The National Cancer Institute estimates there are almost 200,000 newly diagnosed cases of prostate cancer in the United States annually. Prostate cancer is the second leading cause of cancer death in men in the United States with approximately 28,000 men dying of it each year.
Palmdale Regional Medical Center is committed to providing the best care for prostate cancer and high quality healthcare in a compassionate and efficient manner.
Monish Aron, MD, is here to explain all the treatments for prostate cancer available at Palmdale Regional Medical Center.
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Prostate Cancer: Your Options at Palmdale Regional
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Learn more about Monish Aron, MD
Monish Aron, MD
Dr. Monish Aron is an internationally-acknowledged expert in robotic and laparoscopic urologic oncology. Dr. Aron brings a wealth of experience in various applications of minimally invasive surgery including robotic, laparoscopic and percutaneous surgeries. Dr. Aron has a primary interest in advanced robotic and laparoscopic surgery for prostate, kidney and bladder cancers. He specifically performs nephron-sparing (kidney-saving) surgery for cancer, expertise in robotic athermal nerve-sparing radical prostatectomy for prostate cancer and robotic radical cystectomy with intracorporeal urinary diversion for bladder cancer. He is a member of the medical staff at Palmdale Regional Medical Center and at Keck Medicine of USC.Learn more about Monish Aron, MD
Transcription:
Melanie Cole (Host): According to the American cancer society, Prostate cancer is the most common cancer among men (after skin cancer), but it can often be treated successfully. More than two million men in the U.S. count themselves as prostate cancer survivors. My guest today is Dr. Monish Aron. He's a urologist and a member of the medical staff at Palmdale Regional Medical Center as well as a member of the medical staff at Keck Medicine of USC. Welcome to the show, Dr. Aron. Tell us about what's going on with prostate cancer right now. What do you want men and women who love them to know about getting in to see a doctor to get checked?
Dr. Monish Aron (Guest): Hi, Melanie. Prostate cancer is, as you said, one of the most common solid organ cancers amongst American men. It is estimated nearly 250,000 new cases of prostate cancer will be diagnosed every year in the United States. The majority of these cancers, when they are diagnosed, are low-risk cancers, but there are a few patients who will have intermediate-risk to high-risk prostate cancer, as well. Most prostate cancer is diagnosed when patients present to their family physicians or their urologists and have a blood test which is a blood test for PSA, or prostate specific antigen. If the PSA is elevated, then this leads to a patient being referred to a urologist or investigations. Now, normally, a PSA less than 4 nanograms per ml is considered to be normal and any PSA above 4 nanograms per ml is considered to be abnormal. Now, keep in mind that not all abnormal PSA means cancer. In other words, PSA is prostate specific, not cancer specific. So, an elevated PSA does not necessarily mean cancer and it needs to be investigated.
Melanie: Does the PSA go along with a digital and diagnosing prostate cancer and do you think that that's the reason so many men are hesitant to come in to get this test?
Dr. Aron: Usually, a digital rectal examination should be performed in man because an additional rectal exam can point to a more significant cancer than just a PSA. In other words, if there's a palatable abnormality on the digital rectal exam, that would indicate that there could be a significant cancer in the prostate. So, a digital rectal examination should be performed whenever a patient over the age of 40 goes to see his primary care physician or a urologist and there really is no reason to fear a digital rectal examination. It is very straightforward and should not really be feared.
Melanie: So, you'd like men to start at the age of 40 coming in for a baseline PSA and then how often from there?
Dr. Aron: There is no reason to go in for a baseline PSA at the age of 40 unless you have a strong family history of prostate cancer. In fact, currently a routine prostate cancer screening is not indicated. However, if a patient goes to see a urologist for a prostate-related complaint, then at that time, is when a digital rectal examination should be performed.
Melanie: So, what would be a prostate-related complaint? What are some symptoms that might signal that somebody has something going on with their prostate?
Dr. Aron: Well, the most common ailment with the prostate is benign enlargement of the prostate which leads to urinary symptoms. Prostate cancer itself doesn't cause too many symptoms, at least not in the early stages. So, most patients, when they are in their middle ages start complaining of the urinary frequency, some slowing in their urinary stream, and some urgency of urination, and these are the usual symptoms associated with an enlargement of the prostate which most men in their middle ages will experience. Now, these symptoms are not symptoms specific of prostate cancer. These are not symptoms of prostate cancer. These are symptoms of an enlargement of the prostate and most patients see their urologist because of these symptoms and, when they do that, a digital rectal examination should be performed at that time.
