Dr. John Colberg, Surgical Options for Prostate
Cancer
November 14, 2010
Welcome to Yale Cancer Center Answers with Dr. Francine Foss and Dr. Lynn Wilson. I am Bruce Barber. Dr. Foss is a Professor of Medical Oncology and Dermatology specializing in the treatment of lymphomas. Dr. Wilson is a Professor of Therapeutic Radiology and an expert in the use of radiation to treat lung cancers and cutaneous lymphomas. If you would like to join the conversation, you can contact the doctors directly. The address is canceranswers@yale.edu and the phone number is 1888-234-4YCC. This evening Francine and Lynn are pleased to welcome Dr. John Colberg. Dr. Colberg is an Associate Professor of Surgery and Director of the Yale Uro-Oncology Program. Here is Francine Foss.
Foss
I would like to start off by having you tell our audience a little
bit about prostate cancer, what is it?
Colberg
Prostate cancer is not unlike other cancers. It is a
malignancy of the prostate gland that occurs typically in men over
the age 50, although one can see it earlier in life and in fact, it
has been seen in men in their 30s, but it is most common in age 50
or older. 200,000 patients are diagnosed every year. At
any one time in the United States, there are probably 5 million men
that have the diagnosis of prostate cancer, newly diagnosed, or
treated, and about 30,000 men die of prostate cancer every year or
so. About one in six men have a risk of developing prostate
cancer in their lifetime.
Wilson
Is it possible that a patient might be very elderly and not having
any symptoms at all and may die of some other cause, but if there
is an autopsy done, for example, they may find prostate
cancer? How common is that?
Colberg
No question. The issues with prostate cancer, as far as who
develops prostate cancer, it is very common in the elderly, so that
is one of the risk factors. As you get older, there is a
greater chance to have and develop prostate cancer. In fact,
most men, probably two-thirds of the men who have prostate cancer
are 65 or older. So yes, there are a lot of men that actually
die from diseases other than prostate cancer and typically those
are the men we do not go and pursue and make the diagnosis or
screen for.
Foss
A lot of men have difficulties with their prostate as they get
older. How does a man know that he is at risk for prostate
cancer?
Colberg
That is a great question because most of the people we find with
prostate cancer today do not have any symptoms, or they do not have
symptoms related to their prostate cancer. They may have
other symptoms which you were alluding to as far as an enlarged
prostate gland called BPH, which is actually benign enlargement of
the prostate gland, which again is very common in the same age
group, so those men will presumably present with slowing of their
stream, hesitancy, getting up at night, frequent urination, and
those are related more to an enlargement of the prostate gland as
opposed to prostate cancer, but sometimes they could have
both. It is uncommon nowadays to have someone present with
symptoms from their prostate cancer. In the
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old days they came in with bone pain, or weight loss or malaise;
symptoms we would see 20 or 30 years ago. The typical men we
see are ones without symptoms of prostate cancer but they may have
symptoms related to an enlarged prostate gland or something called
prostatitis, which is just an inflammation of the prostate gland
with burning, frequency, or pain.
Wilson
What are some of the risk factors that are associated with
this? We know about smoking and lung cancer, for
example. How about prostate cancer?
Colberg
The three big risk factors of prostate cancer are age, meaning the
older you are the greater chance you have to develop prostate
cancer, race or nationality, meaning that African-Americans
certainly have a higher incidence of prostate cancer and when they
do develop prostate cancer and found to have prostate cancer, they
tend to have a much more aggressive form of prostate cancer.
We know that people of Northern European descent have a higher
incidence of prostate cancer versus someone from Asia, and thirdly
is family or genetics, meaning your family history. If you
have a father, brother, or grandfather who had prostate cancer,
your risk is higher. These men had to have developed their
prostate cancer at a younger age. If your father is 80 years
old and developed prostate cancer, that does not mean you have a
higher risk of getting prostate cancer but if he had prostate
cancer when he is 62, that puts you at a little higher risk of
developing prostate cancer.
Foss
Is there an association between prostate cancer and some of these
other family cancer syndromes like the colon cancer syndromes, and
the lung cancer syndromes?
Colberg
Not that we know, because prostate cancer is so common. We
mentioned that over 200,000 people are diagnosed a year with
prostate cancer. There is no familial or organ system type of
incidence of prostate cancer and other types of cancers.
