Prostate Cancer Report

Transcription

1 Tom R. [ Prostate Cancer Survivor ] Prostate Cancer Report OUTCOMES AND CAPABILITIES The Commission on Cancer (CoC) of the American College of Surgeons (ACoS) has granted a Three-Year Accreditation with Commendation to the Cancer Center at El Camino Hospital.

2 PROSTATE CANCER DATA ANALYSIS AND METRICS FROM 2015 DATA Prostate cancer is the focus of El Camino Hospital s in-depth analysis on monitoring compliance with evidencebased guidelines. It is the most common non-skin cancer in men, and one man in six will be diagnosed with prostate cancer at some point in his lifetime. The following in-depth analysis is one example of our approach in treating this disease. Assessment/Summary and Evaluation of Treatment Planning Each year, a physician member of the cancer committee performs a study to assess whether patients in the program are evaluated and treated according to evidence-based national treatment guidelines. The study must determine that the diagnostic evaluation is adequate and the treatment plan is concordant with a recognized guideline. This study used AJCC staging guidelines and NCCN treatment guidelines. Summary: A detailed study of the diagnostic evaluation and treatment plan was performed on the 57 patients diagnosed and/or treated at El Camino hospital in The patients had either Stage I or Stage IV prostate cancer. PATIENT WORKUP ANALYSIS 58.3% of Stage I patients and 44.4% of Stage IV patients had a digital rectal exam (DRE) performed (combined, 56.1% of patients had a DRE performed) 72.9% of Stage I patients and 66.6% of Stage IV patients had a PSA performed (combined, 71.9% of patients had a PSA performed) 95.8% of Stage I and 66.6% of Stage IV patients had a Gleason score documented in their medical record (combined, 91.2% of patients had a Gleason score documented in their medical record) 12.5% of Stage I and 10 of Stage IV patients had a bone scan performed (combined, 26.3% of patients had a bone scan performed) 20.8% of Stage I patients and 10 of Stage IV patients had a MRI or CT performed (combined, 33.3% of patients had a MRI or CT performed) PATIENT TREATMENT ANALYSIS Stage I patients (48 total cases) 31.3% (15 cases) of patients had a TURP 22.9% (11 cases) of patients had a prostatectomy 31.3% (15 cases) of patients had radiation 6.3% (3 cases) of patients had radiation and hormone therapy 2.1% (1 case) of patients had a TURP, radiation, and hormone therapy 6.3% (3 cases) of patients had surveillance only for treatment Stage IV patients (9 total cases) 33.3% (3 cases) of patients had no treatment 11.1% (1 case) of patients had a TURP 11. 1% (1 case) of patients had radiation 22.2% (2 cases) of patients had radiation, chemotherapy, and hormone therapy 11.1% (1 case) of patients had chemotherapy 11.1% (1 case) of patients had chemotherapy and hormone therapy

3 Prostate Cancer Report PROSTATE CANCER is the most common non-skin cancer in men. For 2017, the American Cancer Society estimated 161,360 new cases of prostate cancer would occur. The most common form of the disease, prostatic adenocarcinoma, is slow growing and highly treatable when detected early. Some tumors are more aggressive, of course, and prostate cancer can be deadly. A man with prostate cancer has a one in eight chance of eventually dying from the disease. In fact, it is the third leading cause of cancer death in men in the United States. As sobering as these statistics sound, the combination of early detection and more effective treatment is steadily improving outcomes. More than 2.9 million men in the United States who have been diagnosed with prostate cancer are currently living with the disease, and most of them will eventually die from other causes. This chart highlights survival rates for El Camino Hospital patients diagnosed in 2012 and treated for prostate cancer over the last five years. Prostate Cancer 5-Year Survival Rates RISK FACTORS FOR PROSTATE CANCER Age The risk and incidence of prostate cancer rises with age. More than 60 percent of cases are diagnosed in men 65 and older. Genetics Certain genes are known to increase the risk of prostate cancer. The risk is also elevated in men with a strong family history of other cancers, such as breast, colon, or pancreatic cancer. Family History Men who have a relative with prostate cancer are twice as likely to develop the disease. Race The risk of prostate cancer is elevated for African-American men. Compared to Caucasians, they are 73 percent more likely to develop prostate cancer and nearly 2.4 times as likely to die from it. Diet A diet high in fat and carbohydrates and low in vegetables raises the risk of developing prostate cancer. 2 Stage I 92.86% Stage II 93.49% Stage III 10 Stage IV 45.53% We achieve comparatively good outcomes despite taking on patients with many complications and comorbidities who have been turned away for treatment by other facilities. No other facility in the Bay Area offers the depth and breadth of treatment options we do. What s more, we ve been offering the more innovative techniques longer than anyone else. You can count on us for both expertise and experience. Rizwan Nurani, MD, Radiation Oncologist 1

