Among American men, prostate cancer is the most common cancer diagnosis and the second leading cause of cancer deaths. When a man receives a diagnosis of prostate cancer, there are many different treatment approaches. These range from no immediate treatment, known as active surveillance, to complete surgical removal of the prostate, called radical prostatectomy. For many men, deciding on a specific treatment could seem overwhelming.
Urologists from the Smilow Comprehensive Prostate Cancer Center, part of NYU Langone’s Perlmutter Cancer Center, explain what men should know about prostate cancer screening and detection, and provide insights to help understand the different treatment options.
Diagnosing Prostate Cancer with Biopsy
Prostate-specific antigen (PSA) is a protein produced by the prostate gland, and elevated levels in the blood may indicate prostate cancer. Historically, an elevated PSA level resulted in men receiving a biopsy of the prostate and some form of treatment for all detected cancers. While this paradigm for screening, detecting, and treating men with prostate cancer decreased the rates of death from the disease, many men had unnecessary biopsies and treatment.
Over the past decade, experts at the Smilow Comprehensive Prostate Cancer Center have made great strides in decreasing the number of unnecessary biopsies and surgeries with the aid of biomarkers. A biomarker is a biological molecule found in blood, other body fluids, or tissues, and is a sign of a normal or abnormal process, condition, or disease. It may be used to see how well the body responds to a treatment.
Using a combination of biomarkers and multiparametric MRI, a noninvasive medical test that can produce detailed pictures of the prostate, NYU Langone experts have determined that about one third of men with elevated PSA levels are at very low risk of aggressive cancer, and biopsy is not necessary.
For men who are at risk of aggressive forms of prostate cancer, an MRI is performed before the biopsy. The MRI reliably identifies the sites of aggressive cancer. NYU Langone urologists use MRI/ultrasound co-registration technology, which was pioneered at NYU Langone. This innovative technique allows experts to target the most suspicious areas of the gland for biopsy, rather than randomly selecting areas of the prostate, which increases the detection of aggressive cancers.
According to Samir Taneja, MD, the James M. Neissa and Janet Riha Neissa Professor of Urologic Oncology and co-director of the Smilow Comprehensive Prostate Cancer Center, “These image-guided biopsies help doctors identify harmful prostate cancers while avoiding small, nonaggressive cancers that don’t require treatment.”
Knowing When to Treat Prostate Cancer
Approximately one half of men who are more than 50 years of age have prostate cancer, but only 3 percent of men die of the disease. Therefore, there are many small, nonaggressive prostate cancers that are harmless and do not require treatment.
NYU Langone doctors strongly advocate for conservative management, such as active surveillance, for men who have low-risk cancers, and have received funding from the National Institutes of Health to develop evidence-based methods for this approach. The challenge is to determine which of these low-risk cancers coexist with undetected aggressive cancers and which low-risk cancers will become more aggressive over time.
In collaboration with Cold Spring Harbor Laboratory, Herbert Lepor, MD, the Martin Spatz Chair of the Department of Urology and director of the Smilow Comprehensive Prostate Cancer Center, is investigating whether deletions or amplifications of genes can be identified from single prostate cells obtained during biopsy. The method promises to more accurately distinguish men who need surgery from those who do not.
Pioneering Treatments for Prostate Cancer
If treatment is deemed necessary, doctors can offer men a variety of therapies, depending on age, overall wellbeing, personal priorities, how contained the cancer is, and the aggressiveness of the cancer.
“One treatment certainly does not fit all, and a menu of options empowers men to make an informed decision that balances outcomes and quality of life.”—Herbert Lepor, MD, Director of the Smilow Comprehensive Prostate Cancer Center
NYU Langone urologists pioneered nerve-sparing radical prostatectomy, a procedure to remove the prostate, in the early 1980s and have performed almost 7,000 of these surgeries.
At NYU Langone, about 90 percent of men who have an open or robotic radical prostatectomy are discharged from the hospital after 1 day, and the majority return to work within 2 weeks. Most men can make a full return to their everyday activities within three weeks after surgery. Some men may experience side effects after a prostatectomy such as incontinence, which often resolves within a few months. NYU Langone urologists have also reported that sexual dysfunction is a problem for many older men who experienced erectile dysfunction before treatment, despite a nerve-sparing approach.
Another treatment option is focal ablation, in which radiofrequency ablation or high-intensity focused ultrasound (HIFU) is used to target cancer cells or selected tissue. Cryotherapy is another focal ablation treatment and involves destroying cancer cells with extremely cold temperatures.
With focal ablation, doctors can target only the areas of the prostate containing an aggressive form of the disease. Focal ablation is an outpatient procedure, and men often return to work within days, experiencing minimal to no side effects that have an impact on urination or sexual function. The limitation of focal ablation is whether aggressive cancer will develop in the nonablated prostate or in the ablation zone due to failure to completely eradicate the disease.
These procedures are relatively new treatment options for people with prostate cancer at NYU Langone. In fact, NYU Langone is the second academic medical center in the United States to perform focal ablation using the HIFU Sonablate® system coupled with ProFuse software to allow precise delivery of ablative energy. NYU Langone surgeons have published many articles on focal ablation and have lectured nationally and internationally on this evolving technology.
Additionally, our researchers are active in clinical trials to develop promising new treatments, including immunotherapies, targeted drugs, and combinations of these medications. Our team can advise whether you are eligible to participate in one of our clinical trials.
Experts also determine when and if hormone therapy, radiation therapy, or chemotherapy is a viable option. They discuss the advantages of some options and ways to manage side effects such as erectile dysfunction and incontinence. Sexual rehabilitation treatment, for example, is available. In addition to traditional treatments for side effects, NYU Langone also uses integrative techniques, which can include mind–body counseling, stress management counseling, and acupuncture, as well as psychotherapy.
Individualizing Prostate Cancer Care
Researchers continue to study ways to improve treatments and outcomes for prostate cancer. NYU Langone is home to one of the most robust patient databases in the world, which provides scientists with a source of long-term quality-of-life information about men who have had radical prostatectomy.
Because every man’s circumstances are different, doctors take this into account when developing a treatment plan.
“At NYU Langone, men seeking treatment for prostate cancer range in age from 37 to their 90s,” notes Dr. Lepor. “For some men, preserving quality of life is the most important consideration, while for others, the highest priority is to cure the disease. One size certainly does not fit all, and a menu of options empowers men to make an informed decision.”