Focus on Prostate Cancer

M. D. Anderson Cancer Center
Date: May 2010

>> Ron Stone Jr.: In the heart of Houston's Medical Center is MD Anderson Cancer Center.  What happens here affects cancer care around the globe. But what do you do when a cancer diagnosis hits closer to home?

>> Getting the diagnosis is like being handed a manual saying, "Here, be an engineer tomorrow."  You know?  It's like there's endless amount of reading to do on this topic.  But what I can often do and most of my colleagues do is just help them organize all this information.

>> Ron Stone Jr.: Prostate cancer is the second most common cancer in American men.  Coming up, learn the facts about prostate cancer from the experts at MD Anderson.  And hear first hand stories from cancer survivors. 

>> You know, I'm about to turn 62.  Nobody lives forever but you sure would like it longer rather than earlier and you certainly would like a quality of life in those years. 

>> Ron Stone Jr.: Join us for this edition of MD Anderson: Making Cancer History, Focus on Prostate Cancer.

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>> Ron Stone Jr.: Hi, I'm Ron Stone Jr. and welcome to MD Anderson.  Last year nearly 200 thousand American men were diagnosed with prostate cancer, making it the second most common type of cancer to be found in men.  So what do you do if you or a loved one are diagnosed with prostate cancer? 
In the next half hour, we'll lay out all the facts, your risks, symptoms, screening guidelines and of course treatment options.  But let's begin by looking at the basics. 
The prostate is a small gland found only in men.  It's roughly the size of a walnut.

>> Prostate is basically a sexual organ. It modulates or changes the pH of the seminal fluid.

>> Ron Stone Jr.:  PSA screening, done through a simple blood test, is the most common way to detect prostate cancer.

>> PSA stands for prostate specific antigen, it”s a protein that is secreted by prostate cancer cells or normal cells.  So if you have a hundred men who have prostate screening, about 85 men would have a normal PSA: so a PSA less than 4.  And about 15 men would have elevated PSA.

>> Ron Stone Jr.: An elevated PSA doesn't always mean cancer.

>> PSA tests can be elevated due to prostatitis or inflammation of the prostate or from a urinary tract infection.

>> Ron Stone Jr.: Often, a PSA test finds the disease before most men show any symptoms. 

>> The strong majority of patients feel fine and they've been told that a blood test, you know we don't like the numbers, and they're told to go see a specialist on this.

>> This is the bladder here.  This is the prostate here.  And behind the prostate is the rectum. Most of the cancer started out in what we call the peripheral zone.  That's kind of the back part here.  Again, most men these days have no symptoms at all and have nothing found on digital rectal exam.

>> Okay.

>> I had been going regularly to my family physician here in Houston.  And it would have been 15 months prior to the test that caused concern, my PSA had been normal.  And 15 months later, I went in and it was elevated.  And it was elevated from normal of about 1.8 to 4.

>> Ron Stone Jr.: Age, family history, and race are all risk factors for prostate cancer.  Menno's  physician decided to monitor his PSA levels.

>> A month and a half later, it had gone up to 5.3.  And so it was clearly not going in the right direction.  So at that stage the doctor suggested it was time for a biopsy.

>> Ron Stone Jr.: George Strake's family doctor became suspicious after a routine physical and sent him for further testing. 

>> I went to this urologist and he said, "I think we better take a prostate biopsy."  And I went in for the biopsy and it didn't hurt at all.

>> Ron Stone Jr.: Prostate cancer is generally a slow growing cancer so patients have time to consider all their options.

>> People looked at various studies in terms of what the difference in time between a biopsy and the definitive treatment and essentially there's no difference in the outcome within 6 months for most men.

>> Obviously when a patient is given a diagnosis of cancer, the first thing they immediately think is, "I have to do something.  This is an emergency."  But making a treatment choice in an emergent way is not always the best thing to do.  So very often, there are options and patients need to hear about those. 