4 OVERVIEW OF OUR PROSTATE CANCER PROGRAM EL CAMINO HOSPITAL takes a multidisciplinary team approach to cancer treatment. Our team includes medical oncologists, radiation oncologists, urologic surgeons, pathologists, radiologists, nutritionists, and social workers, all working in close, synergistic collaboration. We customize the treatment strategy to each patient s preferences, overall health, and the stage and severity of his disease. In the case of localized prostate cancer, most tumors are found in time for effective therapy. When prostate cancer is diagnosed at an advanced stage, we are often successful in controlling it and giving patients more time without a substantial impact on their quality of life. Treatment options include radical prostatectomy, external radiation therapy, and brachytherapy. In some cases, alternate or additional treatments such as chemotherapy, hormonal therapy, or immunotherapy may be appropriate. When surgery is the best option, we offer minimally invasive treatments, including robotic-assisted surgery, the most effective surgery available. Early-stage prostate cancer often will not spread or cause any problems or side effects for a long time, if ever. Sometimes, the best option for a patient with slow-growing prostate cancer is delayed treatment and careful monitoring for any change in the tumor. This is called active surveillance, or watchful waiting. Some physicians use these terms interchangeably while others draw a distinction between the two, with active surveillance involving a physical exam and laboratory tests. We provide several support groups that men and their partners are welcome to attend before, during, and after treatment. Monthly prostate cancer support groups are offered at both our Mountain View and Los Gatos campuses. Dates and times vary, but current information can always be found at by clicking the Classes and Events section. Patients come to us from all over the region for unique brachytherapy expertise they can t find anywhere else. We ve been providing this advanced therapy for years, we handle a large volume of cases, and we have experienced great success with it. Steve Kurtzman, MD, Radiation Oncologist 2

5 A Ramblin Man Gets Back on His Bike Tom R. [ Prostate Cancer Survivor ] I n 2016, 63-year-old independent trucker Tom R. sold his big rig and officially retired. Taking advantage of his newfound freedom, he joined a friend on a motorcycle trip through Cambodia and Laos. When he came back from Southeast Asia, he scheduled his first physical in seven years. As it turned out, he was just in time. Tom had an enlarged prostate and his PSA numbers were alarmingly high. His doctor referred him to urologist David King, MD, for a biopsy. Tom tested positive for cancer, but Dr. King was confident Tom would be fine in a matter of months, and made treatment recommendations. He then referred Tom to radiation oncologists Steven Kurtzman, MD, and Robert Sinha, MD. Dr. Kurtzman reassuringly referred to Tom s condition as a boring case of cancer, and he and Dr. Sinha recommended the best road forward. The first step was brachytherapy. In July of 2017, 59 radioactive seeds were implanted in Tom s prostate. Tom completed six weeks of radiation, and now, will have quarterly checkups with his medical team for at least a year. Most important, no trace of his cancer remains. As I told Dr. Sinha, he says, life is good right now for me. When I was on that radiation table, I felt like I was being given a second chance. There are things in life I want to do not a bucket list, but life changes. Tom plans to sell his house, move to Cambodia, and enjoy motorcycling through the lush green countryside once again. 3

