"" Ralph Moss—Cancer Consultant: Big Advances in Prostate Cancer

Saturday, October 31, 2015

Big Advances in Prostate Cancer

3 Tesla MRIs are revolutionizing detection of prostate cancer

There have been considerable advances in the past few years in both the detection and treatment of prostate cancer. Typically, in the past, patients were screened for prostate cancer using the prostate specific antigen (PSA) test. If the test score was over 4 the man was considered a likely candidate for a prostate biopsy. This biopsy was and is guided by a transrectal ultrasound (TRUS) device. The urologist would take a certain number of “punch” biopsy samples of the prostate gland. This might turn up a malignant area, which was then classified according to the Gleason scale (from a low of 2 to a high of 10).
However, ultrasound typically is not a very precise way of visualizing tumors or distinguishing them from non-malignant areas. Nowadays, much more precise magnetic resonance imaging (MRI) is increasingly being used as a superior way of visualizing the prostate and isolating abnormalities including, possibly, cancer. The modern so-called "3 Tesla" MRI machine has twice the strength of the older 1.5 Tesla MRIs and about 10 to 15 times the strength of low-field or open MRI scanners. It produces remarkably clear images, far ahead of what has been generally available to one's urologists, especially those in more outlying areas. These images can be further enhanced by the insertion of an endorectal coil, which serves as a kind of antenna for the MRI machine. These 3 Tesla MRIs are already in operation at some of the leading medical centers, but even there the patient may need to insist on being screened with a “3T” machine as opposed to the older but more readily available "1.5T" machines. To find centers with 3T machines may require repeated and intense phoning.

While most people who receive an MRI of the prostate have already had a TRUS-guided biopsy, this is not necessarily the case. Some doctors are now willing to prescribe a 3T MRI as the first line for evaluation after detecting a lump via a digital rectal exam (DRE) or through an elevated PSA or other test.

Fusion Technology

A positive finding on the MRI will probably result in a decision to do a biopsy. Typically, this is an outpatient procedure in which a urologist inserts a hollow needle between12 to 24 times into the gland in a search for cancerous tissue. The gland is usually treated with a local anesthetic before the procedure, but still is fairly unpleasant. Older biopsies were to some degree a hit or miss affair. But prostate biopsies nowadays can be performed using a so-called “fusion” system. UroNav is one such system. It provides a way of combining traditional trans-rectal ultrasound with an MRI image to produce a clear picture of which areas need to be sampled for malignancy. In the words of Eric A. Klein, MD, of the Cleveland Clinic, with the typical random biopsy "we're using a scattershot 'blind' approach, hoping that, if a tumor is present, one of the needles will encounter it. These random biopsies can miss some harmful tumors, while turning up others that are inconsequential and may end up being treated unnecessarily." The UroNav system was introduced at a urology meeting in 2013 and quickly became available at many top centers, including Brigham and Women’s and Beth Israel Deaconess, Boston; Cleveland Clinic, Cleveland; New York University (NYU) Langone Medical Center, New York; the National Cancer Institute, Bethesda; Yale Medical Center, New Haven, etc.

Once a patient has undergone this fusion biopsy, there is a good chance that he will have a definitive answer of whether or not he has cancer and if so, how malignant and dangerous it is likely to be. However, the treatment picture remains complex. For instance, lower malignancy tumors (typically, a Gleason score of six or less or low-volume Gleason 7 tumors (i.e., a Gleason pattern of 3+4) can usually be managed through active surveillance (what used to be called watchful waiting). This might involve periodic repeat biopsies. At some centers, such as NYU Langone, there is a comprehensive program of integrative oncology, under the direction of Geo Espinosa, ND, to prolong this period of active surveillance (hopefully) or co-management of more advanced prostate cancer for the duration of the patient’s life. On the other hand, tumors with high volume and a Gleason score of 7, 8 or higher usually require immediate treatment. Treatment decisions need to be individualized, based on many considerations, including the patient’s age, general fitness, and of course desires. This “fine tuning” should be done under the guidance of a knowledgeable urologist/oncologist.

What prostate cancer treatment is best remains a matter of dispute. In the past, radical prostatectomy (RP) was virtually the only option. Then came radiation therapy, both external beam, intensity modulated radiation therapy (IMRT) and/or radioactive seeds (brachytherapy). These still remain valid options for many people. More recently, there has been increasing interest in non-ionizing forms of energy, such as radiofrequency ablation (RFA), high intensity frequency ultrasound (HIFU) and cryo-ablation (freezing the tumor and the prostate gland). As stated, for those with lower malignancy tumors an aggressive program of life-style modification, including dietary changes, might be sufficient. In this sense, urology is moving faster than some other specialties towards a state of integrative oncology.

In any case, while prostate cancer remains an enormous problem in the US and elsewhere, diagnostic and treatment options have expanded in recent years in a direction favorable to the potential patient.

Acknowledgement: My thanks to Dr. Geo Espinosa, ND, of NYU Langone Medical Center, for reading and commenting on this article. Any remaining errors are the author's responsibility.