You Have Choices for Prostate Cancer Care

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A center offering multidisciplinary care is a good place to get help in making the right decision for you.

If you or someone you love has recently received a prostate cancer diagnosis, you're probably scared.  However, you may find comfort in the fact that a large majority of prostate cancers are caught early enough for men to have good outcomes.

"Most men do quite well after treatment and live with a good quality of life for several years. The outlook is especially good for men who get multidisciplinary care, which is the kind of care we provide at Sylvester," says Alan Dal Pra, M.D., a radiation oncologist at Sylvester Comprehensive Cancer Center, part of the University of Miami Health System. Multidisciplinary care refers to a treatment planning approach that includes several doctors with different specialties.

According to the American Cancer Society, roughly one in eight men will develop prostate cancer at some point. The disease is the second most frequent cancer in men, after skin cancer. It usually develops slowly, over many years, though some patients have a fast-spreading, aggressive form of the cancer.

Experts predict about 249,000 new prostate cancer diagnoses and more than 34,000 deaths from the disease in 2021.  About 60% of cases occur in men over age 65. "Other risk factors, besides age, including being Black or having a family history of the disease," says Dr. Dal Pra.

Patients have choices

"Patients need to understand before they begin treatment that they have options," says Dr. Dal Pra. If you have a cancer that is contained within the prostate or one that has only spread to nearby areas, your treatment may ultimately involve one or more forms of treatment including surgery, radiation and hormone therapy.

"The correct person to talk about the role of radiation therapy treatment for prostate cancer is a radiation oncologist," says Dr. Dal Pra. "You can ask your urologist or your primary care doctor for a referral to a radiation oncologist to discuss whether radiation therapy is a good option for you."

The prostate sits under the bladder and in front of the anus and rectum, close to nerves, blood vessels, and muscles involved in a man's ability to get an erection. Therefore, treatment side effects can include problems with bladder and bowel function and impotence. These issues may be temporary or permanent. Your choice of treatment may depend, in part, on which side effects you most want to avoid.

"It's important for men to know that starting active treatment right away isn't always advisable," says Dr. Dal Pra. “Many men with slow-growing, low-risk tumors can be safely monitored without any surgery or radiation, avoiding potential side effects of these treatments." This approach is called "active surveillance." The cancer may never require treatment. When and if it does start to grow, your doctor can recommend the appropriate action.

Decision making can be more complicated for younger men and those with intermediate-risk cancers. "Men with intermediate disease can have radiation treatment or surgery. Both are equally effective at addressing the disease, but the side effects are different," explains Dr. Dal Pra.

"Although most patients with high-risk disease may be getting radiation and hormone therapy, there might still be a role for surgery for select patients, often as part of a multi-modality treatment," says Dr. Dal Pra. "Again, there are risks and tradeoffs a man needs to discuss with his care team."

Understanding a tumor's threat level

The National Cancer Institute divides prostate cancers into three SEER (Surveillance, Epidemiology, and End Results) categories -- local, regional, and distant. Local cancers are confined to the prostate itself; regional ones have spread to nearby structures such as pelvic lymph nodes; and distant ones have spread further than that, to bones or other organs.

"For local or regional cancers, nearly 100% of men survive for five or more years," explains Dr. Dal Pra. "For distant cancers, five-year survival drops to 31%." We catch most prostate cancers before they become distant, though, so five-year survival is 98% for all three categories.

"As encouraging as those statistics are, the prospects for men with prostate cancer actually get better year by year, because our treatments keep getting better," says Dr. Dal Pra. According to the American Society of Clinical Oncology, the prostate cancer death rate has dropped by more than half between 1993 and 2017 due to advances in screening and treatment.

Treatments have not only grown more successful, they are also more tolerable and convenient than ever. The most advanced technologies in radiation treatment are available at Sylvester, including proton therapy. "We target the beam so precisely that it destroys the tumor cells but does minimal damage to nearby healthy structures. It's painless," says Dr. Dal Pra. A man can have an outpatient treatment in the morning and be working or playing golf afterward, he says.

Predicting a tumor's advance through testing

Beyond the broad SEER categories listed above, doctors have other ways to categorize tumors. "For patients with localized disease, we classify patients into low, intermediate, and high risk for progression," explains Dr. Dal Pra. Oncologists base these categorizations on three measures: the Gleason score, the prostate-specific antigen (PSA) test, and the T category.

