Prostate cancer options: waiting, surgery and more

The detection and treatment of prostate cancer is getting high tech. New sophisticated screenings, better tests for evaluating biopsied tissue and use of MRI-ultrasound fusion to accurately map prostate cancer are the latest advancements in detecting and treating the disease. These are the things that are new and exciting, said Dr. Dipen Parekh, professor and chairman of the department of urology and director of robotic surgery at the University of Miami Miller School of Medicine. If you do get a diagnosis of prostate cancer, if you seek out treatment with the right people, and you are in the right hands, you should expect an excellent future course. In addition, robotic-assisted laparoscopic prostatetectomy continues to advance as a surgical tool, along with radiation therapy or brachytherapy, which uses radioactive seeds to kill cancer cells. Still others undergo a radical prostatectomy, the removal of a cancerous prostate and its surrounding tissue. Pre- and post-surgical pelvic floor physical therapy, a series of exercises under the guidance of a therapist, can also strengthen pelvic areas to end incontinence, said Louise Gleason, a physical therapist with South Miami Hospitals Pelvic Floor Center. And, for those for whom prostate cancer has become too advanced and who are not candidates for surgery, Provenge, a restorative treatment of cellular immunotherapy, made from a patients own immune cells, can stimulate a patients immune system to identify and target prostate cancer cells, thus prolonging life, said Dr. Michael Cusnir, an oncologist at Mount Sinai Medical Center in Miami Beach, Fla.

GUIDELINES
Guidelines for screenings of the prostate, a walnut-sized portion of a mans reproductive system that wraps around the urethra, the tube that carries urine out of the body, have changed since May 2013. Instead of every man over 40 getting a PSA (prostate-specific antigen blood test), now its more focused on screening for patients with a high risk for prostate cancer, those who have a family history, or who are African American, said Parekh. MRI-ultrasound fusion, adopted early by the University of Miamis Sylvester Comprehensive Cancer Center, can result in more accurate prostate biopsies than ultrasound alone or digital rectal exams. The American Cancer Society recommends that at age 50, men who are at an average risk of prostate cancer have a discussion about the risks and potential benefits of a screening with their doctor. The screening discussion can start at 45 for men at higher risk of developing prostate cancer, which, according to the American Cancer Society, will impact one out of seven men in the United States -

though only one out of 36 will die from the disease. Most older men who have been diagnosed with prostate cancer will die from other causes before succumbing to the cancer. At-risk men would include African Americans, who have a higher instance of prostate cancer compared with their white and Hispanic counterparts, or men who have an immediate relative such as a father, brother or son who was diagnosed with prostate cancer before age 65. Those who have had more than one immediate relative with the disease at an early age should begin discussions with their doctors even earlier, at age 40. Prostate cancer is the second most common cause of cancer death in men, behind lung cancer and ahead of colon cancer. About 233,000 new cases of prostate cancer will be diagnosed nationwide in 2014, and 29,480 men will eventually die from it, according to the American Cancer Society. The upshot: More than 2.5 million men in the United States who have been diagnosed with prostate cancer at some point - the average age at the time of diagnosis is 66 - are still alive. Active surveillance, or monitoring the disease with doctor and patient working in tandem, can also improve quality of life. Robotic surgery, guided by infrared vision, is a preferred treatment because blood loss is minimized as is the risk of damaging blood vessels and nerve bundles that are responsible for blood flow to the penis that allows a man to achieve an erection. The image-guided surgery is also less traumatic. Most patients go home within a day or two with a catheter, for about a week, to help drain the bladder until the sutures heal. Normal continence resumes for 95 percent of patients within the first six months.

PHYSICAL THERAPY
For patients who need help dealing with issues of incontinence, which can occur before or after prostate cancer surgery, or from an enlarged prostate as a man gets older, therapeutic exercises can be a remedy. The Pelvic Floor Center at South Miami Hospital focuses on a ring of bones that includes the sacrum at the bottom of the spinal column and the pelvic bone on either side. At the base of that bone structure lie muscles that hang like a hammock from the tailbone to the pubic bone, supporting the pelvis. These muscles are voluntarily controlled, like the biceps or triceps, and are used to control the passage of waste from the body. I gear my physical therapy toward the muscles and bones of the pelvis to see if we can help patients restore that function after whatever procedure they have, Gleason said. When these muscles are weak, or not working properly, they cant close that urethra to hold that urine back and thats where I come in. I assign people exercises based on the strength they already have so as to maximize their improvement, she said. In general, it takes about a month before a patient will see real strengthening, Gleason said.

Typical sessions run once a week for about six to eight weeks with home exercises suggested afterward. A simple exercise might go like this: Recline on the floor with knees bent, a hand on the belly, another on a leg. Tighten up around the anal area as if holding back gas. Release and repeat. The first goal is to isolate the pelvic floor and be able to recognize when they are using it, Gleason said. From there, you can begin to exercise because you are using the correct muscle. Still other therapies can utilize electrodes placed on the skin to measure activity in the muscles to train the muscles to contract and strengthen. If the incontinence or sexual dysfunction is muscular related, these exercise combinations can be effective, Gleason said.

IMMUNOTHERAPY
In some cases, prostate cancer has advanced beyond surgical solutions. Provenge, a therapeutic class of cellular immunotherapies, is not curative. But this non-surgical alternative to prostate cancer treatment can improve the survival rate of patients for months or years. Patients cells are collected, infused with an antigen that helps activate the patients T -cells to help fight the cancer cells, and then placed back into the patients body intravenously. Almost like a blood transfusion, explains Mount Sinais Cusnir. We almost train the patients own immune system to recognize the cancer cells and fight them on their own. The process is repeated three times in two-week intervals. Were still looking for a big change, Cusnir said about the treatment of prostate cancer, but at least we keep improving survival.