Prostate cancer patients benefit
from being candid with their doctor

An interview with John Colberg, MD and Richard Peschel, MD, PhD

What men are at the highest risk of developing prostate cancer?

Colberg: There are essentially three risk factors: age, meaning that the older you are the greater the chance you will develop prostate cancer; family history of cancer; and race. We know that African Americans have a much higher incidence of prostate cancer.

When should men start getting screened for prostate cancer, and what kind of screening would you recommend?

Colberg: Men 50 and older should be offered the PSA blood sample and a digital rectal examination. If you have a significant family history, or you are an African American, that screening should probably start at age 40 to 45.

When a patient is given the diagnosis, does he need to make the decision immediately?

Peschel: I think it is essential that he takes plenty of time to think about what he wants to do and get as many opinions as he needs, whether it’s radiation therapy or surgery. There are very few cases where there is a real sense of urgency for beginning treatment.

Brachytherapy, external beam radiation therapy and radical prostatectomy – what exactly are all these things?

Peschel: Brachytherapy (also known as seed implant) is a popular form of treatment for early disease. About 100 tiny radioactive seeds are placed permanently in the prostate. These seeds give off radiation, which treats the tumor. Another form of treatment is Intensity Modulated Radiation Therapy, also known as IMRT. IMRT is an advanced external beam radiation therapy technique used to minimize the amount of normal tissue damaged during treatment. It is an amazing step forward in the treatment of prostate cancer. There are almost no rectal or bladder complications that were experienced by patients in the past.

Men are often concerned with the side effects associated with treatment and how it may affect their quality of life. How do you determine the best treatment option?

Colberg: With radiation therapy and its modern techniques, the only significant long-term complication that affects quality of life is a loss of potency.

Peschel: And it varies depending on the treatment. There can be a 30 to 50 percent chance of side effects developing, so it is an important long-term quality-of-life issue that men have to consider very seriously when they are trying to decide between different types of treatments. We use a multidisciplinary approach, which means that we present options to each patient and explain their pros and cons.

What can you tell us about the surgical options – traditional approaches, laparoscopic and robotic surgery?

Colberg: In the traditional approach, open surgery, the surgeon makes an incision in two places – one in the abdomen below the navel, and one below the scrotum. With laparoscopic surgery, the surgeon makes three to five small holes in the lower abdomen and performs the operation through them. In robotic surgery, the da Vinci ® Surgical System is used to assist the surgeon in performing the operation; the surgeon operates remotely through a console. The robot has three arms and a camera, which enables us to gain entry through five to six small holes in the abdomen with much better visualization of the anatomy. It is performed in 3-D imaging, so we get much more definition and exact precision.

With robotic surgery, we often realize better impotency and continence rates. Post-operative recovery is much shorter as well. Patients go home the next day, and most men are back to work two to three weeks after the procedure. This compares to open surgery, where the patient stays in the hospital for two days and takes a month to get back to full activities.

What are some of the questions that a man with prostate cancer may ask when he is trying to make a decision between surgery and radiation?

Colberg: He wants to know about his quality of life. Initially, his overwhelming concern is that he wants the best treatment that’s going to cure the cancer. Secondly, especially when we talk about surgery, he doesn’t want to be incontinent. Thirdly, he may be concerned about erectile dysfunction.

Peschel: As clinicians, we find that an increasing number of patients are doing online research. Some of the information on the Internet is very reliable, and some of it is not. Patients can become confused about what they should be doing. As long as they are forthcoming about their symptoms and their concerns, we can develop the best treatment plan.

Colberg: Patients need to express concerns to their doctors and not rely solely on the Internet or someone else’s experience when making treatment decisions. However uncomfortable, it’s also necessary for men to share information about pre-existing medical conditions like urinary, bowel and sexual dysfunction. Only then can the best treatment decision be made.

Dr. Colberg is an attending urologic surgeon at Yale-New Haven Hospital; and associate professor of surgery and co-director of the Prostate and Urologic Cancers Program at Yale Cancer Center.

Dr. Peschel is an attending radiation oncologist at Yale-New Haven Hospital; and professor of therapeutic radiology at Yale School of Medicine.