Common Sense Approach


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My Commentary relates to Dr. Steve Strumís Article Referenced from several years ago in the PAACT Newsletter.  Dr. Strumís comments on the Lack of Consistency with Treatment Options among Physicians and Treatment Sites Across this country remain timely and necessitate additional dialogue.  In my opinion, the Inconsistency in Treatment Options for prostate cancer will be slow to change, if at all.  Physicians and Treatment Centers are created equal, but what one does with the diagnosis of prostate cancer varies significantly across the country in the Application of Judgment and Treatment Selection and therefore, the Treatment Outcome.  While we may not have the scientific means to state unequivocally the best Treatment Choice for a particular favorable grade and stage of Prostate Cancer, we do have the ability to Predict with some Accuracy which procedures will likely fail based upon negative parameters studied extensively by Research Experts.  Therefore, we know that certain combinations of Prostate Cancer Risk Factors including but not limited to:  Total PSA, Percent Free PSA, PSA Density, Velocity Change, Ploidy, Tumor Burden and Gleason Score will predict failure. Our job, collectively, is to apply the data uniformly, sensibly, and without bias. 


As a Physician and Urologic Surgeon, I understand the futility of Understaging Prostate Cancer.  None of us want to tell the family or patient that we did not get all of the cancer and that Radiation is next.  None of us want to admit or promote failure in what we were trained to do.  As a group, however, we have failed our patients, as our collective level of success with Prostate Cancer treatment is tantamount to ďa flip of a coinĒ.  We have not failed the treatment intended based upon a lack of skill, but rather an irrational application of the disease factors applied in an overzealous manner.  We have failed to learn from our previous outcomes, other physician experience as noted in the literature, and/or a lack of willingness to apply Common Sense. 


I recently heard from a 63 year old man in Texas who had a PSA of 14.9 ng/ml with presumed Organ Confined Prostate Cancer.  It would appear that Dr. Allan Partinís work from Johns Hopkins Medical School (relating to PSA and organ confined disease) was road-blocked at the Texas Border.  Based on Partinís data, this man had no better than a 50% chance for cure using either Radical Prostatectomy or Radiation (Seeds and/or External Beam).  While the physician may have given the patient a 50% chance for cure, one must question the choice of treatment with such low odds for success.  The patient, nevertheless, underwent Radical Prostatectomy and failed to be cured based on a rising PSA following the surgery.  The patient subsequently received Radiation Therapy with no counseling on Hormonal Manipulation.  This patient case represents another lost opportunity at success and/or improved patient management.  Additionally, this patient never received any counseling on Cryosurgery, a Bonafide Contender to Cure, if one exists at all.  Granted, no one knows for sure if this patient would have been cured by Cryosurgery, but in my opinion, minimally, he would have had a fighting chance as Cryosurgery is the least aggressive option for cure.  That said, my first choice would have offered him a plan of Intermittent application of Anti-androgen therapy with either High Dose Casodex or Eulexin as a Monotherapy, using PSA action points to guide when to start and when to discontinue the medication.  More importantly, the time on anti-androgen therapy would allow the patient the chance to enhance his outcome through improved education and possibly improve his outcome. While I personally believe that Radical Prostatectomy should not be offered to any patient with a PSA of greater than 10 ng/ml based upon the work of Allan Partin, M.D. and others, my previous surgical experience served as an example from which I learned.  I have had patients with Cancer Negative Margins, based on the path report, suggesting success, who failed Radical Prostatectomy as witnessed by a rising PSA post operatively.  Examples of patient failure from Radical Prostatectomy in my practice include men with diagnostic PSA values of 11.3 ng/ml, 13.4 ng/ml, 15.6 ng/ml, and 22.6 ng/ml.  These patients were scared and thought Radical Prostatectomy would give them the greatest chance for cure based on the opinion of others.  While I did not disagree with them at the time, I now know better. Patients are reminded that a PSA value of less than 10 ng/ml does not guarantee success with Radical Prostatectomy either.   I was recently reminded of a case of failure associated with a 56 year-old gentleman from Virginia, whose PSA began to rise within 3 months of his Radical Prostatectomy, despite a diagnostic PSA of only 6.6 ng/ml, a Gleason score of 7 and clear surgical margins.  Therefore, Total PSA, Gleason Score and clear surgical margins pathologically, mean little to the potential final outcome for many patients.  The decision to treat prostate cancer with surgery is much more complex than finding a time slot on the operating schedule while taking the prostate out as quickly as possible.  I, therefore, encourage a complete, unbiased discussion of all pertinent treatment options with full knowledge of the worst-case scenario possible.  Stabilization of the disease through Hormone Manipulation with either Combined Androgen Blockade (CAB) or a form of Monotherapy will give patients a chance to avoid growth of disease while continuing the educational process.  Patients are reminded that the best form of therapy may avoid surgery altogether.  It is possible to live with the disease, as a chronic disease in many cases, if a physician coach can be found to intelligently guide the clinical course. 