>> Ron Stone Jr.: Prostate cancer patients are seen by multiple specialists on their first visit to MD Anderson. 
At MD Anderson, men with prostate cancer may be seen in the multi-disciplinary Prostate Cancer Clinic. Here, they get the opinions of multiple doctors all in different specialties. 

>> If we start with the big picture, we have all the disciplines and that's what our multi-disciplinary clinic is all about.  So you start by seeing you know all of the appropriate physicians to hear first hand about the treatments that might be options.  And then once you choose a treatment, you're going to see an expert in the field. 
We also have experts in imaging.  So for prostate cancer we very often use CAT scan,
MRI, bone scan to be sure that the cancer has not escaped the prostate.  And so here we're so specialized that each of us may only do you know 1 or maybe 2 things.  If we only do 1 thing, we should be good at it. 

>> Ron Stone Jr.: Dr. Kuban specializes in radiation for prostate cancer.  And Dr. Davis is focused on prostate surgery.  But they work side-by-side in the same clinic.

>> Instead of talking back and forth with letters, we're actually in the workroom together.  We actually present the cases to each other. 

>> We have really team of doctors that we can always consult with.  And it's really a privilege to be here and be a part of the team.

>> Ron Stone Jr.: A patient's first visit to the clinic starts and ends with a visit with the Advanced Nurse Practitioner.

>> My name's Lydia. I'm the nurse that works with both Dr. David and Dr. Choi  And you're going to see both today.  We call it the multi-disciplinary clinic.

>> We have an Advanced Nurse Practitioner who is present in every clinic.  And she basically coordinates between the physicians and the patient and she's one of the main contain points for the patient. 

>> Dr. Davis will come in and he'll talk to you about all the appropriate options for you for prostate cancer treatment, from the surgical perspective. 
When he's all done, he'll go out and talk with Dr. Choi who will then come in and talk to you about radiation based options. 

>> Ron Stone Jr.: Patients can call MD Anderson directly for an appointment or may be referred by their physician.

>> The doctor himself had had prostate surgery 16 or 17 years ago at MD Anderson.

>> Ron Stone Jr.: Either way, the clinic process is the same. 

>> For every patient we see, we always get the slides of their biopsy and we always have the slides looked at or as we say read by our pathologist just to verify Number 1 that the patient has cancer, but then to give us all the information possible about that cancer. 

Is it more slow growing?  Is it more aggressive?  What has it invaded?  And our pathologists are very expert in that because just as each of us treat only certain malignancies and only do a certain treatment for that malignancy such as radiation or surgery, our pathologists are all very specialized as well.  So we have a small group of pathologists who look at only prostate cancer.

>> Ron Stone Jr.: Like all prostate patients on their first visit, George met with multiple doctors.

>> One was a proton expert, one was robotic surgery and one was radiation.  What I liked about it was each one of them examined me and sat there and gave me their idea of what their discipline could perhaps do for me.  Then they huddled up in private.

>> We confer with each other.  We try to consider everything about the patient's situation: the tumor stage, the way it looks under the microscope, the PSA level, the patient's other medical problems, the patient's age, their lifestyle, any other social issues they might want us to take into account.  And we like to put all of that together and look at the pros and cons of each treatment and come up with a joint

>> Ron Stone Jr.: If a case is particularly challenging, the entire team of clinic physicians meet to discuss the patient's options.

>> It's a weekly conference where we have all the treating physicians present as well as radiology and pathology.  We usually review about 3 to 5 cases that have a particular challenge to them or of interest to everybody. 
And everything at MD Anderson is on a digital electronic medical record so we basically can put up on the screen all of their x-rays, all of their biopsy slides, their medical history, present the case and we try to come up with sort of a group consensus of how we want to do this.

>> Ron Stone Jr.: Everyone at MD Anderson is working in the patient's best interest.

>> I felt like they were really telling me what was best for me and not look -- each discipline looking at a customer as a dollar bill.

>> Ron Stone Jr.: Multiple treatment options are available to men diagnosed with prostate cancer. 

