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Increasingly, many surgical disciplines have come to grips with the significant complications associated with radical cancer surgery and have modified their approach to cancer excision. For example, surgery for breast cancer has moved away from a radical approach and adopted the lumpectomy or local excision instead of removing the whole organ. This modified approach preserves survival and is associated with significantly less complications and improved quality of life (QoL).
However, since urologists developed the radical surgical procedure as a treatment option for prostate cancer they have wrestled with how to deal with the very significant downsides and after effects associated with this treatment option.The urology hierarchy however, chose intentionally to stay the course with the radical approach. The common post operative complications associated with this radical surgical approach are impotence and incontinence (limp and leaking). As well, these complications result in a significant negative impact on QoL not only for the man, but his wife and their partnership (see prostate cancer treatment:the good, the bad and the ugly).
Eventually, recognizing this disposition for complications after surgical removal of the prostate, surgeons refined their radical approach to prostate cancer treatment and developed the “nerve sparing” technique in attempts to lessen this propensity for “limp and leaking”. However, this “nerve sparing” approach for prostate cancer excision did not realize the expected great improvement in results with better preservation of erectile function and urinary continence. This dilemma then led some surgeons to cheat by creating “new” definitions for impotence and incontinence so that their radical surgery was now associated with acceptable levels of these complications.
Subsequently, when the bio-tech industry found a use for their robotic machines in prostate cancer treatment, technology firms soon discovered that they could report even more impressive post operative results. These impressive treatment results for radical surgery/robotics were achieved through the coupling of these spurious definitions for limp and leaking with more misleading information. This so called data for the non FDA trialed treatment option was then spiced with unbridled and unabashed marketing and propelled into the forefront of prostate cancer treatment as some quasi gold standard. When financial rewards and lobbyists were added to this mix it was not hard to realize that some physicians had lost their soul and credibility. Furthermore, the endorsement of a surgical technique by a professional of stature under these circumstances does not necessarily equate with physician competence or honesty. In fact, some educated people are not above bending science with pseudoscience.
Certainly, there was a time when physicians, as true patient advocates, reported sincerely and honestly on cancer treatment options. However, these ideals have seemingly evaporated and the need for standardization of evaluation criteria and definitions of treatment complications are, apparently, no longer important. Indeed, Hippocrates affirmation: “As to diseases, make a habit of things to help or, at least do no harm” has been made redundant. More over, we have become comfortable with manufacturers speaking for the medical fraternity. In fact, now we do not even need rigorous blinded FDA trials scrutinizing the validity of localized prostate cancer treatment options (for hifu, cryoablation, radiation and surgery). This indolent approach by urologists is an injustice to patients that requires immediate attention and correction.
Important issues regarding negative aspects to prostate cancer treatment have been detailed before in several different media formats.
BOOKS
Gary Onik, Male Lumpectomy: focal therapy for prostate cancer
Several other books have underscored the concerns in prostate cancer treatment as well as the business side of the prostate cancer industry.
MAGAZINES
Men’s Health
L. Stains, I want my Prostate Back. March, 2010
WEB BASED

Fox News/Reuters
Life after Prostate surgery worse than expected. July 1, 2011
Hifurx.com
Bert Vorstman MD, Why should the after effects of some prostate cancer treatments be worse than the disease itself? August,2011
NEWSPAPER
Miami Herald
Prostate Cancer Treatment: the good the bad and the ugly. August 22, 2011
Sun Sentinel
Prostate Surgery is Booming, but at what cost? September 11, 2011

Although September is officially designated as Prostate Cancer Awareness Month (blue month), every month should be recognized for prostate cancer awareness.

Be aware that prostate cancer is for the most part without symptoms and a silent disease.
Be aware that prostate cancer deaths are the second leading cause of male cancer deaths after lung cancer. Furthermore, NOT ALL prostate cancers are slow growing or only found in the elderly.

Be aware that some men have an increased risk for prostate cancer especially those of African heritage or those men with a family history of prostate cancer.

Be aware that the digital rectal examination (DRE) or the rectal exam, only has about a 50% accuracy in picking up a prostate cancer.
Be aware that some 15-20% of all men with a NORMAL PSA of 4ng/ml or less have significant prostate cancer and this cancer will only be identified by measuring the FREE PSA as well as the total PSA in order to determine the %free PSA and your estimated probable risk for having prostate cancer.
Be aware that there are four classes of drugs ( STATINS, NSAIDS, THIAZIDES and 5 alpha reductase inhibitors) that will lower your PSA WITHOUT possible protective benefits and give you a false sense of security, underscoring the need to determine your FREE PSA.
Be aware that ONLY a well-conducted prostate biopsy can determine the presence of prostate cancer and NOT an MRI.
Be aware that there are many subjective issues in reading your prostate biopsy slides and validation of your pathology by a reference laboratory is strongly recommended.

