Transcription:
Prostatectomy, How to Make Informed Decisions When it Comes to Surgery?

Melanie Cole (Host):  Prostate cancer is the most common cancer among men after skin cancer but it can often be treated successfully and more than two million men in the U.S. count themselves as prostate cancer survivors. My guest today is Dr. Ali Zhumkhawala. He's an assistant clinical professor in the Department of Surgery specializing in urologic oncology at City of Hope. Welcome to the show, doctor. So, tell us a little bit about prostate cancer and the treatments that we're seeing now, because the treatments seem to be changing all the time.

Dr. Ali Zhumkhawala (Guest):  Well, thanks for having me. Yes, prostate cancer is one of the most common cancers in men, as you had previously said. So, there's a ton of research being done on prostate cancer and with that comes a lot of changes in the way we treat it. That's definitely to the benefit of patients. When we talk about prostate cancer treatment, our goals are really multifocal and one of the things we really want to focus on is preserving the quality of life of the patients that we're treating and really individualizing the treatment to each patient. Depending on the patient or their cancer characteristics, we need to create a treatment that's going to, not only effectively treat their cancer, but also not sacrifice their quality of life and what their personal goals are. So, all those things need to be incorporated in it.

Melanie:  Are you still taking out the prostate as a form of treatment? Are we looking at more beam radiation? What are you doing, sort of, as a first line of defense?

Dr.  Zhumkhawala:  Well, for men with lower risk prostate cancer, that tends to be localized. What we usually recommend is actually something called "active surveillance" where it's really a cancer that we think is ultimately not going to metastasize and cause major problems for the patient, we tend to put them on a program where we just keep a very, very close eye on the cancer with repeat blood tests, repeat biopsies and if the cancer changes in any way, then we go onto a more aggressive treatment. That's called “active surveillance.” For most men with low-risk prostate cancer, that's a very good option. If they have more intermediate risk or higher-risk prostate cancer, then we lean towards some kind of treatment. The most common type of treatment men get nowadays is still removal of the prostate which is called “radical prostatectomy” and the majority of those surgeries across the country are being done through robotic surgery and, certainly, here at City of Hope, that's our mainstay of prostate cancer surgery is the robotic prostatectomy. There are other treatments that are being used frequently:  radiation therapy--whether it's proton beam therapy done at a couple of specialized centers; external beam radiation therapy which we do at City of Hope or brachytherapy or radioactive seed implants also done at City of Hope, those are also options. Then, there's a different realm where we're really trying to do a lot of research on and that's called “focal therapy.” The idea behind that is that you're treating just the focus of cancer within the prostate and leaving the remainder of prostate healthy and viable. So, the thought behind that is that you're reducing the complications that come with removing the entire prostate. The different types of focal therapy are things like cryotherapy, where you're freezing the prostate, something called HIFU, or a high intensity focused ultrasound where we're using ultrasound waves that are focused on the cancer to destroy that focus the cancer; or radiofrequency oblation.  Also, there are some laser therapies and there are some newer techniques that are going to be coming down the pipeline.  With cryotherapy, you're just treating that focused cancer. You're not treating the entire gland, so men with multi-focal cancer or really higher-risk cancer are not good candidates for that. So, the prostatectomy, at least for now, is still really one of the mainstays of our treatment.

Melanie:  So, let's speak about the robotic prostatectomy for a minute, here. What can men expect and, certainly, men are worried about those side effects, whether it's incontinence or sexual dysfunction and these are main concerns for them. So, speak about the surgery a little and some of those side effects.