>> I mean essentially there are only 3 main ways to treat cancer is chemotherapy, radiation and surgery: I mean as a whole.

>> Ron Stone Jr.: Most prostate cancer patients choose radiation or surgery as their primary treatment. 

>> If you compare a quality surgery to a quality high dose radiation technique, the cancer control for around you know 10 or 15 years of follow-up is essentially the same.

>> It's not about whether or not we can get rid of the cancer.  Typically we have a very good chance to do that.  The patient's dilemma though is just choosing which way they want to do it and that's what I tell them.  I tell them, "You know, you can expect a very good outcome.  That's
the good news.  The bad news which is not really all that bad is that you have to choose how you want to do it."

>> Ron Stone Jr.: Patients are educated on their potential treatment options.

>> We have a very nice multi-disciplinary educational piece for the patients talking about the various treatments, the pros and cons, etcetera. 

>> Just do you don't feel like you've got to remember everything that's said, we've got this handout for you.  Yeah, it's about 30 pages.  It covers everything that they're going to discuss with you today.  And what we'll do is after everyone has seen you and everyone's examined you and told you their specific recommendations, I'll come back in and I'll give you a summary letter that will just list what their recommendations are.  So please don't leave until I say goodbye.

>> Following the visit, the patients get to take a letter home with them that's done real time.  So we do this while they're in the clinic and we actually hand them the hard copy of something so that when they get home, they can refresh their memory about the treatment options we told them you know might be best for them. 

>> Ron Stone Jr.: So, how do you decide what's best for you?

>> I find it's helpful to have the patients organize their thoughts. One is, "Do I need cancer treatment at all for the prostate cancer?"  Which is kind of an interesting question because the mission of MD Anderson is to eliminate cancer and yet in the specific area of prostate cancer, sometimes we don't need to do that.  If it's a small, low grade tumor they can be put on active surveillance and we have a special program for how to organize that. 
Now Step 2 is kind of more lengthy.  And that's the fundamental differences between surgery and radiation.

>> Ron Stone Jr.: Patients are counseled on the potential side effects of prostate cancer treatment and given the information needed to make a good decision.

>> The overall burden of quality of life between the two is very similar, just the details are different. Surgery has more stress incontinence and more early problems with sexual function, both of which have a good chance of healing. 
Radiation then is just more irritative effects on the bowel and bladder and a little bit of treatment related fatigue. 

>> Ron Stone Jr.: The doctors here realize that patients are presented with lots of information and are there to help sort through it all. 

>> You're in what we would call our lower risk group, okay?

>> Okay.

>> So we have 3 different kinds of strategies.  We have the classic radical prostatectomy which you've heard about.  We have 2 other strategies too.

>> What I can often do and most of my colleagues do is just help them organize all this information.  It's sort of like getting the diagnosis is like being handed a manual saying, "Here, be an engineer tomorrow."  You know?  It's like there's endless amount of reading you could do on this topic.

>> They were very open and they gave me all the time I needed to talk to them.  And it wasn't just an issue of sympathy or holding my hand or “There, there.”

It was actually talking on those topics that I had researched to the degree I as a non-medical professional could. 

>> You're welcome.  I'll see you later.

>> Ron Stone Jr.: Men with prostate cancer may choose to be treated with radiation.  MD Anderson offers multiple kinds of radiation all delivered by true experts in cancer.

>> So there are 2 ways to do external radiation: one with x-rays and one with protons which are positively charged particles.  So they both entail a series of treatments.  The average amount is about 7 and a half weeks of treatment so in the 30 to 40 treatment range. 
And so it's once a day, 5 days a week.  The patient must come each day to the center.  The time on the treatment table or the actual treatment time, it's only about 15 minutes.  So it's actually - you know - quite quick.

>> Ron Stone Jr.: Many patients are able to maintain to maintain their lifestyle throughout their radiation treatment. 

