Across the nation researchers continue to look for foods (or the substances within them) that can help lower prostate cancer risk. To date scientists have found that some of the substances in tomatoes (lycopenes) and soybeans (isoflavones) might help prevent prostate cancer. New studies are now taking a closer look at the possible effects of these compounds.

Some scientists are also trying to develop related compounds that are even more potent and might be used as dietary supplements. Most of the current research suggests that a balanced diet including these foods as well as other fruits and vegetables is probably more beneficial than taking these substances as dietary supplements.

Vitamin D may prove to be an important in preventative. Some studies have found that men with high levels of vitamin D seem to have a lower risk of developing the more lethal forms of prostate cancer. However, studies have not proved conclusively that vitamin D protects against prostate cancer.

People often assume that vitamins and other natural substances are completely safe to take, but recent research has shown that high doses of some may be harmful, including those in supplements marketed specifically for prostate cancer. For example, one study found that men who take more than 7 multivitamin tablets per week may have an increased risk of developing advanced prostate cancer. Another study showed a higher risk of prostate cancer in men who had high blood levels of omega-3 fatty acids. Fish oil capsules, which some people take to help with their heart, contain large amounts of omega-3 fatty acids.

Some research has suggested that men who take a daily aspirin for a long time might have a lower risk of getting and dying from prostate cancer. Still, more research is needed to confirm this, and to confirm that any benefit outweighs potential risks, such as bleeding.

Scientists have also tested certain hormonal medicines called 5-alpha reductase inhibitors as a way of reducing prostate cancer risk. Studies like all of these mentioned here could prove to be very beneficial for men in the future.

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As recognized and respected leaders in the field of da Vinci® Robotic Surgery for prostate cancer, Dr. Christopher Knoedler and Dr. Robert Gaertner stay on top of the latest developments in their field. Recently they flew out to the headquarters of Intuitive Surgical in Sunnyvale, California to be introduced to a new robotic surgery prototype.

The doctors were asked to visit the headquarters of Intuitive Surgical to see the newest robot that is currently in development. They engaged with the engineers on a back and forth with their own ideas and suggestions on the new (were asked to help engineers trouble-shoot and refine this new) high tech piece of surgical equipment.

Currently when performing robotic prostate surgery, Drs. Knoedler and Gaertner create six small incisions. The new robot would reduce the number of sites that the instruments need to pass through from six to either two or three. When surgeries become less invasive it benefits patients with quicker recovery times.

The new version of the robot also allows the surgeons easy visual access to all four quadrants of the abdomen and allows them to operate in all four areas as well.

Dr. Knoedler and Dr. Gaertner are pioneers in the utilization of da Vinci Robotic Surgery and have trained hundreds of physicians in the use of this revolutionary technology. They were among the first doctors in the region to routinely use this robotic surgery system and have led the way in using it to improve the extremely challenging surgical procedure to remove the prostate gland (Prostatectomy). To date this team has performed more than 3,000 robotic surgeries.

In 1999 Intuitive Surgical introduced the da Vinci® Surgical System and today they are the global leaders in robotic-assisted minimally invasive surgery. This technology features a 3D high definition vision system for a clean and magnified view inside the patient’s body. The instruments used bend and rotate far greater than the human wrist. The surgeon controls the system which translates hand movements into smaller, more precise movements of tiny instruments inside the patient’s body. This technology allows surgeons to perform complex procedures through a few small openings.

A study titled “A Multidimensional Analysis of Prostate Surgery Costs in the United States: Robotic-Assisted versus Retropubic Radical Prostatectomy,” was recently published in Value in Health.

In the United States, prostate cancer is the most commonly diagnosed cancer among men and accounts for 27 percent of all cancer diagnoses. With the estimated direct costs of cancer diagnoses totaling over $125 billion, and more than 80 percent of prostate cancer surgeries done by robotic-assisted Laparoscopic Prostatectomy (RALP), the financial impact of prostatectomies on the healthcare economy is enormous.

In this study, researchers examined the financial impact of RALP versus Retropubic Radical Prostatectomy (RRP) for each radical prostatectomy by performing a systematic peer-reviewed literature search for clinical outcomes and by creating cost models for three different ways to assess the costs: hospital costs, payers’ expenditure and society’s expenses.