Melanie: So then, if you have a man that comes in and you have diagnosed prostate cancer, what is next?
Dr. Aron: So, before we talk about the diagnosis of prostate cancer, I just want to talk about what to do if somebody has an elevated PSA. So, if somebody has an elevated PSA, usually one has to discuss with them about the need for a prostate biopsy. Now, not everyone should undergo a prostate biopsy if their PSA is elevated. So, if somebody that is elderly and has significant comorbidities and their digital rectal examination is normal, and their PSA is borderline, one may not need to do a biopsy. There are various calculators one can use online such as the PCPT Calculator which can indicate the risk of harboring cancer within the prostate. And, if that risk is very low or if the patient has significant comorbidities, there may not be any need to do a biopsy. However, if the PSA is significantly abnormal, if the digital rectal examination is abnormal, and the patient is relatively young, then a case be made to offer the patient a prostate biopsy. Basically, the decision-making should be a shared decision-making between the patient and their urologist and both should agree on the best course of action. Now, assuming that the patient and the doctor agree that a prostate biopsy is the appropriate course of action, then a prostate biopsy should be performed and this is typically done in the urologist's office using a trans-rectal ultrasound probe. So, the ultrasound probe is placed in the rectum, and under local anesthesia, multiple cores are taken from the prostate to obtain the prostate biopsy and that is sent to the pathology lab. In about a week or so, the pathologist will send out a report which will have a significant amount of information including whether or not there is cancer on the biopsy and, also, if there is cancer on the biopsy, what is the grade of the cancer, which is called the “Gleason grade”. Combining two of the most common areas of the cancer gives you a Gleason Score. So, the pathology report will tell you whether or not there is cancer. It will tell you what is the Gleason Score of the cancer, and also tell you the volume of the cancer--that means how many cores are involved and what is the percentage involvement of the cores. Once the urologist has all that information, then, again, in consultation with the patient, one has to decide on the best course of action.
Melanie: So then, how do you decide with your patients once you have determined all of these factors coming together--radiation, and chemotherapy, surgical intervention--how do you go about starting the process?
Dr. Aron: So, there are multiple factors which determine what is the best course of action for a given patient. These include the patient's age. Number two is the comorbid conditions, which includes what are the other ailments that a patient might have. Number three would be the race of the patient. Number four would be the extent of the cancer, which would be the staging of the cancer. And number five would be the Gleason Score of the cancer. So, if a patient is relatively elderly and has a low volume, low-risk cancer, it is possible that one might decide not to do any active treatment and offer the patient active surveillance. So, basically, the treatments can be divided into whether or not the patient has localized organ-confined disease, or whether the patient has metastatic disease, which means the cancer is beyond the prostate. If a patient has an organ-confined disease, that means that the disease is confined to the prostate, based on the pre-operative imaging such as a CT scan and a bone scan, which can be awkward when indicated. But in that situation, there are basically five treatment options that a patient has. One of them is active surveillance. The other one is surgical excision of the prostate. So, there's radiation, of which there are various forms. Number four is freezing the prostate and number five is what has recently become available in the United States which is high-intensity focused ultrasound. So, these are some of the options with patients with organ-confined disease. For patients who have metastatic disease, that means the disease is beyond the prostate, usually the standard of care is offering them hormonal therapy in the form of androgen deprivation. Because prostate cancer is an androgen-sensitive tumor, that means the prostate cancer cells need androgens to support their growth, if we deprive these cancer cells of androgens, they will shrink. Androgen deprivation therapy does not cure the cancer, but it keeps the cancer under check for a few years. Recently, there are some emerging data that one can also chemotherapy with docetaxel to the hormone therapy and that has improved some of the outcomes in these patients with metastatic cancer.
Melanie: That was just such an excellent explanation, Dr. Aron. Really, really succinct; very well spoken. So, tell the listeners what you would like them to know about all of these different types of therapy and what they can expect for their loved one or for someone with prostate cancer.