>> And I figured out how I could get from my home to the hospital for my 9 o'clock appointment, and then I was usually in my office downtown by 10 o'clock so it went like clockwork.

>> Ron Stone Jr.: George had external radiation called IMRT or Intensity Modulated Radiation Therapy.

>> We've come a long way in radiation techniques.  I mean if we go way back to the most simple technique, we used to use 2 beams: one from the front and one from the back. 
And then we were able to apply computer technology and in doing so, then we got to see the radiation doses and the beams in 3-dimensions.  So we used a CAT scan to plan the treatment and we could see how the beams were applied and we could see how the dose would fall around the prostate and the normal tissues. 
And then from that we progressed to the IMRT or the Intensity Modulated Technique where not

only did we apply multiple beams from multiple angles, but during each one of those beams the normal tissues could be blocked at a precise time during the treatment., so as to shield the normal tissues as much as possible from the highest radiation dose. 
And by doing that, we were able to target the prostate maximally and avoid the normal tissues. 

>> Ron Stone Jr.: Proton therapy is also external radiation.  MD Anderson is one of only 7 centers in the United States offering this treatment.

>> Protons are different in that instead of x-rays, they're using actual protons which are small particles.  Now these particles, they may deposit a little bit of radiation as they enter the target or into the patient, but they deposit the majority of their dose right where the target is: right where that tumor is.

>> Ron Stone Jr.: Proton therapy allows extreme precision in targeting the tumor which may lead to decreased side effects.

>> Prostate cancer is a disease site where we have to treat with a very high dose of radiation in order to insure that we have the best tumor control.
However, adjacent to the prostate are a number of sensitive areas that can be prone to radiation side effects: typically the bladder, bladder-neck as well as the rectum.
Proton therapy has the ability to treat high doses to that tumor target which typically is the entire
prostate and minimizes much of the radiation dose as possible off the bladder and rectum.  And that will subsequently lead to fewer side effects. 

>> Ron Stone Jr.: MD Anderson offers the most advanced technology to their patients, delivered by cancer experts.

>> I think MD Anderson has one of the most sophisticated and advanced proton therapy centers in the world.  But having wonderful technology is only part of the solution. 
We have the luxury of having some of the most profound experts in the field and some of the most dedicated professionals in order to execute that technology appropriately.  You know, having the fancy tools and the wonderful technology will only get you part of the way there.  If you don't have the expertise in order to use it appropriately, you're not going to get the job done.

>> Ron Stone Jr.: IMRT and proton therapy are both forms of external beam radiation.  Internal radiation may be another option.

>> Internal radiation is what we call brachytherapy.  And brachy simply means short distance in Greek. 
So by inserting these small radioactive seeds that are the size of a grain of rice into the prostate, they're able to emit radiation.

>> Ron Stone Jr.: Brachtherapy involves implantation of seeds that emit radiation over a predetermined time. 

>> The seeds are inserted into the prostate through the skin.  And the amount of seeds can range from anywhere between 80 to 100 seeds.  Number of seeds are dependent on the patient's prostate and so they're individualized to the patient. 

>> Ron Stone Jr.: MD Anderson is the only center of excellence in Texas performing brachytherapy.

>> The seeds are permanent, meaning that following the completion of the treatment, they will stay in the patient.  They are titanium and so they're inert and they will not harm the patient in any way. 
The treatment itself takes approximately an hour and following their treatment, they're able to be discharged home and are generally back to their normal daily activity in a couple of days.

>> Ron Stone Jr.: Surgical removal of the prostate is another option for patients.

>> If the decision is for surgery, then my job is to sort of take over and say, "Alright, how can I deliver that surgical care and make it perfect and limit the amount of side effects to them?"  And that's really the goal. 
And the MD Anderson environment allows a surgeon like myself to get all the practice you could ever need, all the experience you could ever need and you have a whole network of friends and colleagues to lean on for advice and for help.  So you're not working in isolation.  You're working as part of a team.