Wilson
How is prostate cancer usually diagnosed? Tell us what
happens if a patient's doctor is concerned maybe about an enlarged
prostate and they refer the patient to you. What steps would
you take?
Colberg
There are two reasons why men will come to see us with a concern
for prostate cancer. One is their doctor may feel an
abnormality on the rectal examination. When the doctor feels the
prostate with his fingers through the rectum, he may feel a lump or
bump, firmness or hardness, and that does not mean he has prostate
cancer, but it is something that needs to be further pursued. Much
more commonly we see men come in with an elevated PSA level.
PSA is a blood sample and it has been around since 1988. In
1989 it was approved by the FDA for screening. This measures
a protein in the blood called prostate specific antigen and it has
been shown that if it is elevated it is a little bit of a red
flag. It does not mean that everybody who has an elevated PSA
level has prostate cancer, but that may be a test that you want to
pursue to make sure they do not have prostate cancer.
Typically the two other things that make the PSA level go up are an
enlarged gland, again we talk about BPH, or some type of
inflammation of the prostate gland.
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The normal numbers of PSA gets a little bit confusing as to what
the normal level is. People historically have thought that a
number 0 to 4 is normal. Now we know that in younger men
probably 4 is too high and for an older man 4 may be too low and
that is why they came up with age reference PSA levels that take
that into effect. Also an important thing is the change of
your PSA level, meaning that if you have a "normal" PSA level in
the ones, and you present a year later and your PSA is three, even
though it is still less than 4, that is a concern that there may be
something actively going on in the prostate gland.
Wilson
If you had someone with an elevated PSA, say it was significantly
elevated with an abnormal finding on their examination, and they
were 72 years old, what would be the next step for that person?
Colberg
You sit down with your patient, you discuss that these are
concerning findings on exam and the blood work and then the next
step, if he wants to know if he has prostate cancer, would be to
have a biopsy. The biopsies are done in the office. We
use an ultrasound to guide us with the biopsy. We do it under
local anesthesia like the dentist does. It takes 5 to 10
minutes to perform, usually results come back in 2 to 3 days
depending on pathology and you get your answer. I think that
is probably the next step for someone who is 72. If he was 82
or 85, he may not want to do that. He may want us to just
follow him, so it gets a little bit grey when you start talking
about ages, but certainly a 72-year-old healthy man with a 10 year
life expectancy will want to be more aggressive.
Foss
Can you just back up one minute and talk to us a little bit about
the process of screening, how old should a man be when he starts
getting annual rectal exams and PSAs?
Colberg
That it is a great point because the American Cancer Society has
very good recommendations, and if you have a family history like we
have talked about, a father or brother who developed cancer in
their 60s or less and you are African-American, you should be
screened somewhere between 40 and 45 with a PSA level and a rectal
examination. Everybody should be offered screening at age 50
or older with the yearly digital rectal examination and PSA level
knowing that screening may lead to a biopsy, which may lead to the
diagnosis of prostate cancer, so the patient is informed what his
options are.
Foss
When do you use ultrasound or any other kinds of imaging
studies?
Colberg
We use the ultrasound to do the biopsy because it aids us in
directing where we want to put the biopsy specifically. There
are certain points in the prostate gland where more than likely the
cancer is going to develop, they are not usually in the middle of
the prostate, they are in the posterior zones, or posterior lateral
zones, so that is where you want to target your biopsies, where 80%
to 90% of the cancers will develop. The ultrasound will tell
us two things, it will tell us the size of prostate gland, so if
you do an ultrasound and the prostate is really big, and it has
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an elevated PSA level, that may be a reason why his PSA level is
elevated, but if he has a very small gland with PSA levels
elevated, that is a time when you will be more concerned. It will
not tell us where the cancer is, it would not tell us how big the
cancer is per se, unless there is a very big abnormality in
examination.
Wilson
Tell us about some of the different treatment options?
