At Perlmutter Cancer Center, No Two Patients Are Treated Exactly the Same (Not Even Twins)
As identical twins, Paul and Phil Malenczak share many affinities. The 68-year-old brothers both played lacrosse in college, served together in Brooklyn with the Fire Department of the City of New York, work as bartenders at an East Hampton golf club, and share a lifelong passion for fishing. Last year, they discovered they have something else in common: both men have prostate cancer.
After a routine physical, Paul (Phil’s junior by 3 minutes) learned that his prostate-specific antigen, or PSA, score was 14. While the blood test is far from definitive and numerous factors can account for elevated levels, a score above 4.0 merits further evaluation. Last summer, Paul underwent an ultrasound-guided biopsy at another institution and was diagnosed with low-risk adenocarcinoma, the most common form of prostate cancer.
In August, on the advice of Robert I. Grossman, MD, the Saul J. Farber Dean and CEO of NYU Langone Health, whom Paul knew from the golf club where he worked, Paul consulted urologic oncologist James Wysock, MD, assistant professor of urology and a surgeon at Perlmutter Cancer Center who specializes in cancers of the urinary tract and male reproductive system.
To arrive at an accurate diagnosis and treatment plan, Dr. Wysock recommended two advanced tests. A multiparametric MRI showed that additional regions of Paul’s prostate were suspicious, and an MRI-ultrasound-fusion targeted biopsy indicated that the cancer was slightly more advanced than the initial biopsy had indicated. This moved Paul into an intermediate-risk, or stage II, category, requiring treatment rather than surveillance.
Dr. Wysock, a pioneer in fusion biopsies, has performed more than 500 of these procedures, which help differentiate harmful prostate cancers from small, nonaggressive forms that may not require treatment. “This sophisticated biopsy was very valuable to us,” explains Dr. Wysock, “because it made possible a more accurate diagnosis and treatment.”
Like Paul, Phil had no symptoms, but he was so startled by his brother’s news that he consulted Dr. Wysock in December 2018. Though Phil’s PSA score was 8, lower than Paul’s, Dr. Wysock felt an abnormal nodule on the prostate during a rectal exam. An MRI and targeted biopsy revealed that Phil’s cancer was more extensive than Paul’s. Though it, too, was classified as intermediate risk, the MRI raised a concern that the tumor was starting to invade through the lining, or capsule, of the prostate. Phil admits to being a bit more rattled by the diagnosis than his brother. As Christmas approached, he thought to himself, “This can’t be happening.”
Dr. Wysock explains that while Paul and Phil Malenczak are the first set of twins he’s ever diagnosed with prostate cancer, their simultaneous onset doesn’t really surprise him. “If you have a brother or a first-degree male relative with prostate cancer, your likelihood of getting the disease may be twice as high as that of the general population. With identical twins who have the same genetic pathways, the risk is absolutely greater.”
As firefighters, Paul and Phil pride themselves in being men of action, so they were eager to learn about their treatment options. They soon discovered, however, that men with prostate cancer face an avalanche of information and a bewildering array of choices. While many forms of prostate cancers are slow-growing, others can progress rapidly. Men diagnosed with a less aggressive form are typically offered the option of active surveillance; they’re monitored closely and treated only if there’s evidence that the cancer is advancing. For men who require treatment, however, the choice between a conservative or aggressive approach is often a difficult one. Depending on the case, the options may include surgery, hormone therapy, radiation, or ablative treatments that destroy diseased tissue.
“There are critical differences,” explains Dr. Wysock, “so the discussion about the short-term and long-term implications of each one makes the shared decision-making process complex.”
Among men in the United States, prostate cancer is the second most common cancer (behind skin cancer) and the second leading cause of cancer death. The disease strikes one in five men. This year, more than 174,000 men are expected to be diagnosed, about 60 percent of them over age 65. The risk for black men is 60 percent higher than for the general population.
Dr. Wysock considers a radical prostatectomy (removal of the prostate) the most definitive treatment because it yields the most data about the tumor, reveals whether cancer has invaded surrounding structures, and leaves the door open for other treatment options, such as radiation therapy. Because the prostate lies deep within the pelvis, surgery can impact urinary control and sexual function. Dr. Wysock notes, however, that more than 90 percent of patients regain urinary control over time, and those who experience sexual dysfunction can be treated.
While radiation therapy is less invasive, it can have the same side effects, but “if cancer recurs,” he says, “it may limit treatment options.” A second round of radiation therapy is usually off the table due to the risk of further complications, he explains, and if surgery is necessary, prior radiation therapy can complicate both the surgery and the potential side effects.
Given the complex treatment decision Paul and Phil faced, Dr. Wysock wanted them to be well informed about both surgical and nonsurgical options. Learning that they preferred to receive their care close to home, he referred them to Jonathan Haas, MD, clinical associate professor of radiation oncology and chair of the Department of Radiation Oncology at NYU Winthrop Hospital in Mineola, which officially merged with NYU Langone on August 1. Among the options Dr. Haas discussed was stereotactic body radiotherapy (SBRT), a procedure that delivers precise, high-dose radiation. NYU Langone offers SBRT at all of its radiation oncology facilities to treat a variety of cancers, including prostate cancer. Dr. Haas delivers SBRT with a machine called the CyberKnife®, which targets the tumor from hundreds of angles. In 2005, NYU Winthrop became one of the first adopters of CyberKnife® technology, invented in the 1990s to treat brain tumors. Now the largest such practice in the country, it treats more than 600 patients annually at its hospital on Long Island and a satellite site in Manhattan.
Dr. Haas’s proximity and approach appealed to the twins. NYU Winthrop is a short drive from their home. Unlike conventional radiation therapy, which demands nine weeks of therapy, the CyberKnife® requires only five consecutive days, with each session lasting less than an hour. For Phil, a personal trainer who works out six days a week, the convenience was particularly important. In his case, however, treatment had to be delayed for six months. Drs. Wysock and Haas were concerned about the possibility that Phil’s cancer had invaded through the lining of the prostate, so they recommended a course of hormonal therapy—an androgen blockade administered by Dr. Wysock—to shrink the prostate gland and its tumor, the target for radiation. By mid-June, Phil was ready for the treatment his brother had undergone four months earlier.
Dr. Haas reports that the Malenczak brothers are doing “absolutely fantastic.” Their prognosis is excellent, he says, and to underscore the point, he notes that “men with intermediate-risk prostate cancer have a survival rate in the low-90 percent range, for all forms of treatment.”