A new study shows how important it is for men to carefully consider treatments for early stage prostate cancer. 15 years after surgery or radiation treatment, nearly all of the older men in the study had some problems having sex. This research, which appeared in the New England Journal of Medicine, paints a pretty dire picture of life after prostate cancer treatment, with large numbers of men facing sexual problems and urinary incontinence. Dr. Samadi, what is your reaction to the findings?
Dr. David Samadi: I think that’s one of the biggest fears for everyone that’s diagnosed with prostate cancer. Of course they’re thinking about incontinence and sexual dysfunction. This study actually came in a New England Journal Medicine, as you mentioned, and one of the things that the audience needs to know is that this study actually comes from the VA hospital. They looked at thousands of patients and what they realized is that, over time, whether it’s radiation or surgery, there were a lot of complications and issues. What you should know is that this was all open surgery series and we know that, in open surgery, it’s really difficult to really look at those nerves. You’re counting on your tactile feedback and the touch factor. This is the kind of surgery that we were doing many years back and now it’s almost going out of fashion. Reason for this is because there’s a lot of blood in open surgery and if you can’t see well, you have to touch. Unfortunately, this touch factor and tactile feedback is not going to really help the patient with the nerve sparing and with the continence. A lot of these surgeries were done by residents and fellows at the VA many years back. Now, since then, there has been a lot of advances in the field of prostate cancer: we have taken the experience of open surgery, we have built up the laparoscopic experience from France and now we’ve done well over 4,000 robotic cases. Plus, there are a lot of skilled robotic surgeons out there, who know how to save the nerves. Now, the most recent advances in robotic surgery is what we invented the SMART technique, which is getting more and more popularity out there. Initially, we were taking the nerves from the prostate, opening it from the side and mobilizing the nerves.
This exposed the nerve to the threat of damage. Instead, I reversed the operation where I remove the prostate away from the nerves. This way, the entire skeleton of the nerves and the sphincter and surrounding tissues are untouched. Now we’re seeing about 97% continence, we see about 85% sexual function and the patients are basically leaving the hospital in 24 hours. What that tells you is that it’s not just the robotic technology, it’s the experience of the surgeon behind it and the dedicated centers where there are surgeons that are doing high-volume – over 3-400 surgeries per year.
That results in better outcome and that’s what we’re learning from this. I think that we’ve come a long way in this field, where we’ve taken the experience of open surgery and now we’re combining it with our fancy technology. Typically, when I see these patients in the office, within six weeks to two months or so, they are gaining their continence and their sexual functions, so we’ve come a long way in this field.
Now, when we talk about early stage prostate cancer, is it generally over treated, and, if so, why is that?
DS: It’s an excellent question, and I truly believe that it is over treated and partly because our diagnostic tools are really weak. We’re talking about when somebody goes with an elevated PSA or a prostate nodule to the doctor, they end up getting a biopsy. It’s important for people to know that these are random biopsies. Your doctor is taking certain samples of your prostate from different parts of it. Now, if you get the same biopsy a week after, or two weeks after, you may end up with completely different results. I think the fear that your diagnosis could be that of a low risk prostate cancer before the surgery, while after the intervention, you will find a lot more agresive cancer, is the reason why there is over-treatment and over-diagnosis. The day that comes, that we would have better imaging and better diagnostic tools, I think those numbers will go down. There’s also a lot of studies coming in in genetics. Trying to find out who is really at high risk and who is not, then we can really decide who should get the surgery or not. But, in general, I think it’s important for people to know that when you remove the prostate, unlike radiation, you get a very accurate staging. You will find out how much cancer you have and what type of prostate cancer. Other treatments like cryotherapy or radiation and HIFU won’t give you that kind of answer.
Now, I want to focus a little bit closer on the factors that go into determining whether a prostate cancer patient should have surgery radiation or no treatment at all and undergo what is called “watchful waiting”. Talk about those factors.
DS: If you are much older, you have a low risk prostate cancer, your PSA hasn’t changed for a long time, you may have medical issues such as diabetes or heart disease, you would be a fantastic patient for what we call “watchful waiting” or, better term would be “close surveillance”. What that means is that you need to come into our office every three months. If the PSA continues to go up, there will be multiple biopsies in the future and the major condition for that is that the patient needs to be compliant and follow up. If the patient is not compliant, close surveillance would not be a good option. When it comes to the decision of radiation versus surgery, the options are completely different. In surgery, you basically remove the entire prostate and you will find out what your accurate and precise staging is. What does that mean? How much cancer do you have? Is it 30% of your prostate? 80%? Has the cancer gone into seminal vesicles or surrounding tissues? What’s the status of lymph nodes? And, of course, moving forward, your PSA should be always zero and undetectable, so you are in charge of your life. If the cancer comes back after surgery you can still have a plan B, which is you can get radiation after surgery.
When you talk about radiation as a first treatment, that’s a totally different world: we don’t know exactly what the stage is. We’re basically going with what we found on the random biopsies, and I certainly don’t want to risk my life on some just random biopsy that somebody did. So you’re radiating the prostate, not knowing what the seminal vesicle condition is and what the lymph nodes are.
If the cancer comes back after radiation or cryotherapy, surgery will not be a good option for you. You have burned too many bridges. And so, we got to be very careful. The follow-up after radiation is also very difficult, because the PSA is not going to be zero. So I think more and more people who are educated are finding out that in the hands of experienced surgeons, the quality of the sex life and urinary control is great. Removing the prostate, making sure that there is no cancer left behind, with the easy follow-up and all options ahead is a way to go. Of course, robotic surgery is becoming more and more popular.
Well, you were at the forefront of the robotic surgery revolution, you’re a pioneer in this field and one of the experts, one of the best in the world. What are some of the advantages compared to more conventional surgery?
DS: Well, you know, with the new and latest SMART technique, what we have done is we really have saved the sex life for a lot of men. Now we see patients in the early 40’s and 50’s and sex is a big part of their lives. I really want them to make sure that they have quality of life. Urinary control is a big part of this, also. We were able to really preserve as much urethra for them, meaning they are able to get rid of those pads very soon. The surgery is now about an hour to an hour and a half. Patients stay in our private floor one night and they go home the next day. The catheter duration is much shorter, pain is minimum, getting back to work is much faster. There hasn’t been any transfusion for the last six years and I think that’s really one of the medical miracles in this country. Now we’re seeing a lot of patients coming from all over the world to us, to seek our expertise, and that has revolutionized the field of prostate cancer.
And patients can get back to feeling like men again, which has obviously emotional mental and health benefits as well. Dr. David Samadi great talking with you and hope to see you really soon.