The results of the study revealed cost savings for hospitals, payers and society, when RALP surgeries are performed with da Vinci® Surgical Systems compared to RRP surgeries. Statistical analyses showed a clear cost savings with RALP for payers (99%) and society (83%) and for the individual hospital 38 to 79 percent of the time.3 While previous research has been limited to a single cost model, often direct hospital and robotic system costs, this study included multiple ways to assess the costs, reporting cost savings of $1,451 per patient for the payer and $1,202 per patient in societal savings.

“It is clear that the adoption of robotic-assisted Laparoscopic Prostatectomy eases the financial burden of prostate cancer on our healthcare system,” said Dr. Ashutosh Tewari, Professor and System Chair of Urology at Mount Sinai Health System. “As the healthcare providers strive to improve both patient outcomes and achieve greater value, this data shows that technologies like the da Vinci Surgical System can simultaneously deliver cost-effective treatment and care that can make surgery easier on patients.”

The study also calculated the costs of the robotic system in two different ways – as hospital overhead including hospital costs, inpatient bed, and inpatient days (resulting in $1,094 in hospital savings) and using the annual volume of robotic procedures ($341 in extra costs). This demonstrates that potentially higher robotic surgical expenditures are counteracted by cost savings due to better clinical outcomes, including reduced complications , improved functional outcomes (e.g. continence and sexual function), and a faster recovery.

“This study further demonstrates that hospital administrators need to look beyond visible operating room costs when analyzing the robotic-assisted surgery value proposition,” said Myriam Curet, M.D., Senior Vice President, Chief Medical Officer at Intuitive Surgical, Inc. “The ability of robotic-assisted surgery to reduce complications and shorten hospital stays, undoubtedly leads to greater value for patients and healthcare providers.”

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Eleven compounds that have the potential to significantly improve the treatment and diagnosis of prostate cancer have recently been identified by a group of scientists, who say the compounds could be used in the future to develop more effective and targeted drugs. Currently prostate cancer is similar to most other types of cancer in that it is fought using drugs that damage healthy cells as well as cancerous ones.

Researchers in four institutions across Russia looked at a cancer marker called the prostate specific membrane antigen (PSMA), to determine whether specific types of molecules can be more selective in the type of cells they target. Prostate cancer tissues have 10 times the level of PSMA proteins. These PSMAs can be a highly effective way of spotting secondary tumors that could be present after the removal of the initial tumor.

Once the PSMA was identified, the scientists evaluated three different groups of molecules capable of binding to it. After a detailed analysis, the team identified ligands as having the best potential to offer a targeted approach to prostate cancer, and the team was able to build on previous work done in this area. The scientists highlighted a set of eleven promising cancer-fighting compounds based on a substance called urea. Urea is a part of urine and has long been of interest to cancer specialists because of the way it can be modified to block DNA replication and thus the division of cancer cells.

The team reported that they have discovered eleven substances that have demonstrated the characteristics necessary. These substances are now being tested in clinical trials and according to the scientists, the results so far are encouraging.

According to the US National Cancer Institute, prostate cancer is the second most common cancer in men after skin cancer, and despite the fact that most men don’t die from the disease, it’s still the second most common cause of cancer-related death in the US after lung cancer.

The study referred to in this article has been published in the Journal of Drug Targeting.

Prostate cancer is the most common non-cutaneous malignancy diagnosed in men. Last year in the U.S. an estimated 240,000 men were diagnosed with the disease, and 29,000 died because of prostate cancer. Approximately one in six men will be diagnosed with prostate cancer in their lifetime.

Over the last five to 10 years we have seen dramatic changes in the way prostate cancers are detected and treated. Traditionally, prostate cancer was detected using PSA testing and digital rectal exam with the primary treatments being surgery and/or radiation. For metastatic disease, patients were treated with hormonal therapy and cytotoxic chemotherapy. In this article we will discuss what’s new in prostate cancer screening, diagnosis, and treatment of localized and metastatic disease.

