April 25, 2001 (Dana Point, Calif.) -- It's now clear that nearly half of all U.S. men one day will hear the dread news that they have prostate cancer. What's unclear is what they should do about it.
New tools can help men make this difficult decision, according to experts gathered here at the American Cancer Society's Science Writers Seminar.
"For men today diagnosed with prostate cancer, 90% have localized, early cancer," says Peter Scardino, MD, of Memorial Sloan-Kettering Cancer Center in New York. "The dilemma they face is, 'What shall I do about this? Should I treat it at all -- or is the word cancer scaring me into taking potentially dangerous treatments?' It is an agonizing decision among a wide array of different types of treatments. The better we understand the consequences of these choices, the more we can help men make wise decisions they can live with."
Three conference presentations show that much progress is being made:
- Michael Kattan, PhD, outcome research scientist at Memorial Sloan-Kettering, has developed a computer-based tool called a nomogram. The program takes in a man's personal and medical data and then tells him -- in cold, hard numbers -- what his chances are for success and side effects with each available treatment.
- Mark S. Litwin, MD, MPH, associate professor of urology and health services at the UCLA Jonsson Cancer Center, has gathered data on the quality of life for patients who have undergone various treatments for prostate cancer. These findings can be used by new patients to make informed treatment choices.
- Joseph J. Disa, MD, a reconstructive and plastic surgeon at Memorial Sloan-Kettering, has helped to develop a new nerve-grafting technique that greatly reduces two of the most feared consequences of prostate surgery: erectile dysfunction and urinary incontinence.
What Are My Chances, Doc?
When a patient first learns he has prostate cancer, he is faced with a bewildering array of options:
- Surgery can cut away the tumor -- and maybe also the nerves that control erections and urination.
- External-beam radiation can kill prostate cancer cells, but the treatment can cause painful bladder symptoms and other problems.
- Brachytherapy is the implanting of small, radioactive seeds into the prostate, where they kill cancer cells -- but new studies suggest that this treatment may have the same drawbacks as external radiation.
- And then there is watchful waiting, based on statistics that show a man is more likely to die with prostate cancer than to die of it. But for many patients -- especially Americans with their can-do attitude -- living with cancer is hard to accept.
Now Kattan and colleagues have developed the nomogram, a new program that lets a doctor punch in all relevant medical details into a computer or handheld device. Then, at the press of a button, the program shows what the chances are that a particular treatment will work for a particular patient -- and what the chances are for something to go wrong.
"This approach is attempting to maximize the accuracy with which you can do that," Kattan says. "The nomogram generally predicts better than a doctor's prediction. ... When it comes down to predicting, we as humans tend to predict the outcome we want to happen, not the outcome most likely to happen."
A new, recently completed study of more than 4,000 patient records showed that the nomogram's predictions come amazingly close to actual patient outcomes.
"I think what the nomograms will help do is put a number on the likelihood of success with different treatments," Scardino says. "But it will not show whether one treatment is better than another. It will show that a certain treatment may be more likely to help, and then the decision will be whether the potential side effects are worth it."
Litwin and Scardino already use the program in clinical practice. "My patients love it -- even the ones that get bad news," says Litwin.
Quality of Life
"The primary purpose of prostate cancer treatment has to be a marriage of the dual goals of preserving survival and preserving or even improving quality of life," Litwin says. "Prostate cancer is an insidious, slow disease -- so dying of prostate cancer takes a long time compared to other cancers. The effects of treatment remain with a man for a very, very long time."
To Litwin, health is not merely the absence of disease but the entire spectrum of a person's physical, emotional, and social well-being. He has developed measurements capable of putting a value on each of these different components.
What these scales boil down to is the question of function vs. bother.
"In urinary domains, sexual domains, and bowel domains, function and bother are really separate," Litwin says. "Some men may have severe dysfunction and not be bothered by it, whereas it may make a huge difference to other men."
In his latest study, Litwin looked at urinary function and bother in men who underwent either external-beam radiotherapy or surgery for their prostate cancers. It is generally believed that surgery is more likely to result in a rapid cure, but that the risks of losing erectile function and urinary control are much higher.
This was true in the first year after treatment. But beginning in the second year, men who underwent surgery began to regain lost erectile and urinary function, while those who underwent radiation therapy began to lose it.
As for urinary bother, the results were surprising. Men were bothered significantly more by urinary symptoms after radiation than after surgery for the entire two years after treatment.
"Physicians tend to push their own particular type of therapy because they believe in it," Litwin says. "But I do believe that patients who choose either of the therapies have a concept of what the outcome will be. That is why patients are often surprised, and bothered, when the outcome isn't what they expected."
A major problem with prostate surgery is that the nerves that control both erectile function and urination run through bundles on either side of the prostate gland. Unfortunately, prostate tumors often appear on the side of the gland right next to these nerve bundles -- and sometimes they push right up against them.
New nerve-sparing surgery has greatly reduced the number of men who lose the ability to have erections and to control urination. But when the tumor sits in a bad place, a surgeon often will have to cut the nerve to make sure the entire tumor is removed.
"Patients with nerve-sparing surgery do best in terms of recovering their sexual potency," Disa says. "If you damage the nerves but don't destroy them, you have a 75% chance of recovery. If one of the nerves is destroyed, this drops to about 50% -- and if both nerves are destroyed, there is no chance of recovering potency."
But now, help is on the way. Disa and colleagues have pioneered a new technique in which a nerve taken from just below the ankle can be used to replace one or both of the nerves destroyed by prostate surgery.
"If you graft patients with one nerve removed, up to 75% without prior radiation or chemotherapy are regaining sexual function," Disa says. "With prior therapy, it seems to be about 50%, equivalent to what you would see if nerve-sparing therapy were possible for patients in this group. With bilateral nerve construction, after 24 months, 33% are recovering erections good enough for intercourse -- and another 25% have improvement with Viagra. This is the group that would have had no erectile function without the grafts."
Scardino warns that the new technique is not free of risk.
"There are potential downsides," he says. "We have shown that the operative time is longer, costs are greater, blood loss can be greater, so there may be a need for transfusions. And there may be problems at the donor site [the ankle], which, though uncommon, are not unheard of. Before it can be considered for everyone, it needs to be proven in a [scientific] trial."