Be aware that early prostate cancer is curable

Be aware that a prostate cancer diagnosis does NOT constitute an emergency.
Be aware of ALL of your treatment options for your particular cancer as NOT ALL prostate cancers are the same.
Be aware that that the SURVIVAL benefits of the four treatment options for LOCALIZED prostate cancer, HIFU, Cryoablation, ALL radiation options (including brachytherapy and proton beam) and the radical surgical/robotic options are SIMILAR, but their COMPLICATIONS are significantly different.

Be aware that the complications of prostate cancer treatment especially those of impotence and urinary incontinence (limp and leaking) AFFECT both YOU and YOUR PARTNER.

Be aware that you and your wife/partner need to EMPOWER yourself with knowledge as knowledge is king. Get several opinions and check prostate cancer resource websites like www.hifurx.com, particularly about prostate cancer treatment options and articles about prostate cancer referencing “The good, the bad and the ugly” in the prostate cancer treatment arena.

Localized Prostate Cancer, Treatment Options
and Their Complications

The accompanying table features the four definitive treatment options for localized prostate cancer. All four basic treatment options, high intensity focused ultrasound (hifu), cryoablation (freezing), radiation (includes brachytherapy and proton beam) and surgery/robotics have similar survival benefits.
Also included with the table are several important footnotes, one of which highlights the very misleading subject of cure rates which are at best very rough approximations and their results are not worthy of print.
The complications associated with all four treatment options can be broadly categorized into two main groups,
A. Unique to that treatment option only and,
B. Common, those complications that are common to all four treatment options for localized prostate cancer. By far the biggest category within that Common group are those selected risks of impotence and incontinence. However, the incidence of these Common complications, particularly those of incontinence and impotence, varies considerably between the four treatment options of hifu, cryoablation, radiation and radical surgery/robotics.
A. Unique Complications
These possible complications are uncommon but should be understood and for radical surgery/robotics they are peri-operative blood loss and the need for possible blood transfusions. A shortened penis is also possible as a consequence of radical surgery/robotic prostate removal. For radiation options a unique but possibly life threatening complication is that of hemorrhagic cystitis and hemorrhagic proctitis while for cryoablation a unique complication can be a numb penis.
B. Complications Common to All Treatment Options
1) Severe Complications
These include those of prostato-rectal fistula or death and fortunately, are rare and mostly seen after radical surgery/robotics.
2) Moderately troublesome, relatively infrequent but common to all treatment options are those complications of urethral stricture and bladder neck contracture.
3) Minor and temporary complications that occur relatively frequently in all four treatment options are those post operative issues such as urinary tract infections, epididymo-orchitis, burning, urinary frequency , urgency,etc
4) Quality of Life (QoL) issues which are common and often NOT temporary and vary considerably between the four treatment options have been listed on the accompanying table as Selected Risks.
These risks are the damaging effects on manhood as in impotence or erectile dysfunction (ED) and those of urinary leakage or incontinence.
These are the two most important and the most common and are often permanent complications that negatively impact the QoL of not only the man and his spouse but also their union and partnership.
The treatment option, by far, that achieves the highest rate of impotence as well as all types of urinary incontinence from total to partial and with the biggest negative impact on QoL is the radical surgical/robotic option for prostate cancer treatment. In fact these surgical treatment options represent a direct assault on manhood and men choosing this radical surgical/robotic removal option to treat their prostate cancer are playing Russian Roulette with their QoL.
Prostate cancer just does not have to be cut out to offer cure and men and their spouses would do well to empower themselves about treatment options for localized prostate cancer. Especially, about those minimally invasive options such as hifu as patients are unlikely to receive unbiased information about these options for localized prostate cancer from their treating physician or their prostate cancer support group.