>> Ron Stone Jr.: As a part of that team, Dr. Davis performs minimally invasive robotic surgeries. 

>> I still trained in the era where as a resident and fellow we did all open surgery and with a lot of practice that operation can work very well for patients. 
Two of the biggest obstacles for a successful operation of the prostate is being able to see it way down the pelvis, and then dealing with limiting blood loss.  So the minimally invasive environment basically fixes both of those problems.  You basically have a slow, very minimal bleeding case.  You can see extremely well.

>> Ron Stone Jr.: Whether it's an open or a minimally invasive surgery, the goal is a successful outcome for the patient.

>> All these cancer operations are called radical this, radical that.  Radical always meant you took out the organ and a lot of stuff around it to get a good margin. 
With the prostate early diagnosis, often we're only taking out the prostate right at its edge and trying to spare all the surrounding anatomy that can affect man's sexual and urinary functions. 

>> Ron Stone Jr.: Studies show that experience affects patient outcomes.

>> I tell patients the only variable you can control with your diagnosis if you're going to pick surgery is a high volume surgeon who is good at the technique they do.  And in my case it's robotic surgery.  We do have surgeons who are excellent at open surgery and that still works in a high volume center as well.

>> Ron Stone Jr.: After meeting with his MD Anderson team, Menno chose robotic surgery.  Dr. Davis customized his procedure for the best possible outcome. 

>> We went to surgery and did basically the adjustments I've made for high grade prostate cancer robotically where we use an MRI image to help direct how we do the surgery on the prostate.  And then we do a very detailed lymph node dissection. 

>> The feedback immediately from Dr. Davis to my wife was all so very appreciated, the fact he came out and said, "You know, this one wasn't without its challenges but it looks like it's come out well." 

>> Ron Stone Jr.: Menno spent one night in the hospital with no complaints.

>> Nothing short of miraculous in my mind.  It really was.  And honestly, there was no pain.  I was moving - like I say - moving carefully of course but you know the pain killers that they gave me, they're still in my closet. 

>> Ron Stone Jr.: The experts at MD Anderson have access to state of the art treatments for cancer, but for some men the best option is actually no treatment at all.

>> About 40 percent of men have early prostate cancer that are low risk.

>> Ron Stone Jr.: Low risk is defined by tumor stage, PSA level and Gleason score. 

>> Patients with a Gleason score 6 or less, PSA less than 10 and lower clinical stage - that is T1 or a T2 - which means that the cancer is clinically organ confined to the prostate.

>> Ron Stone Jr.: For patients who fall into this low risk category, active surveillance - also known as watchful waiting - may be an option.

>> These men could be followed without any immediate treatment for a long time without really impacting their life expectancy.

>> Ron Stone Jr.: A patient's overall health and lifestyle is a factor in determining if he qualifies for active surveillance.

>> An interesting statistic is that still the Number 1 cause of death in men is cardiac disease.  And actually once you have prostate cancer, the Number 1 cause of death is still cardiac disease.  So we do go over some of the lifestyle issues. 
One thing that's convenient about all this is basically anything that your family doctor or cardiology physician tells you to do for heart health, all of that is good for prostate cancer as well.  In terms of low fat diets, losing weight, control your blood pressure, you know monitor your cholesterol: all this can help your prostate cancer in terms of incidence and potentially how severe it can be.

>> Ron Stone Jr.: Age is another risk factor.

>> Patient's life expectancy has a big role in terms of choosing watchful waiting versus active treatment.  You have the Senior Multi-Disciplinary Prostate Cancer Clinic where we see patients who are diagnosed with a prostate cancer and who are 75 years or older. 

>> Ron Stone Jr.: MD Anderson has a protocol for monitoring patients on the active surveillance program.

>> The basis of active surveillance is an exam and as part of that, a digital rectal exam and a PSA.  And built into our protocol actually is a biopsy or a repeat biopsy after the first year to determine in a little bit more detail if the cancer is progressing or not if we find more on biopsy versus not.  And then depending on the results of the first biopsy, we might recommend a biopsy again in one year or perhaps in 3 years. 

