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U-M CCC - Progress Newsletter Spring 2004 Online

Inside Prostate Cancer's Toolbox

David Wood, M.D., and the daVinci robot

For the one in six U.S. males facing a prostate cancer diagnosis, evaluating the treatment options available can be a daunting task. Science continues to produce new weapons for the prostate cancer arsenal. At the same time, health care marketers flood the marketplace with messages about which methods are “best” for treating the disease.

Fortunately, the Multidisciplinary Urologic Oncology Clinic at the U-M Cancer Center provides the expertise to navigate these confusing waters. Cancer is a complex disease, and every patient is unique. Rarely will one treatment modality emerge as preferable in all cases. That’s why U-M takes a comprehensive approach to treating cancer, offering expertise in multiple treatment options so that the care team can tailor the right approach for each patient. When it comes to treating early-stage prostate cancer at U-M, patients have the
benefit of multiple opinions in one consultation through the clinic’s multidisciplinary tumor board, ensuring immediate access to the latest techniques in surgery and radiation therapy. Two of several examples are presented here, each illustrating Michigan’s commitment to integrating research into the treatment equation.

Surgery: A steady hand, a better view

For early stage prostate cancer, the most common surgery is the removal of the prostate gland, called a radical prostatectomy. A relatively recent advancement in prostate surgery is the use of laparoscopy, which involves making several small incisions to insert a tiny camera and probes. The surgeon operates remotely, viewing the camera’s images while manipulating the probes.

The U-M Cancer Center offers the robotic laparoscopic prostatectomy procedure. Urologist David Wood, M.D., who performs the surgery, believes that as many as half of the radical prostatectomies performed today could be candidates for this method. “The benefits to the patient make it worth considering in many instances,” he says. Smaller incisions may mean less time healing, less post-operative pain and less chance of infection. Moreover, adds Wood, “laparoscopic surgery results in significantly less blood loss, which also contributes to the body making a speedier recovery.”

Because a camera provides what the surgeon sees, magnification of the image is possible, allowing a better view of the prostate and the surrounding nerves and blood vessels. Avoiding these vital adjacent structures during surgery is critical to maintaining key functions including bladder control and sexual function.

Several institutions in Southeast Michigan and elsewhere endorse robot-assisted prostatectomy as the preferred method for treating prostate cancer. Some even promote their “exclusive” robotic techniques. What’s to be made of such claims? According to Wood, there are no such easy answers. “Although I’m a major proponent of this technique, I’m the first to tell my patients that it isn’t for everyone. Each case should be evaluated on its individual characteristics.” For instance, the procedure isn’t the best avenue to pursue for the removal of very large tumors, or for patients who have undergone previous abdominal surgery. Wood also corrects the misperception that some institutions perform a unique technique. “The da Vinci® robot is the only such device on the market. Although more and more institutions are offering the robot-assisted option, the procedure is the same everywhere.”

The difference at Michigan, notes Wood, is the emphasis on research. “Clinical data has yet to definitively show that laparoscopic prostatectomy is ‘better’ than the traditional method either in terms of survival or quality of life,” he notes. ”Both require an overnight hospital stay and the use of a catheter for about a week. Although laparoscopy results in measurably less blood loss, the procedure takes longer. Because of the instrumentation involved, laparoscopy is also a more expensive option.”

“It’s important to weigh all of these factors when discussing surgical options with our patients,” Wood continues. “At U-M we’re committed to conducting the research necessary to assess all of the differences between the two approaches.” A study will soon be underway to measure patients’ quality of life. “That’s the main difference – and the big advantage – in seeking treatment at a major research center like ours,” notes Wood. “A patient can be assured that his treatment is being approached scientifically, and that all of the latest options are made available. The best care is research-based.”

Wood also looks forward to further advances in the technology, which may soon make it possible to even more precisely avoid nerve and blood vessels while removing the prostate. “We need to continue to push the technology forward while quantifying the real differences in techniques in terms of recovery time and quality of life for our patients.”