PROSTATE CANCER WITH A NORMAL PSA

Some 15-20 per cent of men with a normal total PSA (tPSA) of 4 ng/ml or less can have clinically significant prostate cancer.
These men have no symptoms and usually no findings on examination.
The only way these men can be identified is by calculating their per cent free PSA (%freePSA) which is determined from their tPSA and free PSA levels ( free PSA divided by tPSA X 100 = % free PSA).
The free PSA is so called as it is not bound to a carrier protein in the blood. However, the tPSA is bound to a protein called
alpha1 antichymotrypsin while the free PSA is unbound in the blood or, somewhat to alpha 2 macroglobulin.
Unfortunately, most physicians and screening studies do not make use of the %free PSA estimation so a good number of men have their prostate cancer undetected due to the MISTAKEN belief that all is well if the tPSA is 4 ng/ml or less.
The use of the %free PSA was approved initially only for men with a total PSA of between 4-10 ng/ml in the belief that if one could identify more accurately those men who could benefit from a prostate biopsy we could minimize the number of men having unnecessary biopsies.
However, the real value of the %free PSA is in identifying those men that have an increased probability of prostate cancer before the PSA is significantly elevated. Ideally, the %free PSA level should be greater than 25 and the lower the level of the %free PSA (converse of tPSA level where the higher levels suggest greater risk) the greater the probability of prostate cancer.
Some studies have shown that with tPSA’s of between 2.6-4 ng/ml and using the cutoff %free PSA of 19% that a prostate cancer detection rate of about 90% was achieved.
In my practice however, I advise men to consider a prostate biopsy who have a tPSA of 1.6 ng/ml or greater but with a
persistently abnormal %free PSA of 19 or less.
Early detection of prostate cancer by using the %free PSA is critical in identifying more men with organ confined disease.
Early detection,especially when the tPSA is under 4 ng/ml may increase the chance of a cure particularly with a minimally invasive option such as HIFU.
Importantly, one should not act on one abnormal laboratory value but have it repeated so as not to act on spurious lab results.
The tPSA blood test may be incorrect if the specimen has not been handled by the lab properly or has been assayed without proper calibration of the equipment. Also, the free PSA is affected by renal function leading to a false %free PSA estimation in those men with renal dysfunction. Furthermore, both tPSA and free PSA increase with age, after prostate examination, after biopsy, ejaculation and after a urinary tract infection but will normalize with time. Proscar and other medications reduce both tPSA and free PSA and can engender a false sense of security. Lowering the PSA in this way may not have a protective benefit.
Finally, nothing is absolute and no marker or MRI diagnoses prostate cancer. These studies may suggest a prostate cancer and having your %free PSA determined and repeated if necessary, can lead too an important prostate biopsy and an early jump on your prostate cancer if identified.

When prostates removed surgically for prostate cancer are examined, 50-75% of these specimens contain more than one area or focus of cancer and called multifocal prostate cancer. In other words, only about 25% of men may have a unifocal prostate cancer lesion that may be suitable for focal therapy. In these prostates with multifocal cancer, however, the gland has on average 3-5 tumors in various stages of evolution.

One of these cancerous areas is commonly bigger in volume than the others and called the index lesion.
In attempting to sort out when a focus of prostate cancer becomes significant and needing treatment, there is some acceptance that an index lesion with a Gleason score of 6 or more and with a volume of >0.5 cm3 is a size where treatment may become necessary.
Smaller index tumor volumes,or, smaller total tumor volumes as in those with multifocal disease can probably forgo treatment but diligently followed through active surveillance (AS).

During AS, PSA velocity (PSAV) monitoring can be valuable and a PSAV greater than 0.75ng/ml/year is associated significantly with prostate cancer and possibly progression. On the other hand, a PSA density of 0.08ng/ml/cc at first re-biopsy is a significant predictor of prostate cancer progression and probable need for treatment. However, no tumor marker is definitive and only a needle biopsy of the prostate can definitively diagnose prostate cancer, assess Gleason score and suggest progression of the cancer.

For the significant index lesion then, what is a tumor volume demanding treatment? Do we consider focal treatment of just that index lesion (focal ablation) with a minimally invasive treatment option such as HIFU, cryo or laser and disregard the other smaller satellite lesions in a multifocal prostate cancer?
Prostate cancer has a very varied biological potential and the clinical and prognostic significance of these smaller satellite lesions in men with multifocal prostate cancer is unknown.

Some have suggested that prostate cancer spread or metastasis, probably originates from a precursor cell and that the precursor cell may arise from the index lesion and therefore maybe treating only the index lesion is necessary. In this manner, by focusing treatment on only the index lesion, we may reduce the risk of collateral damage, a common byproduct of robotic prostatectomy and radiation and so preserve a man’s quality of life (QOL).
However, the desire for focal ablation or treatment of just the index lesion in those with multifocal disease needs to be tempered somewhat because of a number of concerns, least of which is the issue that men with higher tumor volumes have a greater risk for recurrence after treatment. Furthermore, prostate cancer located in the peripheral zone of the prostate (about 70% of prostate cancers are located in this zone) in contrast to those located in the transitional and central zones of the prostate, have a greater ability for prostate capsule,sphincter and seminal vesicle penetration and also lymph node spread. In addition, if the index lesion is substantial and or associated with a Gleason 7 or above and located in the base or apex of the prostate, infiltration of the sphincter or base of the prostate is likely. These margins should be biopsied to check if the prostate cancer is outside the prostate and no longer localized and therefore unsuitable for a minimally invasive treatment.

Also, in multifocal prostate cancer, there is a greater risk of higher grade prostate cancer and therefore a higher Gleason score, stage and recurrence rate when compared to unifocal prostate cancer.

With these issues in mind, most of my patients with significant localized prostate cancer prefer total prostate ablation with a minimally invasive option such as HIFU rather than just focusing only on the index lesion (focal treatment) and disregarding treatment of the satellite lesions.

Finally, much of the prostate cancer data needs to be viewed with caution as few if any studies include independent validations of the prostate pathology and, also, prostate cancer is still something to be reckoned with as it is the second leading cause of male cancer deaths after lung cancer.