Dr.  Zhumkhawala:  Sure, so with the surgery, the difference between the old-fashioned radical prostatectomy and what we do now with the robotic radical prostatectomies, really, one of the main things that patients notice right away is the size of the incision. So, we're doing it with smaller incisions where we're putting in robotic instruments and through that, we have a robotic camera that's three-dimensional. We can get really up close and have excellent magnification of the tissue of the prostate and the rest of the body, as well. So, it really enables us to do quite fine surgery with techniques that we couldn't do with laparoscopic or even an open surgery. We do know that there's a decrease in blood loss. That's been proven. We think that the recovery is a little bit faster because of the smaller incisions. Most surgeons that do a lot of robotic surgery think that overall, the outcomes are going to better in terms of cancer control, incontinence, and erectile function.  You talked specifically about the two major concerns that most men have that are related to incontinence, or leakage of urine, after surgery and impotence, or difficulty with erections after surgery. Those are very, very common side effects from the surgery. Now, at City of Hope, we do a really good job trying to control those side effects and our continence rates are excellent. So, at about one year, 95% of our men are continent and, really, at about 6 weeks half of our men are continent. So, those are really high rates and I think there are a lot of techniques that we try to use to improve on continence in men that are undergoing robotic surgery. When you talk about sexual side effects, those are also significant and erectile dysfunction after prostate cancer surgery is very common. Probably about 70% of men are able to attain their erections after surgery, with the help of oral medications. But, even in the 30% of men that don't, there are options. So, if a man, after surgery is having trouble with erections and the pills aren't good enough, there are other medications, there are vacuum pumps, there are injections directly into the penis, and then, ultimately, if those all fail, there are surgical options to try to treat the erectile dysfunction. So, there is still a lot of hope, even if the pills are not enough. Then, we can certainly find a way to make sexual function still viable part of someone's life after prostate cancer surgery.

Melanie:  Doctor, if somebody has a robotic prostatectomy, if they have the prostrate removed, can they still get prostate cancer? Can it come back?

Dr.  Zhumkhawala:  It can. So, there are multiple why prostate cancer can come back after the prostate is removed. One is that there's cancer left behind at the time of surgery or a positive margin where we don't cut all of the cancer out and sometimes that's something you can control for and sometimes it's not. When the cancer's invading organs next to the prostate that are really vital for life, sometimes we do have to leave a little bit of cancer behind. Usually, those patients are treated with radiation after surgery to try to eradicate the remaining prostate cancer cells. But, there are also some patients where the cancer has microscopically spread prior to surgery and the lesions that it has9 spread to are not necessarily big enough for us to pick up on imaging scans. And so, sometimes we don't find that out until later but even when patients have a recurrence after prostate cancer surgery, there are multiple lines of treatment and there are multiple clinical trials that patients can go on. So, it's a paradigm that's changing quite a bit with the new research, but there are definitely treatments out there. 

Melanie:  And what are you doing that's exciting there at City of Hope?

Dr. Zhumkhawala:  Well, I think that a lot of the things that we do that are exciting relate to our research studies that are really aimed at treating patients throughout every step of the prostate cancer highways, so to speak, from the beginning to the end. So, we have trials that almost every patient with prostate cancer can embark on and some of the trials that we have that are unique are things like, we do have a high-intensity focused ultrasound trial--HIFU trials--for focal therapy. We do have a lot of surgical trials where we're looking at imaging techniques to try to improve our visualization of the cancer during surgery. We completed a trial using a chemical called Indocyanine Green, and we're currently doing another trial using an antibody to prostate cancer that is fluorescent and the idea is to see that intra-operatively and be able to see where the cancer is and where the prostate is and find those margins quite nicely. We also have trials for a patient that has cancer that recurs so there's imaging trials and we have some novel agents that we're using. A lot of these trials are in conjunction with other major cancer centers across the country.

Melanie:  That's absolutely fascinating, doctor. Really, such great information. So, in just the last few minutes, tell us why patients should come to City of Hope for their prostate care.

Dr. Zhumkhawala:  I think the main thing that we pride ourselves on is that we provide multidisciplinary care. When you come to City of Hope and you see a urologist, it's not just the urologist that's involved in treating you, there are a multitude of people that may be involved, whether it's physical therapists, whether it's nutrition and then, afterwards, there are radiation oncologists that we work closely with, there are medical oncologists that we work closely with. So, it's really a big team with a bunch of different people that can provide input and really help guide your care in a positive direction.

Melanie:  Fantastic. Thank you so much for being with us, doctor. You're listening to City of Hope radio. For more information, you can go to cityofhope.org. That's cityofhope.org. This is Melanie Cole. Thanks so much for listening.