Dr. Aron: So, we can go over these therapies one by one. Active surveillance means you are watching the patient and their PSA and their cancer over time. You are not ignoring it; you're watching it carefully over time. Active surveillance, in general, is offered to people who have very low-risk, low volume cancer. Also, it is ideal for patients who are older. Some young patients may also choose to undergo active surveillance because they are concerned about the side effects of the different treatment options, such as surgery or radiation. For the most part, active surveillance is ideal for low-risk, low volume cancer. The second option is surgical excision which is called a “radical prostatectomy”. It can be done robotically or open surgically and is a treatment which has been around for over three decades. There are excellent data with the radical prostatectomy or surgical excision of prostate cancer. Currently, the vast majority of radical prostatectomies are performed robotically. The main side effects of a surgical excision of a prostate include erectile dysfunction and urinary incontinence. The urinary incontinence usually gets better with time and in about 6-9 months, over 90% of the patients will regain continence. The erectile dysfunction takes longer to recover and sometimes there will not be complete recovery of erectile dysfunction. So, these are the two main adverse effects of surgery for prostate cancer. However, surgery has been the vanguard for treatment of prostate cancer for a long time and there are robust data about its efficacy. The third option is radiation. There are various forms of radiation. One is called “seed implantation” or “brachytherapy” where radioactive seeds are implanted inside the prostate and they deliver radiation locally to the prostate. Another form of treatment is external beam radiation Currently, the most popular external beam radiation methodology is called IMRT or intensity-modulated radiation therapy and that delivers a beam of radiation from the outside onto the prostate, and can also cover the surrounding areas, and can also cover the lymph nodes in the pelvis. The fourth option is freezing of the prostate or cryotherapy, and the fifth option is high-intensity focused ultrasound which ablates the prostate using heat. Now, both of these modalities which is cryotherapy and high-intensity focused ultrasound are approved for ablation of prostate tissue, but not necessarily for the treatment of prostate cancer. So, one has to keep that in mind when undergoing these treatment options for prostate cancer.
Melanie: So, in just the last few minutes, Dr. Aron, what should people with prostate cancer think about when seeking care?
Dr. Aron: A lot of men think about what their outcomes are going to be in terms of cancer specifics survival and overall survival. In addition, they think about incontinence and erectile dysfunction. These two things weigh heavily on the mind of a patient when they are seeing the urologist and having a discussion about treatment options. And these are real concerns because quality of life is important and these treatment modalities might impact the quality of life. The least impact on the quality of life is with active surveillance which is where you are monitoring the patient's PSA and following them along. The maximum impact on quality of life with a major effect is with surgery, but the side effects from the surgery usually get better with time. Radiation also impacts quality of life. Not right away, but it does so over the next few years. With cryotherapy and HIFU, the impact on quality of life is less well-defined because robust data are not yet available as much as they are for surgery and radiation, but over the next few years, we will probably have some more data in this regard.
Melanie: And why should they come to Palmdale Regional Medical Center for their care?
Dr. Aron: Well, at Palmdale Regional, we have the ability to provide high-quality care for these patients and they will get the optimal consultation where they can discuss all the options and appropriately decide what is the best course of action for them and their family.
Melanie: Thank you so much, Dr. Aron. What great information and so important. Thank you for being with us today. You're listening to Palmdale Regional Radio with Palmdale Regional Medical Center. For more information, you can go to palmdaleregional.com. That's palmdaleregional.com. Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole, thanks so much for listening.
Melanie Cole (Host): According to the American cancer society, Prostate cancer is the most common cancer among men (after skin cancer), but it can often be treated successfully. More than two million men in the U.S. count themselves as prostate cancer survivors. My guest today is Dr. Monish Aron. He's a urologist and a member of the medical staff at Palmdale Regional Medical Center as well as a member of the medical staff at Keck Medicine of USC. Welcome to the show, Dr. Aron. Tell us about what's going on with prostate cancer right now. What do you want men and women who love them to know about getting in to see a doctor to get checked?
Dr. Monish Aron (Guest): Hi, Melanie. Prostate cancer is, as you said, one of the most common solid organ cancers amongst American men. It is estimated nearly 250,000 new cases of prostate cancer will be diagnosed every year in the United States. The majority of these cancers, when they are diagnosed, are low-risk cancers, but there are a few patients who will have intermediate-risk to high-risk prostate cancer, as well. Most prostate cancer is diagnosed when patients present to their family physicians or their urologists and have a blood test which is a blood test for PSA, or prostate specific antigen. If the PSA is elevated, then this leads to a patient being referred to a urologist or investigations. Now, normally, a PSA less than 4 nanograms per ml is considered to be normal and any PSA above 4 nanograms per ml is considered to be abnormal. Now, keep in mind that not all abnormal PSA means cancer. In other words, PSA is prostate specific, not cancer specific. So, an elevated PSA does not necessarily mean cancer and it needs to be investigated.
Melanie: Does the PSA go along with a digital and diagnosing prostate cancer and do you think that that's the reason so many men are hesitant to come in to get this test?
