these patients have is palpable, because they feel 'gosh, if I make the wrong decision here I'm going to die of this disease.' That's not the way it works."

"They took me through, in a very precise and articulate and understandable way, what the options were," says Carpenter. "They gave me all the information there is to make this kind of decision… including a pretty clear discussion of what they don't know."

For many patients, the first step will often be a trip to BIDMC's state-of-the-art diagnostic tool which combines the latest in magnet resonance imaging technology with the latest in software.

On the hardware side, the implementation of a high field strength MRI unit operating at 3T (T for Tesla, or a unit of measuring magnetic strength) and the development of a specialized coil to detect the MRI signal enable imaging of the prostate gland at higher spatial resolution than previously possible.

This capacity has been combined with 3TP (for time points), a software analysis tool. The software yields color-coded images that display benign images in green - and cancerous lesions in red.

"This technology helps find cancers that routine biopsies miss," says Dr. Sanda.

Once a diagnosis is confirmed, it's time for the patient and his family to weigh the options from the team.

"The first big branch point is whether or not they should be considered for a watch and wait protocol," says Kaplan. Because prostate cancers grow slowly, there is a potential to defer treatment, perhaps as long as an entire lifetime, depending on the patient's age.

If watchful waiting is ruled out, a patient faces two additional choices - surgery or radiation. But within these broad categories are a number of options including brachytherapy - the implantation of radioactive "seeds" or the use or external beam radiation.

"If everything we know about the patient gives me a very firm conviction that the cancer is confined to the prostate, those are the ideal candidates for the brachytherapy," says Dr. Kaplan, describing the procedure as "a rifle shot aimed at the prostate."

"If I think it is likely there will be cancer outside the prostate, that's when we tend to recommend external beam radiation," he adds, describing this approach as "more of a shotgun. It treats the prostate with a little bit more of a margin around it, which is a good thing if I think the cancer is beginning to break outside the prostate."

BIDMC offers several options of external beam treatment, including intensity modulated radiation therapy and image-guided radiation therapy. In the latter method, gold seeds are implanted to help direct the radiation more precisely. BIDMC also conducts clinical trials into potential new drug therapies as well as use of the CyberKnife as a prostate cancer treatment option.

If surgery is determined to be the correct course, BIDMC offers a variety of options among nerve-sparing prostatectomies that can be done either with an open incision or with minimally invasive surgery performed by Dr. Sanda and by  Dr. Andrew Wagner. The options can include chemotherapy or hormonal therapy prior to or after surgery. Drs. Sanda, Bubley, and Kaplan each have lead roles in several national clinical trials evaluating new treatment approaches to prostate cancer.

Dr. Sanda notes the lists of options are tailored to include information about the success rate of various procedures and BIDMC clinicians - as well as data on patient and family "satisfaction" with the outcomes. BIDMC has the largest number of patient participants in NIH-funded prostate cancer studies in New England, and led a national study describing quality of life among prostate cancer patients and their spouses that was published earlier this year in the New England Journal of Medicine.

Carpenter says he opted for surgery after a thorough review of the choices, aided by the luxury of time because his cancer was at a very early stage.

"It was fairly simple. Watchful waiting will only postpone the evitable. I'd be impossible to live with if I know I have cancer and don't do anything. The mortality experience (for surgery) is a little better for a guy my age with this stage of this disease."

Above content provided by Beth Israel Deaconess Medical Center.
For advice about your medical care, consult your doctor.

Posted October 2008