Screening

The PSA (prostate specific antigen) blood test is the most widely used screening test for prostate cancer since it first came into use in 1994. Men who are screened for prostate cancer using PSA are more likely to find their cancers earlier and have a higher chance of cancer cure. It is, however, not a perfect test, and many patients and physicians question its role in prostate cancer screening.

First, a PSA test can give both false­positive and false-negative readings. Men with normal PSA readings may have prostate cancer, a false negative. More commonly, men with high PSA readings do not have cancer, a false positive. Men with high readings but without cancer go through unnecessary prostate biopsies and follow-up testing.

Second, prostate cancer in many men is indolent. PSA screening detects non­lethal as well as lethal cancers. One of the key challenges is differentiating those cancers which can be followed via active surveillance and those potentially aggressive cancers that will lead to significant morbidity and mortality. Most experts agree that not every prostate cancer needs to be treated. A significant trend clinically has been the acceptance by patients that not all cancers need immediate, aggressive treatment.

Controversy regarding PSA testing increased substantially after the U.S. Preventative Services Task Force came out with its position statement in 2010, giving the PSA blood test a “D” rating as a screening tool. Although many urologists and oncologists were critical of the rating, many practitioners at the primary care level drastically changed their discussion with patients and practice patterns regarding PSA testing. Patients also became more critical of the test after heavy publicity of the USPSTF rating.

In 2013, the American Urologic Association established its own guidelines. The AUA does not support the USPSTF position on PSA screening. The AUA recommends the omission of PSA screening for men with a life expectancy less than 10 years or those under 40. For all other men the AUA advocates shared decision­making for men and their physician regarding PSA testing; especially those men between ages 55-70 or those with a strong family history of disease.
Shared decision-making relies heavily on the guidance of a medical practitioner looking out for the best interest of the patient. We would encourage you to review the AUA guidelines at: www.auanet.org/education/guidelines/prostate-cancer-detection.cfm
As urologists we strongly advocate for prostate cancer screening. In 2015 the current standard is the PSA test; in the future we hope a more cancer-specific test will emerge.

Diagnosis

The PSA is a basic screening test. It is often a starting point with patients as we discuss whether to perform a prostate biopsy, and, if a cancer is found, whether treatment or surveillance is most appropriate. Here we have also seen advances.

There are new genetic and biomarker studies which have added to our ability to find prostate cancers.
Examples include the PHI (Prostate Health Index) or a 4Kscore- measures 3 or 4 different types of PSA kallikreins in the blood, and the PCA3; a urine test that looks for a protein that is produced by prostate cancer cells. These tests are used to predict risk of high grade cancer prior to a patient having a biopsy. Advances in genetic testing allow us to better determine which cancers should be treated. Examples of this include the Oncotype DX and Prolaris-genetic tests run on a biopsy specimen to help determine if the biopsy sample represents low or higher risk disease.

Recent advances in MRI of the prostate have improved our ability to identify prostate cancers and, in some cases, differentiating indolent from aggressive tumors. Urologists traditionally use trans-rectal ultrasound as a guide during a prostate biopsy, but the ultrasound is a low-resolution image. We now have software that can fuse a fixed MRI image with real time ultra­sonography. The radiologists reading the MRI will draw out specific areas requiring biopsy; the urologist can “fuse” that image with the ultrasound and insure that those specific areas are biopsied. This sequence creates a more targeted biopsy, detecting cancers we may have otherwise missed.

Treatment of Localized Disease

There is an increasing interest in active surveillance for low-grade prostate cancers. Active surveillance is a close monitoring process that typically involves frequent PSA testing and rectal exams, repeat prostate biopsies, and imaging studies such as MRI to try to detect progression of disease. While active surveillance is gaining traction, the gold standard for treatment of prostate cancer remains radical prostatectomy. Over the last decade daVinci robotic radical prostatectomy has emerged as the preferred surgical approach in the overwhelming majority of hospitals and centers of excellence. Robotic prostatectomy has shortened recovery times, decreased blood loss and, in experienced hands, improved outcomes.

Radiation, brachytherapy seed placement, cryotherapy (freezing), and a recently FDA approved treatment, high­intensity focused ultrasound (HIFU), are also options for treatment of localized prostate cancer. Traditionally we treat or remove the entire prostate, even the benign ti ssue.