Dr. Aron: Usually, a digital rectal examination should be performed in man because an additional rectal exam can point to a more significant cancer than just a PSA. In other words, if there's a palatable abnormality on the digital rectal exam, that would indicate that there could be a significant cancer in the prostate. So, a digital rectal examination should be performed whenever a patient over the age of 40 goes to see his primary care physician or a urologist and there really is no reason to fear a digital rectal examination. It is very straightforward and should not really be feared.
Melanie: So, you'd like men to start at the age of 40 coming in for a baseline PSA and then how often from there?
Dr. Aron: There is no reason to go in for a baseline PSA at the age of 40 unless you have a strong family history of prostate cancer. In fact, currently a routine prostate cancer screening is not indicated. However, if a patient goes to see a urologist for a prostate-related complaint, then at that time, is when a digital rectal examination should be performed.
Melanie: So, what would be a prostate-related complaint? What are some symptoms that might signal that somebody has something going on with their prostate?
Dr. Aron: Well, the most common ailment with the prostate is benign enlargement of the prostate which leads to urinary symptoms. Prostate cancer itself doesn't cause too many symptoms, at least not in the early stages. So, most patients, when they are in their middle ages start complaining of the urinary frequency, some slowing in their urinary stream, and some urgency of urination, and these are the usual symptoms associated with an enlargement of the prostate which most men in their middle ages will experience. Now, these symptoms are not symptoms specific of prostate cancer. These are not symptoms of prostate cancer. These are symptoms of an enlargement of the prostate and most patients see their urologist because of these symptoms and, when they do that, a digital rectal examination should be performed at that time.
Melanie: So then, if you have a man that comes in and you have diagnosed prostate cancer, what is next?
Dr. Aron: So, before we talk about the diagnosis of prostate cancer, I just want to talk about what to do if somebody has an elevated PSA. So, if somebody has an elevated PSA, usually one has to discuss with them about the need for a prostate biopsy. Now, not everyone should undergo a prostate biopsy if their PSA is elevated. So, if somebody that is elderly and has significant comorbidities and their digital rectal examination is normal, and their PSA is borderline, one may not need to do a biopsy. There are various calculators one can use online such as the PCPT Calculator which can indicate the risk of harboring cancer within the prostate. And, if that risk is very low or if the patient has significant comorbidities, there may not be any need to do a biopsy. However, if the PSA is significantly abnormal, if the digital rectal examination is abnormal, and the patient is relatively young, then a case be made to offer the patient a prostate biopsy. Basically, the decision-making should be a shared decision-making between the patient and their urologist and both should agree on the best course of action. Now, assuming that the patient and the doctor agree that a prostate biopsy is the appropriate course of action, then a prostate biopsy should be performed and this is typically done in the urologist's office using a trans-rectal ultrasound probe. So, the ultrasound probe is placed in the rectum, and under local anesthesia, multiple cores are taken from the prostate to obtain the prostate biopsy and that is sent to the pathology lab. In about a week or so, the pathologist will send out a report which will have a significant amount of information including whether or not there is cancer on the biopsy and, also, if there is cancer on the biopsy, what is the grade of the cancer, which is called the “Gleason grade”. Combining two of the most common areas of the cancer gives you a Gleason Score. So, the pathology report will tell you whether or not there is cancer. It will tell you what is the Gleason Score of the cancer, and also tell you the volume of the cancer--that means how many cores are involved and what is the percentage involvement of the cores. Once the urologist has all that information, then, again, in consultation with the patient, one has to decide on the best course of action.
Melanie: So then, how do you decide with your patients once you have determined all of these factors coming together--radiation, and chemotherapy, surgical intervention--how do you go about starting the process?