Colberg
This is where it gets very delicate as far as options are
concerned. The same option may not be ideal for every patient
you see. It is not like breast cancer, colorectal cancer, or
lung cancers where the algorithms are worked out as far as if you
present with X, you get Y and Z. Prostate cancer is very
individualized; the disease is heterogeneous. Cancer in one man may
not be the same as in another man. We look at several things
when you talk about treatment for prostate cancer, a patient's age,
a patient's health, PSA level, clinical exam based on what you feel
during the rectal examination, what we call the Gleason score, what
the pathology is under the microscope from the biopsies, and
ultimately it depends on the patient's wishes and what he would
like to do. But essentially there are three options. He
can have some form of radiation therapy, which is either giving
external beam radiation therapy, where he would come in every day
Monday through Friday for usually about 8 weeks where they get
radiation to the prostate area, or they can have another form of
radiation therapy called brachytherapy which is little pellets that
are implanted in the prostate gland and it is kind of a one shot
deal where they are placed under anesthesia. The patients
come in one time and the radiation therapy is released over a
couple month period depending on what type of implant you get,
typically we use either iodine or palladium, and the seeds stay
there forever, but the radiation therapy is released over a 2 month
period. That can be done in combination with we call hormonal
therapy, depending on what type of grade a tumor you have. The
Gleason score and the grade is based on the system of 2 to 10, ten
being the worst and 2 being the best. Most patients are 6s
and 7s. They get what we call hormonal therapy which is an
injection that drops the level of testosterone; sometimes you do
not need hormonal therapy. Some people will combine the
radiation therapy both external beam and seeds together and that
depends on exactly what type of grade the tumor is and the clinical
stage. The other option is to do surgery, and surgery is to
remove the prostate gland with the seminal vesicles which are
little structures behind the prostate gland and you also take out
lymph nodes at the same time, and thirdly, something which
is getting more and more interest is something called active
surveillance. We know that everybody who has prostate cancer
does not die of their prostate cancer. We know that the vast
majority actually do not. Only 30,000 people die of prostate
cancer a year and 200,000+ get it a year, so there is certainly a
difference between the incidence and the mortality, so there is a
sliver of patients, maybe 20% of patients who actually do not need
treatment for their prostate cancer. The problem is how to
identify those patients you can safely follow without
treatment. There have been lots and lots of studies looking
at who can be followed safely without treatment, on a protocol
called active surveillance versus ones who should not and those
patients who decide to not be treated are followed very
closely. They get blood samples three times a year, they get
exams three times a year, they get repeat biopsies, usually after
one year and then if everything is unchanged, we will do it
every
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two to three years, but it requires a very compliant act of an
actively involved patient who desires to do this and often times
that is very difficult. You tell a 65-year-old man he has
prostate cancer and that we probably do not need to treat them,
they can be followed, a lot of men will be attracted to that
option, but often times they are not.
Foss
There must be some significant downsides to some of these
therapies. Could you talk a little bit about that?
Colberg
I think that has been the Achilles' heel for prostate cancer
treatment since the first prostatectomy was done in the 30s and
40s. The real complication from surgery, and we can talk
further about it, is incontinence, the inability to control urine,
and also something called erectile dysfunction. Both of them
are measurable, percentage wise, usually incontinence, depending on
who you talk to and how you define it, may be on the order of 5% to
20%. Erectile dysfunction is more difficult because it is a
harder thing to get at, it may be depending upon age, the younger
you are the better you do, and what your function is before the
operation.
Wilson
We are going to take a short break for a medical minute.
Please stay tuned to learn more information about prostate cancer
with Dr. John Colberg.
Wilson
Welcome back to Yale Cancer Center Answers. This is Dr. Lynn
Wilson and I am joined by my co-host Dr. Francine Foss. Today
we are joined by Dr. John Colberg and we are discussing prostate
cancer. John, before the break you were talking about some of
the side effects such as erectile dysfunction, go ahead and
continue that conversation with us.
Colberg
We talked a little bit about surgery and the way we do the
operation. The way a man becomes impotent or loses erection after
the operation is a fact that the prostate is kind of enveloped by
certain nerves that supply the vessels that result in an erection
in a man, so when you take the prostate out, you try to preserve
those bundle fibers on the sides of the prostate gland and
depending on the tumor and where it is located, will depend on if
you can save one or both or neither of the nerves. Certainly,
the better outcome is the one where you try to preserve both
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bundles. After the operation, the man may not get erections for 3
months to 6 months. It may take 12 months to 18 months to
actually get some function back. Often times, what we will do
is we will begin the man on oral medication. Typically, the
ones we use are Viagra, Cialis, and Levitra. If that does not
work, there are other treatments we can use, there are vacuum
erection devices, we can use injection therapy where we actually
inject medication into the penis with a liquid medication that
allows them to obtain an erection for a period of time. If
all those fail after a period of time, the last option would be
something called an implantation, or penile prosthesis.