But we have a whole protocol and a whole algorithm so that all of this is done in a very systematic way.

>> Ron Stone Jr.: MD Anderson has created a unique support group for men who choose not to have treatment.

>> Certainly it is really anxiety provoking for patients to have cancer in their body and not really doing anything about it.  In order to alleviate you know some of their anxiety, we have started patient support group meetings on a monthly basis since 2007.  And we believe that you know, empowering patients with knowledge about you know different aspects of prostate cancer has been very helpful and I think is one of the ways to alleviate some of their anxiety. 

>> Ron Stone Jr.: At MD Anderson you'll find the top cancer experts, the latest technology and ground breaking research, but the focus is and always will be on the patients. 

>> I'm about to turn 62.  Nobody lives forever.  You sure would like it longer rather than earlier and you certainly would like a quality of life in those years.

>> Ron Stone Jr.: Quality of life for patients is a top priority at MD Anderson.

>> You know, the whole institution is just so pro-patient.  I mean you know everything goes toward doing our best for the patients and you see it in everybody's attitude.  We so very often get that feedback from patients that you know everybody has just been you know so caring and so
concerned you know for their well being.  And I think you can feel it all over the institution.

>> Everybody I've met out here from Maria the parking attendant out there who greets you and tells you goodbye, to the people actually at the reception desk, Alicia and Brenda.

>> Ron Stone Jr.: Throughout his radiation treatments, George found support in his family and in his fellow patients at MD Anderson.

>> When I first went in to the treatment in the first part of the 7 weeks I called myself a freshman and then a sophomore and then a junior and senior.  And some of the people I met - patients - were really kind of neat guys.  We call it the Class of '08.  [Laughter]  You build up a little camaraderie.  I did with them. 

>> People are quite willing to share their experiences and there's just a general atmosphere of support here.

>> Ron Stone Jr.: Each patient in the Prostate Clinic is given a Quality of Life study.

>> We've found that the best way to know how these treatments affect patients is by asking the patient.  So it's a series of questions about their urinary function, bowel function and sexual function.  And so we would get them to do the survey both before and after treatment.  And this protocol involves all of the treatments we do for prostate cancer.

>> Ron Stone Jr.: MD Anderson also has a survivorship clinic for long-term follow up care.

>> In that clinic, we would monitor patients for the long-term and so once the patients are over the acute stage and we think that there's quite a good chance that the cancer's not coming back, we can all relax a little and they can go to the survivorship clinic where they're still monitored but we take into account not just the cancer, but also any effects that the treatment may have had and any screening for perhaps other malignancies that they patient might need going forward.

>> Ron Stone Jr.: Keeping a positive attitude helped George Strake get through his prostate cancer experience. 

>> I've got a wife that's put up with me for 51 years so this is just another day in the saga. [Laughter]

>> Ron Stone Jr.: Life after cancer hasn't slowed George down one bit.

>> I still go to the office everyday.  I still play tennis.  I'm going to take a trip to Europe and Egypt and the Holy Land in April and May.  I love to hunt.  And you know, I'm still doing everything I did before.  So I think I'm lucky.

>> Ron Stone Jr.: After his surgery, Menno’s outcome is looking good. 

>> Though I have passed the test - the PSA test - of the non-measurable PSA levels, I'm pretty well.  My energy levels are back.  I'm working pretty much as I had done. 

>> Ron Stone Jr.: George's advice to anyone facing a cancer diagnosis is "Don't panic." 

>> Just go out there and listen and make -- read up on it and make your own decision.  And you know, stay on the good side of God.  That's the only thing I know.  I just figure you just take the hand that's dealt you and make the best you can of it.

>> Ron Stone Jr.: We hope you've enjoyed this show and that you've learned some valuable information about prostate cancer.  For more information or to view the show again, please visit  We'll see you next time. 

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