Dr. Aron: So, there are multiple factors which determine what is the best course of action for a given patient. These include the patient's age. Number two is the comorbid conditions, which includes what are the other ailments that a patient might have. Number three would be the race of the patient. Number four would be the extent of the cancer, which would be the staging of the cancer. And number five would be the Gleason Score of the cancer. So, if a patient is relatively elderly and has a low volume, low-risk cancer, it is possible that one might decide not to do any active treatment and offer the patient active surveillance. So, basically, the treatments can be divided into whether or not the patient has localized organ-confined disease, or whether the patient has metastatic disease, which means the cancer is beyond the prostate. If a patient has an organ-confined disease, that means that the disease is confined to the prostate, based on the pre-operative imaging such as a CT scan and a bone scan, which can be awkward when indicated. But in that situation, there are basically five treatment options that a patient has. One of them is active surveillance. The other one is surgical excision of the prostate. So, there's radiation, of which there are various forms. Number four is freezing the prostate and number five is what has recently become available in the United States which is high-intensity focused ultrasound. So, these are some of the options with patients with organ-confined disease. For patients who have metastatic disease, that means the disease is beyond the prostate, usually the standard of care is offering them hormonal therapy in the form of androgen deprivation. Because prostate cancer is an androgen-sensitive tumor, that means the prostate cancer cells need androgens to support their growth, if we deprive these cancer cells of androgens, they will shrink. Androgen deprivation therapy does not cure the cancer, but it keeps the cancer under check for a few years. Recently, there are some emerging data that one can also chemotherapy with docetaxel to the hormone therapy and that has improved some of the outcomes in these patients with metastatic cancer.
Melanie: That was just such an excellent explanation, Dr. Aron. Really, really succinct; very well spoken. So, tell the listeners what you would like them to know about all of these different types of therapy and what they can expect for their loved one or for someone with prostate cancer.
Dr. Aron: So, we can go over these therapies one by one. Active surveillance means you are watching the patient and their PSA and their cancer over time. You are not ignoring it; you're watching it carefully over time. Active surveillance, in general, is offered to people who have very low-risk, low volume cancer. Also, it is ideal for patients who are older. Some young patients may also choose to undergo active surveillance because they are concerned about the side effects of the different treatment options, such as surgery or radiation. For the most part, active surveillance is ideal for low-risk, low volume cancer. The second option is surgical excision which is called a “radical prostatectomy”. It can be done robotically or open surgically and is a treatment which has been around for over three decades. There are excellent data with the radical prostatectomy or surgical excision of prostate cancer. Currently, the vast majority of radical prostatectomies are performed robotically. The main side effects of a surgical excision of a prostate include erectile dysfunction and urinary incontinence. The urinary incontinence usually gets better with time and in about 6-9 months, over 90% of the patients will regain continence. The erectile dysfunction takes longer to recover and sometimes there will not be complete recovery of erectile dysfunction. So, these are the two main adverse effects of surgery for prostate cancer. However, surgery has been the vanguard for treatment of prostate cancer for a long time and there are robust data about its efficacy. The third option is radiation. There are various forms of radiation. One is called “seed implantation” or “brachytherapy” where radioactive seeds are implanted inside the prostate and they deliver radiation locally to the prostate. Another form of treatment is external beam radiation Currently, the most popular external beam radiation methodology is called IMRT or intensity-modulated radiation therapy and that delivers a beam of radiation from the outside onto the prostate, and can also cover the surrounding areas, and can also cover the lymph nodes in the pelvis. The fourth option is freezing of the prostate or cryotherapy, and the fifth option is high-intensity focused ultrasound which ablates the prostate using heat. Now, both of these modalities which is cryotherapy and high-intensity focused ultrasound are approved for ablation of prostate tissue, but not necessarily for the treatment of prostate cancer. So, one has to keep that in mind when undergoing these treatment options for prostate cancer.
Melanie: So, in just the last few minutes, Dr. Aron, what should people with prostate cancer think about when seeking care?
Dr. Aron: A lot of men think about what their outcomes are going to be in terms of cancer specifics survival and overall survival. In addition, they think about incontinence and erectile dysfunction. These two things weigh heavily on the mind of a patient when they are seeing the urologist and having a discussion about treatment options. And these are real concerns because quality of life is important and these treatment modalities might impact the quality of life. The least impact on the quality of life is with active surveillance which is where you are monitoring the patient's PSA and following them along. The maximum impact on quality of life with a major effect is with surgery, but the side effects from the surgery usually get better with time. Radiation also impacts quality of life. Not right away, but it does so over the next few years. With cryotherapy and HIFU, the impact on quality of life is less well-defined because robust data are not yet available as much as they are for surgery and radiation, but over the next few years, we will probably have some more data in this regard.
Melanie: And why should they come to Palmdale Regional Medical Center for their care?
Dr. Aron: Well, at Palmdale Regional, we have the ability to provide high-quality care for these patients and they will get the optimal consultation where they can discuss all the options and appropriately decide what is the best course of action for them and their family.
Melanie: Thank you so much, Dr. Aron. What great information and so important. Thank you for being with us today. You're listening to Palmdale Regional Radio with Palmdale Regional Medical Center. For more information, you can go to palmdaleregional.com. That's palmdaleregional.com. Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole, thanks so much for listening.