Again, the important part of who is going to get erections after
the operation is the younger you are the better you do and also
what your status is before the operation. If you have a man
who is 70 years old having difficulty getting erections before the
operation, there is a very good chance he is not going to keep his
erection no matter what type of a perfect operation you do, but if
you have a 50 year old man who has good erections before the
operation, then he should do quite well, and those numbers
vary. For the younger man their potency rate after the
operation should be 70% or 80% or higher, if you are 70 years old,
that number is well below 20% or 30% probably.
Foss
If you opt to have the surgery or the brachytherapy, are there
effects on erectile function?
Colberg
Yes, I think that the difference between surgery and radiation
therapy is the fact that men who have radiation therapy actually
have fairly good erections maybe during and after the radiation
therapy if there are not on hormonal therapy and then over the
years maybe 2 to 3 years their erections kind of dwindle down, so
the lines kind of cross with radiation and surgery probably 3 to 5
years after the original treatment. So the erections in
radiation patients are usually quite good initially, but then they
get worse over time as opposed to surgery, where they start out
poorly and they get better overtime.
Foss
What are the complications of the hormonal therapy?
Colberg
The big complications for short term hormonal therapy are hot
flashes, so the decrease of testosterone level, the man will feel
warm when he's cold and cold when he's warm. They will have
these hot flashes or sweating episodes. It probably happens
in half the patients and some can be just minor, some can be very
debilitating. The other issues are that you will lose your
sex drive or libido because you do not have a testosterone
level. Once he stops the hormone shots, the testosterone
level will come back and both those symptoms will get better,
that's for short term treatment. If you are on it long term,
there are lots of other issues of bone density, loss of muscle
mass, cognitive issues, anemia, that is when you are on it for
years and years and years and typically a man with localized
prostate cancer is not on it more than six months to a year
typically for radiation therapy.
Wilson
John, what about incontinence?
Colberg
Yes, that is the other issue with surgery, not so much as with
radiation therapy because radiation
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therapy, both seed implants and radiation therapy, it is usually
the opposite. The man may have difficulty urinating
perhaps, they have a slowing of their streams, they have some
hesitancy, they may actually not be able to urinate at all, as
opposed to surgery where he has trouble controlling the
urine. That is based on the fact that they have two sphincter
mechanisms ones at the bladder neck and one at the pelvic
floor. When you take the prostate out, you are relying on the
pelvic muscle to keep control of your urine and it is developed
differently in different men so that when you take the catheter out
after the operation, usually a week or 10 days, these men will have
difficulty urinating, often times they will be incontinent for
days. They will wear six or eight diapers a day, but they
slowly get control over the urine and that may take a week, it may
take a month, it may take six months, or a full year. Usually
men improve, so if I see a man back from the operation a month or
two after the operation and he is leaking like it will do when the
catheter comes out, I get concerned, but if he says, listen I am
50% better or 30% better, then I am not so worried that he will get
control of his urine. Men will always have what we call
stress incontinence when they cough or sneeze, or pick up something
heavy, they may squirt a little bit of urine, but the incontinence
rates are kind of difficult to tease out, but usually somewhere
around 5% if you do a lot of the surgeries, if you do not do a lot
of the surgeries and only do 1 to 2 a month, that number may go up
to 15% to 20%.
Wilson
Just a real quick question, on average, how many nights are
patients in the hospital for if they have the operation?
Colberg
The way we do the operation, and most of them are done today not
with an incision but with what we call robotic, laparoscopic or
assisted robotic prostatectomy using a system called da Vinci
System, and those men, at least my patients, probably 90% or plus
will go home the next day, versus 5 year or 6 years ago when we did
an open operation, we made an incision, those men typically were in
the hospital 2 to 3 nights.
Foss
Can you explain the da Vinci System to us?
Colberg
Initially the first step in this was to do it purely
laparoscopically where you put instruments in to the body and you
did the operation like you did an open operation, but through small
incisions. Now, there is a robotic system where the surgeon
operates arms of this robot from a remote position in the same room
but across the room, you control a camera and 2 arms with an
assistant and actually do the same operation but through much
smaller incisions, so you make usually 6 small incisions with a
camera and you can do the operation like you would do an open
one. The advantages of a robotic prostatectomy are less pain,
less time at the hospital, less time with a catheter, minimal blood
loss, and the results seem to be comparable, meaning incontinence,
impotence, and ultimately cancer control, meaning the patient does
as well with that operation versus an open operation.