Given my previous dialogue, how in world could a surgeon with good conscience remove the prostate of a 72 year-old man with a PSA of 380 ng/ml?   This man failed to be cured by the procedure, but more importantly, was forced to struggle for his life with a 3 week stay in the Intensive Care Unit battling complications of his surgery including Phlebitis and Pulmonary Embolus (a blood clot to the lungs).  To make matters worse, he received radiation to the surgical site and subsequently suffered from a bladder neck contracture (scarring) and sepsis (systemic bacterial infection that could cause death).  This case exemplifies the pervasive ignorance within our profession when we use the ďOne Size Fits AllĒ approach to our disease treatment decision model.   We had information in the late 80ís that should have guided a skilled surgeon in the mid 90ís from making this errant treatment recommendation.  While I would stop short of calling this travesty a case of malpractice, it minimally represents gross mismanagement, poor judgement and the inability to apply Common Sense, where the physician was asked to guide the patientís decision.  My argument is not with the physician, who should have applied better judgement, but rather, with the patient who canít afford to allow ignorance to play a role in this all important decision process.  All patients must learn to question their physiciansí recommendation as related, primarily, to side effects and expected outcome.  Patients who feel inadequate to challenge the authority of their physician are encouraged to get second, third, and even fourth opinions.  To qualify as an additional opinion, the physician must have a different approach from that given by previous caregivers.  


All patients who fail to be cured from prostate cancer with so-called Definitive Therapy, based primarily on a rising PSA, will live to battle the devastation of this disease another day without the knowledge of when, where, or why the battle needs to continue.  Men are reminded that a successful battle plan includes proper diet, appropriate nutrition, exercise, stress reduction, continued education, and an individualized treatment course tailored to the specific patient and his needs. My heart grows heavy for the patient and the unsuspecting family as I struggle to re-establish some semblance of quality of life and attempt to suppress the resurgence of an aggressive disease.


In the year 2002, I would encourage patients who feel the need to defeat prostate cancer to learn more about Cryosurgery.  Cryosurgery is the least invasive, least traumatic, yet equally effective form of definitive therapy when an attempt at prostate cancer cure is considered.  Despite this fact, fewer than 5% of all prostate cancer cases are associated with Cryosurgery while fewer than 1% of Urologists are involved.  Patients need to know that Cryosurgery is no longer experimental and has been approved by the American Urology Association, Medicare, and most insurance carriers.  In my opinion, there is no gold standard in definitive treatment for patients with prostate cancer.  Thus, Radical Prostatectomy, Radiation therapy, and Cryosurgery continue to be investigative for all physicians.  Excepting the patient with the PSA of 380 ng/ml, Cryosurgery would have been my first choice for all patients with a PSA of greater than 10 ng/ml.  That does not suggest that Cryosurgery would not be equally effective for men with a PSA of less than 10 associated with prostate cancer.  Our clinical Cryosurgery experience with more than 50 cases shows a 92% ďcure rateĒ at 8 years for men with a PSA less than 10 ng/ml.  These patients were considered cured with an undetectable PSA and a negative biopsy.  Significant patients were cured with higher PSA values but the percentage cure dropped dramatically once the PSA was noted above 10 ng/ml.  While our Cryosurgery data is excellent, none of this would be possible without a willingness to understand and learn the benefit of this unique, innovative and patient friendly procedure.  No longer, in my practice, are patients with a total PSA of greater than 10 ng/ml offered Radical Prostatectomy.  I refuse to promote a procedure replete with significant and predicted failure and call it good medicine.  I am convinced, while I do not have all of the answers, Common Sense added to my present medical knowledge will allow me an improved opportunity for eradication of prostate cancer in most patients who have curable disease.  I encourage and challenge my esteemed colleagues to do a little soul searching and evaluate their personal practice data for success with their prostate cancer patients.  We must not deny our patients all viable treatment options today, while we will take 10 years or longer to validate the appropriateness of what we endorse.  I believe our success ratio will rise collectively as we begin to look at other alternative techniques and become more selective with the application of Radical Prostatectomy.  Earlier detection of prostate cancer demands greater scrutiny of treatment application if we expect to improve our track record collectively.  While Cryosurgery is not a panacea for all prostate cancer, it comes closer to achieving that end than more traditional and frequently applied methods of Radical Prostatectomy and Radiation, in my opinion.  Many thousands of patients will face an uncertain future of Incontinence, Impotency, and Disease Recurrence if we change nothing at all while protecting traditional values that no longer apply and/or have become obsolete.  I encourage all physicians to take the initiative and get on board the train of thought to understand all of the risk factors more clearly, re-evaluate their decision making process and start treating their patients as they would want to be treated themselves.  If a patient is going to make the ultimate sacrifice and give up his prostate based upon our skill and judgement, let us then, give him the educational tools to build upon so that the decision made is patient driven and accepted and not physician dependent.