One of the most respected robotic surgeons, Dr. David Samadi, is an active online participant, with regular blogs on relevant prostate cancer topics. The New York Daily News recently (Sep. 22, 2016) carried an article by Dr. Samadi, “Prostate Cancer Means Deciding between Surgery or Radiation.”[i] In talking about the necessity of doing research in order to make that all-important treatment decision, he advises patients to have a thorough discussion with their doctors about the pros and cons of each type of therapy. I agree. Doctors play a significant role. Besides being a physician, we also often act as teachers, coaches and even mentors in helping patients understand their disease and the best treatment for it.
However, as the article title shows, Dr. Samadi’s article focuses on only two treatment choices: surgery or radiation. I was disappointed with this either-or approach for newly diagnosed men. A next-step alternative to total gland treatment is focal treatment, such as our Focal Laser Ablation (FLA). Focal therapy offers unique benefits for properly diagnosed and qualified patients. It treats the cancerous tumor, spares urinary and sexual function, and leaves all future treatment options open if cancer comes back.
When it comes to prostatectomy, Dr. Samadi points out that “several studies have shown that prostate cancer patients who have localized prostate cancer do better with surgery versus radiation treatment.” While it’s not clear exactly what he means by “do better,” we know that failure rates are lower for surgery than for radiation. Data points to higher rates of biochemical failure (rising PSA) at 5 years after radiation than surgery. But there is more to “doing better” besides cancer control. Patients are looking for a treatment that will not only destroy disease immediately (radiation takes many months for cancer cells to die off) but will also do better for their quality of life as well as for their disease.
Many prostatectomy patients are unaware that it can take up to 24 months to regain potency, and even more patients are unprepared for the fact that they may have less firm erections when they regain function. It’s difficult to pin down data because of different surgical methods, surgeon experience and skill level. A Danish study found that only 23.3% of their patient cohort reached their pre-treatment level of performance almost 2 years after surgery. Their patient questionnaire asked a pointblank question: Is your erectile function as good as before the surgery: yes or no? Only 6.7% responded yes.[ii] In a German study[iii], the one-year potency rates reported by patient age were:
< 65 years 59.3%
> 65 and < 70 46.9%
> 70 and < 75 44.4%
> 75 31.3%
These prostatectomy studies involved open or laparoscopic (not robotic) RP. For robotic surgery, picture seems more optimistic for patients who have either unilateral nerve sparing (UNS means one nerve bundle spared) or bilateral nerve sparing (BNS means both nerve bundles spared) treatment – but the older the patient, and the poorer his presurgery function, the more the rates of regaining potency drop. In one study[iv] of men under age 65 who had “normal” erectile function before treatment, at 24 months the potency rates were reported as:
Unilateral nerve sparing, potency regained at 24 months 80%
Bilateral nerve sparing, potency regained at 24 months 93%
The study authors caution, however, that following robotic surgery it may be necessary to undergo penile rehabilitation. “About 30-40% will start having return of function at about 6 months, but as noted above this is variable and depends on a number of factors other than time (preoperative erectile function, age, nerve-sparing, prostate size etc)…. Your initial erections, when they occur, will be soft and partial, however as you continue to recover they will become stronger and more full.”
This is where focal treatment comes in. At least one third of patients will be diagnosed with unifocal disease, meaning a tumor in one location with no evidence of spread throughout the gland. In fact, multiparametric MRI can not only identify that there is a treatable focus of disease, but when imaging is done on a 3T magnet and interpreted by an experienced reader, the scan offers specific tumor characteristics, including shape, size and even aggression level. An in-bore MRI-guided targeted biopsy provides the accurate Gleason grade, so the diagnosis is as precise as possible. With such detailed information, we are able to qualify patients for FLA. This is an ideal scenario for the following patients:
- Low-to-intermediate risk localized prostate cancer who don’t want surgery or radiation
- Qualify for AS but who don’t like the idea of cancer growing in their body
- Want an outpatient procedure with no general anesthesia and very quick return to normal activity
- Want no incontinence
- Want minimal-to-no impact on sexual function
To return to Dr. Samadi’s article, I believe that we embrace the same patient-centered values. With that said, I would have been happier had he included focal therapy as a middle ground treatment between radical therapies (surgery and radiation) and AS. When patients and doctors sit down to discuss treatment options, focal therapy should be presented to patients as an additional option, with information on the use of 3T multiparametric MRI to learn if they are qualified. Doctors would be doing patients an even greater service then they broaden treatment options to their full range, including AS.
Dr. Samadi makes a particularly important point: whichever treatment a man chooses, he should seek out the experts in that treatment. Dr. Samadi writes, “Bottom line, all men diagnosed with prostate cancer should find a qualified, experienced urologist/oncologist who will guide them through this journey, providing individualized care and helping them make the best decision for him and his family.” I heartily agree, adding that this also applies to interventional radiologists as well as urologists and oncologists. At our Center, we are proud to provide 3T multiparametric MRI as the foundation for further diagnostics and treatment decisions, and our mission is to take time to go over all imaging results in detail, and compassionately assist with decision-making.
[ii] “Return to Full Potency Rare After Prostate Surgery.” Renal and Urology News, March 24, 2015. http://www.renalandurologynews.com/prostate-cancer/return-to-full-potency-rare-after-prostate-surgery/article/405192/
[iii] Mandel P, Graefen M, Michl U et al. The effect of age on functional outcomes after radical prostatectomy. Urol Oncol. 2015 May;33(5):203.e11-8. doi: 10.1016/j.urolonc.2015.01.015. Epub 2015 Mar 24.
[iv] “Sexual Function or Potency after Robot Assisted Radical Prostatectomy. ”http://www.urology.uci.edu/prostate/Potency_info.html