Wilson
This is a somewhat newer technology, John, and any kind of surgery
is complicated, could you comment on the importance of the
operator's experience? Is this something that you can watch
a
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couple being done and you are pretty good at it, or do you have a
sense that it is something that you should do quite a few times
with supervision, tell us about the learning curve?
Colberg
I will give you some numbers. In 2003, 2004 there were about 400
robotic prostatectomies done in the whole United States. This
year 85% of all prostatectomies, probably somewhere between 60,000
or 70,000, will be done by robotic system, it is a technology that
takes some learning, has a learning curve, but it is not as great
as doing pure laparoscopy. I have done probably over a
thousand open prostatectomies before I learned the technique.
You need to observe the patients, you need to have proctored cases,
meaning people who have experience come and help you do your first
three to ten to twelve, depending on what your hospital requires,
and then basically you do your operations by yourself.
Anatomy is anatomy, it is the same anatomy, it is just different
tools and skills. There is a learning curve and I think that
just like any type of operation in urology, the more you do the
better you are at them, the better results you have, and the better
outcomes you have.
Foss
Are there specific men that may not be eligible for this
approach?
Colberg
I would say for every 20 robotic prostatectomies, I do one open
prostatectomy and that is based on if the patient had a significant
amount of prior surgeries, colon surgeries, prior bladder surgery,
prior prostate surgery, maybe he has got a really big prostate
gland and it may be difficult to do robotically, but it is becoming
very, very uncommon to do an open proctectomy.
Foss
And this does not require general anesthesia, is that correct?
Colberg
No, they have the same anesthesia as for an open
prostatectomy.
Wilson
We have talked about a lot of details, John. Tell us a little
bit about the program itself. How can patients come to Yale,
where are they seen, how does multidisciplinary care work?
Give us some comments along those lines.
Colberg
Probably by early next year, we will all be located on the fourth
floor of Smilow Cancer Hospital. Right now, I am still seeing
patients in the Physician's Building on Howard Avenue. We
have a team of radiation oncologists, medical oncologists,
radiologists, and pathologists that will be centralized on the
fourth floor in Smilow, so we will be seeing patients all at the
same time, so that if you need help with medical oncology,
radiology or radiation oncology, we will all be able to look at the
patient and give them the best care, hopefully in one visit or
minimal visits. We have a tumor board that meets twice a
month, where we discuss all the patients, and again, the patients
are shared mutually so that they get the best outcome and the best
treatments.
Foss
Can you talk about supportive care for the patient and their
family as they go through this process?
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Colberg
It is really important and probably not something we have done a
great job with historically, but certainly now my patients go the
15th floor of Smilow Cancer Hospital to a brand new floor.
There are social workers, there is nursing, and my resident staff
is there. We try to meet all the non medical day to day issues of
the patient so that they are able to, when they go home, have
supportive care as far as visiting nurses, so that they have
a little more support staff and structure for when they go home and
take care of themselves.
Wilson
Are there clinical trials that are available for patients, and what
do you see in the next five to ten years down the road for patients
with prostate cancer?
Colberg
There are clinical trials and I think where we focus a lot of
clinical trials is on the patients who we have not done very well
with using just one form of treatment whether that is radiation
therapy or surgery, where we find a patient that may be an
operative candidate, radiation therapy candidate, but maybe that is
not enough, maybe they need more treatment before or after. So one
area that we are working on is what we call the high risk patient,
the patient that even though you may think it is still confined to
the prostate gland, the radiation or surgery may not alone help.
And the other patient is obviously the patient who has developed
metastatic disease where the prostate cancer has come back after
surgery, it has come back after radiation therapy, and you try to
treat them with different types of chemotherapy or hormonal therapy
and that is where I think that we are starting to make a little bit
of inroad with.
Dr. John Colberg is an Associate Professor of Surgery and Director of the Yale Uro Oncology Program.If you have questions for the doctors or would like to share your comments, visit yalecancercenter.org, where you can also subscribe to our podcast and find written transcripts of past programs. I am Bruce Barber and you are listening to the WNPR Health Forum on the Connecticut Public Broadcasting Network.