Radiation therapy: Seeds of change

When radiation therapy is called for, again the patient and his care team have decisions to make. Radiation can be applied either externally (called external beam radiation) or internally through a procedure called brachytherapy or "seed" implant therapy. The use of radioactive "seeds" - particles smaller than a grain of rice implanted in the prostate - is growing in popularity and accessibility.

Available to patients through a partnership with the Providence Cancer Institute in both their Southfield and Novi Michigan sites, the U-M Prostate Implant Program is overseen by Patrick (Bill) McLaughlin, M.D.. Like Wood, McLaughlin is a passionate advocate of his specialty, but is quick to note that it is not right for every patient. "One of the reasons we've been so successful is the care we take in identifying who will likely benefit most from implant therapy. Patients with a history of bothersome bladder symptoms, prior prostate surgery to relieve obstruction, or those with relatively large prostate glands are not the best candidates."

But for men with the right profile, the approach offers marked benefits. Implants deploy the highest dose of targeted radiation possible, and do so with rapid dose "drop-off", the amount of radiation measured as you move away from the treated area. So they afford higher radiation with maximum precision.

U-M research efforts focus on enhancing the technique and finding better ways to determine whether seeds have been implanted for maximum effectiveness. McLaughlin's work has resulted in several distinct enhancements to the current "standard" seed implants available at other institutions.

Treatment planning and execution in one step

Individualized treatment planning is a key to success, according to McLaughlin. "We're unique in that we've condensed the procedure from multiple steps to one. In one session, imaging, computerized treatment planning and the seed implant take place. The patient stays in exactly the same position, so the process is not only quicker, but more precise."

Reducing side effects

Because the dose of radiation is higher, patients may experience more related symptoms than with external radiation therapy, a fact sometimes overlooked by marketers boasting that implants produce “no side effects.” The primary concerns following seed implants are temporary urinary problems and rectal irritation. These can be treated with conventional medications until the seeds deliver their radiation over months. The key to minimizing urinary side effects, according to McLaughlin, is to screen out poor candidates for the procedure, including those with large prostates and pre-existing urinary problems. A planning method unique to U-M, keeps seeds at least one centimeter from the urethra and sphincters, has drastically decreased urinary side effects. The best defense against sexual side effects is a quality implant that does not allow radiation beyond the prostate to surrounding blood vessels responsible for erections.

Patrick McLaughlin, M.D.

McLaughlin’s research focuses on improving the vital post-procedure check of the implant. He points to a recent study where one implant case was reviewed by six experts. Using the common method of verification, the CT scan, the doctors provided vastly different opinions. Two considered the implant quality excellent, two good, and two poor. The U-M solution: combine the CT scan, which provides an excellent view of the seeds, but a poor view of the prostate, with MRI technology, which yields a superior image of the prostate and surrounding vessels (but not the seeds). “Together, they provide the full picture,” McLaughlin asserts, “so that we can confirm full dose to the prostate and avoid the over-treatment to surrounding areas that causes side effects.”

Although the C/T-MRI combination requires technical time and expertise that makes it unfeasible for widespread use, McLaughlin is leading a national effort to apply the learning to develop expertise that can be employed with C/T alone.

“Another research goal is determining the optimal level of radiation per seed,” explains McLaughlin. “The average implant requires 90 – 150 seeds. With the higher-dose seeds we use, our average is 70 – 120. That means fewer needles and less swelling. We’ve completed a randomized trial demonstrating consistently better coverage with these high activity seeds. Also, by reducing the number of seeds, we cut the cost of the procedure by one-third. When there is an indication that cancer may spread to areas beyond the prostate, combining implant therapy with external beam radiation may be called for. In this modality, too, Michigan is at the forefront of improving treatments and enhancing quality of life.”

For more information on developments in the treatment of prostate cancer, call the Cancer AnswerLine™ at 1-800-865-1125 or visit these web sites:

Laparoscopic radical prostatectomy: www.med.umich.edu/urology/PatientInfo/PatInfoPages/LapRP.htm

Seed implants: www.providence-hospital.org/prostatecancer

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This article is part of the Cancer Center's News Archive, and is listed here for historical purposes.

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