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Taking a new tack on prostate cancer

Philadelphia Inquirer (PA)


Oct. 01--Decades after lumpectomy became a standard option for women with breast cancer, men are seeking a similarly targeted approach to prostate cancer, one that gets rid of the tumor while preserving the organ.

This sensible tack has lagged in prostate cancer for many reasons, starting with the fact that the golf-ball-size gland is inaccessible. It lies deep within the pelvic cavity, surrounded by sensitive structures that are vital to sexual and urinary health.

Now, however, an array of technologies is enabling doctors to visualize and zap away prostate malignancies. Tissue is destroyed, or "ablated," by energy from lasers, microwaves, extreme cold, or ultrasound.

The presumed -- but unproven -- advantage of focused ablation is less collateral damage. In other words, less incontinence and impotence.

"I'm very happy with the results," Gary Crissman, 60, of Pittsburgh, said of his care with high-intensity focused ultrasound (HIFU). "My sexual, urinary, and rectal function are normal. I feel I won the trifecta."

Still, his experience shows not only a big risk of organ conserving treatment -- more about that later -- but also the eagerness of patients to undergo treatments before they get U.S. approval. Targeted prostate cancer ablation remains experimental and is available primarily in research centers. Nonetheless, HIFU is being marketed to American men by SonaCare Medical and by some American doctors trained to use its Sonablate HIFU system.

Patients go to a SonaCare "international treatment center" and pay out of pocket. Crissman went to Puerto Vallarta, Mexico, and paid $25,000 for the two-hour procedure.

SonaCare, based in North Carolina, did not provide a representative for an interview. But its website explains that it "operates a unique service coordination program for physicians and patients" who travel to its clinics in Canada, Argentina, the Dominican Republic, the Bahamas, and Mexico.

On Wednesday, the Prostate Cancer Foundation -- founded by a survivor, financier Michael Milken -- will hold its annual Philadelphia fund-raiser, an all-day event that ends at the Crystal Tea Room in the Wanamaker Building. More than $1 million has been raised this year, exceeding last year's total, to underwrite local research.

The urgency has never been greater. The PSA screening test, once seen as a lifesaving early-detection tool, is no longer recommended by health experts because too many men are being treated for cancers that, left alone, would not become life-threatening.

Urologists point out that the disease kills 30,000 American men a year, despite a 30 percent reduction in deaths since the PSA was introduced in the late 1980s. They urge wider use of an option men find nerve-racking: Monitor rather than treat early-stage cancer, hoping it doesn't grow.

Targeted ablation is seen as a possible solution to this dilemma, at least for some patients.

"We need something more than all or nothing," said Herbert Lepor, a prominent urologist and surgeon at New York University Langone Medical Center.

Lepor believes targeted ablation is "an exciting new realm." He is studying the use of laser ablation guided by imaging that marries MRI and ultrasound.

"I don't think it matters whether you laser, HIFU or freeze the cancer," he said. "The real challenge is patient selection."

That's because studies suggest two-thirds of men have cancer in several locations in the gland. Even with the best technology, pinpointing these microscopic malignancies before and during ablation therapy is hard.

It is not yet clear whether the best candidate for ablation has cancer in only one spot, or whether missing some early malignancies does not undermine long-term cancer control. What is clear from studies in Japan is that 20 to 40 percent of men had cancer recurrences five years after treatment.

"Men electing to pursue targeted ablation must realize there are uncertainties as to whether all the cancer has been eradicated," Lepor and coauthors wrote in their new book, Redefining Prostate Cancer. "These men must be followed with post-treatment" tests and biopsies.

Leaving cancer cells behind is also a concern with radiation. But if radiation fails, it can't be repeated, and the gland is usually too damaged to be safely removed with surgery.

Ablative treatment, in contrast, can usually be repeated if cancer comes back. Or, the man can opt for radiation or surgery.

That was a deciding factor for Crissman, a manufacturer's representative who was 54 when he was diagnosed in 2007. He and his wife decided "we'll take the chance that if we don't get all of it, the procedure could be redone, and all the other options are still open."

Last year, his rising PSA level signaled trouble.

"So I did HIFU again," he said. "When they redid it, I got a discount. They charged $12,500."

While Crissman has had no lasting side effects, the safety profile of HIFU has not been established in controlled studies. Less rigorous work in several countries suggests HIFU has a 2 to 3 percent risk of incontinence, and a 20 to 30 percent risk of impotence.

David Chen, a urological oncologist at Fox Chase Cancer Center, is not convinced that HIFU is safer or more precise than radiation, especially when the tumor is at the edge of the prostate.

Chen is testing Sonablate as part of a multi-center clinical trial for men whose cancer recurred after radiation. SonaCare hopes to use the results to get Food and Drug Administration approval.

"It's like weeds," Chen said. "If weeds are in the middle of the yard, you can use a shovel or weed-killer. But if the weeds are against the fence, how do you treat it without damaging the neighbor's lawn? I worry that men who give these testimonials were undertreated."

In a recent review, Memorial Sloan-Kettering Cancer Center urological surgeons concluded that targeted ablation methods are not yet "game-changing." But they are changing attitudes.

"They have contributed to a movement towards less invasive, focal treatment," wrote lead author Jonathan Coleman.




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