6 PROSTATE CANCER SCREENING THANKS IN PART to the success of our robust Men s Health Program in Los Gatos, El Camino Hospital excels in early detection of prostate cancer. We do this by opening a dialogue about risks and treatments when men come to us with other medical concerns, such as sleep apnea, heart disease, or erectile dysfunction. Two tests are commonly used to screen patients for prostate cancer: the digital rectal exam (DRE) and the prostate-specific antigen test (PSA). These tests may be part of a routine physical, depending on a man s age and discussions between patient and physician. The doctor may also ask the patient whether he has any urinary or sexual performance problems, and if there is a history of prostate cancer in his family. Most prostate cancers are found using one or both of these commonly administered tests. However, neither of these tests is enough to make a conclusive diagnosis, which requires a follow-up prostate biopsy. A prostate ultrasound may also be performed if there is a diagnostic reason to do so. The digital rectal exam is performed manually. The doctor inserts a gloved finger into the rectum to palpate the prostate, determine whether it may be enlarged, and feel for any abnormalities. The PSA blood test is used primarily for screening purposes in men who don t have prostate cancer symptoms. It is also the first test performed on a man who presents possible prostate cancer symptoms. The test measures blood levels for prostate-specific antigen (PSA), a substance made by the prostate. PSA levels can be higher in men who have the most common form of prostate cancer. Generally, the higher a man s PSA levels, the more likely he is to have prostate issues. However, PSA levels also can be affected by certain medications, prostate infection, or an enlarged prostate (prostate hyperplasia), and further testing may be required. The chances of having prostate cancer for a man whose PSA level is between 4 and 10 are roughly one in four. With a PSA of more than 10, the man is more than 50 percent likely to be diagnosed with prostate cancer. What s more, for 15 percent of men suspected of having prostate cancer despite a PSA below 4, a biopsy will reveal prostate cancer. Once a biopsy has been performed, the patient s care team can stage the tumor, and determine how aggressive it may be based on the Gleason grading system. Used to stage the cancer and evaluate a man s prognosis, Gleason scores are based on the size and shape of the cancer cells when viewed under the microscope. Cancers are scored with numbers from 2 to 10. The higher the number, the more virulent the cancer, and the greater the risk of mortality. SCREENING PROS AND CONS Unless a man has known risk factors, there is some debate about the merits of prostate cancer screening as part of a yearly checkup. Many prostate cancers grow so slowly that they may never become lifethreatening or even cause symptoms. At El Camino Hospital, we have evaluated the research and our outcomes to arrive at our own screening recommendations. Now that watchful waiting and active surveillance have been accepted as part of the standard of care, we believe that the advantages of early diagnosis outweigh the risks. Our screening recommendations are as follows: A prostate-specific antigen (PSA) blood test, usually starting at age 55, at intervals of yearly to every two years, at least until age 70 A digital rectal exam as part of a man s annual physical exam An ultrasound if the PSA blood test or digital rectal exam indicates something abnormal THE LATEST TECHNOLOGY FOR PRECISE DIAGNOSTIC CARE We were one of the first South Bay hospitals to offer Artemis 3D Imaging and Navigation. Designed specifically for magnetic resonance imaging (MRI) of the prostate, Artemis combines MRI technology with ultrasound to better visualize prostate cancer tissue. An MRI image is fed into Artemis, which fuses it with a live ultrasound and converts it from a 2D monochromatic ultrasound image to an enhanced 3D color image. This advancement helps determine if a man with non-aggressive, slow-growing cancer can still safely avoid or delay surgery through active surveillance, or if he needs a biopsy and more invasive treatment. We use several advanced testing methods to help determine the need for biopsy, including the 4Kscore, ConfirmMDx, and the prostate health index (PHI). These help identify patients at higher risk for aggressive prostate cancer and/or the likelihood of progressing during active surveillance. The Oncotype DX Genomic Prostate Score is also used to decide who may benefit from treatment vs. active surveillance. 4