A different and developing strategy is focal therapy. Using some of the newer technology such as HIFU or cryotherapy we can ablate only the cancerous lesion while leaving the normal prostate intact. While focal therapy is not yet considered standard of care, improving imaging with MRI and other means of identifying the tumor location within the prostate will likely make focal therapy a more common and standard option in the near future.

Treatment of Advanced Disease

Prostate cancer is hormone sensitive and creating castrate levels of testosterone can help control the disease. Androgen deprivation therapy (ADT) uses either surgical castration, medical castration, and/or combined androgen blockade with the use of anti-androgens.

Despite initial tumor response to ADT, most cases will become resistant over time. Historically once the cancer became castrate resistant (CRPC) the only options were cytotoxic chemotherapy. Newer treatments have shown improved survival.

Abiraterone acetate (Zytiga) and Enzalutamide (Xtandi) are second-line inhibitors of androgen activity in the body either by reducing production (Ztytiga) or by androgen receptor blockage (Xtandi). Both are being used commonly by urologists and oncologists for treatment after failure of initial ADT. Both show very good response and extension of survival.

Sipuleucel-T (Provenge) was a first of its kind cancer vaccine. It involves the autologous infusion of patient’s own blood cells after they are exposed to the prostate cancer antigen in a lab. It has been shown to extend overall survival as well.

Radium 223 (Xofigo) is a radioactive agent used to target bone metastases. It is especially useful for men with late stage, painful bony metastatic disease.

Conclusion

The landscape of prostate cancer diagnosis and treatment continues to evolve and improve. We believe this will help the lives of the many men diagnosed with prostate cancer. As urologists who are part of a larger practice, Metro Urology, that focuses on prostate cancer we see the benefit of adopting and employing these new technologies. We are excited about the future of prostate cancer care.

Todd Brandt, MD, has practiced with Metro Urology since 2000, focusing on prostate cancer and men’s health.

Basir Tareen, MD, is a fellowship-trained urologic oncologist. He has practiced with Metro Urology since 2011.

English scientists say that there are five distinct types of prostate cancer, and they’ve found a way to distinguish between them. This research could possibly lead to better treatments of the disease because doctors would be able to know which tumors are more likely to grow and spread.
The team, from the Cancer Research UK Cambridge Institute and Addenbrooke’s Hospital, studied samples of healthy and cancerous prostate tissue from more than 250 men. To group the tumors into five distinct types, they looked for abnormal chromosomes and measured the activity of 100 different genes linked to prostate cancer.

In the journal EBioMedicine, they say this form of analysis was more accurate at picking up the most aggressive types of prostate cancer than tests currently used by doctors, including the prostate specific antigen (PSA) test. But further and larger trials are needed to confirm the findings, they say.

Dr. Alastair Lamb, one of the researchers, calls the results exciting. “These findings could help doctors decide on the best course of treatment for each individual patient, based on the characteristics of their tumor,” he says in a statement.”By carrying out more research into how the different diseases behave, we might be able to develop more effective ways to treat prostate cancer patients in the future, saving more lives.”
Prostate cancer is the second most common cancer in U.S. men, behind skin cancer, according to the American Cancer Society. In 2015, the society estimates, about 220,800 new cases will be diagnosed, and about 27,540 men will die. About 1 man in 7 is diagnosed with prostate cancer during his lifetime, according to the society.

Expert: Research Could Be a Game-Changer

“The challenge in treating prostate cancer is that it can either behave like a pussycat — growing slowly and unlikely to cause problems in a man’s lifetime — or a tiger, spreading aggressively and requiring urgent treatment,” says Professor Malcolm Mason, Cancer Research UK’s prostate cancer expert. “But at the moment we have no reliable way to distinguish them. This means that some men may get treatment they don’t need, causing unnecessary side effects, while others might benefit from more intensive treatment.
“This research could be game-changing if the results hold up in larger clinical trials, and could give us better information to guide each man’s treatment — even helping us to choose between treatments for men with aggressive cancers. Ultimately this could mean more effective treatment for the men who need it, helping to save more lives and improve the quality of life for many thousands of men with prostate cancer.”