A pathologist assigns a Gleason score after studying a biopsy sample. It ranges from 1 to 5 and conveys how much the sample resembles healthy tissue. A score of 1 means that the tissue looks close to normal, while a 5 means that it appears highly abnormal. Most Gleason scores fall between 3 and 5. Pathologists grade the two most prevalent patterns and add these two numbers together to result in the final Gleason sum that ranges from 6 to 10. The higher the Gleason score sum, the more aggressive your cancer is likely to be and the greater the chance that it will spread.

The PSA test is a blood test that determines how much of a particular protein (prostate-specific antigen) is in the blood. Both malignant and healthy prostate tissues produce this protein, and the blood typically contains slight amounts of it. High PSA levels may indicate the presence of a prostate tumor, but they do not always mean cancer is present. Other problems, including an enlarged prostate, can also boost PSA levels. In a patient diagnosed with prostate cancer, a higher PSA often means that the tumor is more advanced.

The T category describes the tumor's size locally and if it has spread outside the prostate.  It also indicates how far and where it has gone.

Advances in genetics and imaging provide even better predictors

In recent years, doctors have also begun classifying prostate cancer cases by analyzing genetic material in a tumor. "Genomic data has greatly improved our ability to identify which tumors are likely to spread widely," says Dr. Dal Pra. The genomic classifiers have proven more useful for predicting poor outcomes than traditional factors such as Gleason score or tumor size.

"New imaging modalities, including prostate-specific PET scans, have allowed us to locate cells that have already spread at a very early stage. This has changed treatment patterns and opened a fantastic opportunity to offer treatments that can potentially cure patients that once were considered incurable," says Dr. Dal Pra.

"Every man's experience with prostate cancer is individual, but we are much better at estimating how a cancer at a certain stage will respond to the different forms of treatment available," explains Dr. Dal Pra. "This helps patients decide how to proceed."

Seek multidisciplinary care

For most men, the best way to decide on a treatment plan is to seek care at a center that takes a multidisciplinary approach. At such a center, you can speak with a urologist about possible surgery. You can also meet with a radiation oncologist about options for radiation treatment. You may also need to see a medical oncologist if therapy with drugs or hormones will be useful in your case.

"One of the advantages of being treated at Sylvester is that all specialties work closely together to design the best care plan for each unique patient," says Dr. Dal Pra. Evidence has shown that multidisciplinary care improves cancer patients' outcomes in many important ways, he explains. "It’s not wise to just proceed with the first alternative you learn about, whether it’s surgery or radiation, without exploring all the options.”

Talking to doctors with different specialties will help you make a decision that you are less likely to regret in the end. “Patients are often living with the consequences of their treatment choices longer than they used to,” explains Dr. Dal Pra. “So it’s important to gather good information early on what different treatment plans will involve and how they will affect your long-term quality of life.”

Clinical trials can be highly advantageous

Cancer patients who receive multidisciplinary cancer care usually face a shorter lag between receiving their diagnosis and the start of treatment, research has shown. When a care plan grows out of discussions between doctors with different backgrounds, the plan is more likely to follow the most up-to-date guidelines and involve joining a clinical trial, which can be highly advantageous.

“Patients in clinical trials do better than other patients with similar cases for several reasons,” says Dr. Dal Pra. One reason, he explains, is the emphasis on quality assurance in clinical trials. Even if a patient is not in the group that receives a new treatment, they still receive care that adheres to the latest guidelines for quality care.

“Another reason patients do better in clinical trials is that there are so many doctors and nurses involved in their care. Every aspect of the treatment plan is checked, and triple checked. Nothing is overlooked,” says Dr. Dal Pra. Sylvester is the only cancer center designated by the National Cancer Institute in South Florida and offers a wide range of clinical trials for prostate cancer patients.

You may find that weighing treatment options and choosing the best plan yourself feels overwhelming. If so, you may find clarity by talking privately with your primary care doctor or the medical oncologist.

Anticipate and deal with your feelings

The American Cancer Society webpage provides useful medical information. So does the  Prostate Cancer Foundation. Be aware, though, to care for yourself, you have to deal with your feelings too.

It is natural for a cancer patient to feel scared and confused. A recent CancerCare survey that involved 633 men with a new prostate cancer diagnosis found that 77% felt anxiety and depression. Ninety-seven percent of them thought that men needed help to recognize and deal with such feelings.

So as you deal with your physical health, also be prepared to seek support for your mental health. Ask a doctor or nurse about support groups or individual therapy. You may be able to see a counselor remotely. At the very least, confide in a close friend or relative.

Remember, mental and physical health go hand in hand.


Milly Dawson is a contributing writer for UMiami Health News.


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