7 TYPES OF PROSTATE CANCER THE MOST COMMON form of prostate cancer, by far, is prostatic adenocarcinoma, which accounts for 90 to 95 percent of prostate tumors. However, there are other types of prostate cancer. PROSTATIC ADENOCARCINOMA Prostatic adenocarcinoma occurs either in the acinar cells, the cells that line the prostate gland itself, or in the cells lining the ducts of the prostate gland. Acinar adenocarcinomas are slow growing and highly curable when detected early enough. Ductal adenocarcinoma, which is less common, tends to grow and spread more quickly. SMALL CELL CARCINOMA Small cell carcinoma shows up under the microscope as small round cells. This highly aggressive, neuroendocrine form of prostate cancer is hard to detect because it does not affect PSA levels. As a result, small cell carcinoma often reaches an advanced stage before it is diagnosed. SQUAMOUS CELL CARCINOMA Squamous cell carcinoma develops in the flat cells that cover the prostate. This non-glandular, fast-growing prostate cancer does not affect PSA levels. It is highly aggressive and spreads rapidly. Treatment for prostate cancer is a very personal decision. We collaborate closely with each patient and his family, presenting comprehensive information and varied options, so each man can make the right choice for his own circumstances and lifestyle. Frank Lai, MD, Robotic Surgeon PROSTATIC SARCOMA Prostatic sarcoma is extremely rare, accounting for less than 0.1 percent of prostate cancers. It occurs in relatively younger men between the ages of 35 and 60. Untreated, this type of prostate cancer can spread as far as the lungs, brain, liver, and bones. Twenty-five percent of the prostatic sarcoma cases have metastasized by the time they are diagnosed. TRANSITIONAL CELL CARCINOMA Transitional cell carcinoma rarely originates in the prostate. In the majority of cases, it has spread from tumors in the bladder or urethra. 5

8 TREATMENT METHODS AT EL CAMINO HOSPITAL WHEN TREATMENT for prostate cancer is needed, El Camino Hospital offers a wide range of options and an impressive breadth and depth of expertise. There is no one size fits all treatment strategy for most cancers, and prostate cancer is no exception. Due to common side effects of prostate cancer treatment (erectile dysfunction and incontinence), we work closely with each patient to consider a variety of factors, including whether active surveillance is an option, what side effects are acceptable, his age and general health, and whether he is sexually active or planning to have children. CYBERKNIFE STEREOTACTIC RADIOSURGERY CyberKnife Stereotactic Radiosurgery is an advanced form of radiation treatment that allows us to eliminate solid tumors 90 percent of the time. This treatment is administered on the Mountain View campus at our Center for Advanced Radiotherapy and CyberKnife Radiosurgery. SURGERY Surgery (prostatectomy) is the most common treatment for prostate cancer, often in combination with external beam radiation. Our surgeons excel at both minimally invasive and roboticassisted surgery. When performed by an expert robotic surgeon, this approach is more likely to achieve complete eradication of cancer and retention of bladder control and potency. We perform the highest number of these surgeries in all of Northern California. Both our Mountain View and Los Gatos campuses have da Vinci Surgical Systems. Our surgeons have such a strong track record of success with robotic-assisted prostatectomies that we are currently doing 95 percent of prostatectomies robotically. Our robotic surgical systems allow the surgeon to work from a console, using tiny instruments guided by 3D, high-definition images of the body s internal structures. The benefits of robotic surgery include: Smaller incisions, which reduce blood loss and scarring Significantly less pain A shorter recovery time A faster return to normal daily activities Despite the name, the CyberKnife does not involve any cutting, which makes it especially useful when treating tumors in soft tissues. This technology uses advanced imaging to pinpoint solid tumors with submillimeter accuracy, reducing the risk of damaging tissues and structures surrounding a tumor. The precision of the therapy greatly reduces the number of treatments needed. In certain cases of prostate cancer, we can perform just four or five sessions of CyberKnife within one week, as opposed to the more than nine weeks of multiple treatments needed for traditional radiation therapy. Surgery and anesthesia are not necessary and patients can go home the same day they are treated. EXTERNAL BEAM RADIATION THERAPY External beam radiation therapy is the most common form of therapeutic radiology. It destroys cancer cells using ionizing radiation. A variety of machines can be used for external beam radiation therapy. We use both conventional intensitymodulated radiation therapy (IMRT) and RapidArc. IMRT is a form of computer-driven 3D therapy in which the machine moves around the patient as it delivers radiation. RapidArc is an advanced form of image-guided IMRT that delivers radiation two to eight times faster than conventional IMRT. Our expert radiation oncologists determine the type of therapy used and the dose and frequency of the radiation. To protect healthy tissue around the tumor, small doses of radiation are delivered at one time. A typical schedule is once a day for five days a week over a two- to nine-week period. 6

9 It has been an exciting decade watching El Camino Hospital establish and grow outstanding cancer programs at both campuses. Thoughtful, dedicated, and ambitious hospital and physician leaders have created a superior model for integrated, multidisciplinary cancer care delivery in our communities. J. Augusto Bastidas, MD, Surgeon and Chief of Staff, Los Gatos Campus BRACHYTHERAPY Brachytherapy is radiation treatment delivered from inside the body using delivery devices called implants, or seeds. These radioactive implants are placed as close to the tumor as possible. The advantage of brachytherapy is that it allows the radiation oncologist to use a higher total dose of radiation over a shorter time as compared to external beam therapy. The physicians at El Camino Hospital perform brachytherapy with an intraoperative planned (real-time) seed implantation technique. This is a simple one-time outpatient procedure that takes less than an hour. The entire procedure is done through very thin needles, so there is no cutting or stitches required. Anesthesia is used so there is no discomfort during the procedure. Using an ultrasound and advanced computers for guidance, a live picture of the prostate is obtained and a three-dimensional computer model of all the anatomy is generated. After optimizing the needle path and seed position in the virtual model of the patient, and needles are accurately placed through the perineum (the area of skin just above the anus). As the seeds are placed by the radiation oncologist, the computer instantly calculates the doses of radiation delivered. Any movement or change of the prostate during the implant procedure is immediately accounted for, ensuring optimal seed placement. The seeds emit an intense amount of radiation to the cancer, with only minimal radiation outside the prostate, to areas such as the bladder and rectum. The seeds give off radiation only for a few weeks and then are permanently inactive. Cancer cells are selectively killed because they are much more sensitive to radiation than normal cells. Prostate brachytherapy can be delivered via these methods: In permanent seed implantation, dozens of tiny radioactive seeds are injected into the prostate gland. They give off a low dose of radiation over several weeks or months and are left inside the prostate permanently. In high-dose rate (HDR) temporary brachytherapy, radiation is delivered via seeds inserted into the prostate through tiny catheters. When the catheters are removed, no radioactive material is left behind. The radiation oncologist is able to control the radiation dose in different regions of the prostate based on the length of time the seed is left in place. This allows for the delivery of a higher dose to the tumor while limiting radiation exposure in the urethra and rectum. While the modern radiotherapy techniques discussed here are effective at largely sparing adjacent organs from a meaningful amount of radiation, physicians at El Camino Hospital worked with Augmenix Inc. to test and ultimately demonstrate that a temporary absorbable hydrogel (SpaceOAR ) placed between the prostate and rectum can further reduce the likelihood of rectal complications. In an office procedure, the hydrogel mixture is injected through the skin of the perineum using a needle under ultrasound guidance. The gel solidifies inside the body and creates a physical barrier between the rectum and the prostate, protecting the rectum from radiation directed at the prostate gland. After three months, the solidified hydrogel is completely broken down and eliminated from the body. This protective gel virtually eliminates the risks of long-term rectal side effects. HORMONE THERAPY Hormone therapy, also known as androgen deprivation therapy (ADT), reduces levels of androgens, male hormones that stimulate the growth of prostate cancer cells. While reducing androgen levels can make prostate cancers shrink or grow more slowly, hormone therapy alone will not cure prostate cancer. Hormone therapy may be used in conjunction with radiotherapy as a curative regimen for high-risk cancers. It can also be used when the cancer has spread too far to be cured by surgery or radiation or if the cancer returns after primary treatment. CHEMOTHERAPY Chemotherapy is the use of drugs to interfere with cancer cells ability to reproduce. In the treatment of prostate cancer, chemotherapy is generally used as part of a curative regimen of localized, very high-risk prostate cancer. In this setting it is used as an adjuvant after radiation therapy that is directed at the primary cancer. Chemotherapy is also used in patients with metastatic prostate cancer that has stopped responding to hormonal therapy. The goal is to kill fast-growing cancer cells while minimizing damage to healthy cells. Chemotherapy can be delivered in pill form, intravenously, or through a port. Our medical oncologists have extensive experience treating patients and conducting research and are always on the lookout for breakthroughs in chemotherapy. In addition to wellestablished drugs for various cancers, we offer an advanced targeted therapy, in which we examine a patient s cancer cells to create a mixture of drugs that specifically targets those cells. We currently provide chemotherapy treatment in our infusion center in Mountain View, and we are opening a new infusion facility in Los Gatos. 7

10 PROSTATE CANCER STATISTICS FOR THE U.S. AND EL CAMINO HOSPITAL Age at Diagnosis ECH NCDB AGE < >90 ECH NCDB.01%.05% 1.65% % 23.89% 47.33% 43.28% % 7.82% 5.68% 1.23% 0.73% Stage at Diagnosis 6 5 ECH NCDB First-Course Treatment Methods ECH NCDB Surgery only STAGE I II III IV** Unknown ** We strongly support improved screening tactics that will enable earlier detection for more successful treatment. Radiation only Radiation and hormone therapy Surgery and hormone therapy Surgery and radiation Surgery, radiation, and hormone therapy No first-course treatment* Hormone therapy only Active surveillance Surgery and chemotherapy Other * Patients in this category were seen regularly by physicians under our Active Surveillance protocols. 8

11 Grandpa Ready to Ride After Prostate Surgery Steven S. [ Prostate Cancer Survivor ] S ix years ago, Steven S. had retired from real estate but had a wonderful job babysitting his granddaughters with his wife, Julie. He had been in relatively good health and was diligent about getting PSA tests for prostate cancer over the years. When his PSA numbers crept up, he was referred to Dr. Frank Lai, a urologist who recommended a biopsy. The biopsy showed Stages II and III prostate cancer. Dr. Lai led Steven and Julie through a careful discussion of potential treatments: surgery, radiation, or watchful waiting. Steven says, I never felt I needed to get a second opinion. Dr. Lai was so open in discussing things that I totally understood what was going on. He made his recommendation, but it was ultimately our decision. Steven chose surgery, and in June of 2017, Dr. Lai removed Steven s prostate using the robotic da Vinci Si Surgical System. Dr. Lai was able to save the nerves that go to the penis because the cancer had not permeated the walls. Immediate surgery turned out to be a good decision, as pathology results revealed cancer cells that were more advanced than those initially biopsied. After some healing time, Steven is back on his bike, and back in action with his grandkids. He is cancer free, with a zero on his latest PSA score. He says, My wife and I are happy and thankful we were at El Camino Hospital. My advice to anybody is, if you think there s a better place, there isn t. They are just the best.

12 One man in six will be diagnosed with prostate cancer at some point in his lifetime. We are committed to delivering comprehensive, compassionate care, and are proud of our exceptional outcomes in the treatment of prostate cancer. For more information or referral to one of our experts, please call or visit our website El Camino Hospital E-0533A_CancerCtrProstateReport_Dec17