Advanced Trends & Concepts in Prostate Cancer Treatment From Dr. S. Adam Ramin

A recent report published in the Journal of the American Medical Association compared active surveillance and surgical intervention for patients with prostate cancer to learn about the life expectancy of patients with the disease.

The researchers found 58 percent of men in the surgery group and 71 percent of men in the "watchful wait" group died during the study. Cancer was the cause of 18 percent of the deaths in the surgery group and 28 percent of the deaths in the active surveillance group. The study was performed in Scandinavian countries, where the active surveillance, also known as watchful waiting is more widely deployed; in the United States surgery is often available as an option. Watchful waiting means a patient with prostate cancer undergoes periodic evaluation for growth of his cancer, but no treatment is provided unless and until the cancer becomes more severe.

"In any given patient suspected of having prostate cancer, it is vitally important to establish the presence and degree of aggressiveness of cancer. Once the diagnosis is made, one can decide if watchful waiting is appropriate, or treatment should be offered," says S. Adam Ramin, MD, director of Urology Cancer Specialists in Los Angeles. "Although recently there has been a push by non-medical groups to minimize the need for prostate cancer screening, as physicians we should stick to our guns and continue to survey and diagnose prostate cancer at early stages. The patients who are not diagnosed at an early stage have a higher chance of dying from prostate cancer."

In Dr. Ramin's opinion, studies show surgery has a superior outcome to active surveillance, because patients under active surveillance are offered treatment too late.  As long as the surveillance is done properly, physicians can direct patients toward surgery before their cancers become incurable.

Short of performing a biopsy, physicians are unable to tell the difference between aggressive high grade prostate cancer and minimally aggressive or low grade cancer. "That's why it's really important to biopsy a patient suspected of having prostate cancer and make the initial diagnosis," says Dr. Ramin. "Once the diagnosis is made we can determine the treatment pathway.

"Aggressive types of prostate cancer grow fast and progress quickly. Therefore, is it vital to recommend curative treatments such a robotic surgery without much delay. The less aggressive types that grow slowly are good candidates for initial watchful waiting, with the understanding that the cancer may eventually need treatment before it progresses. Young patients with less aggressive prostate cancers might be able to avoid treatment during the early phases of diagnosis.  However, because of their longer life span, their cancer may have enough time to grow and spread. Therefore, in young patient's placed on active surveillance, my challenge is to safely delay treatment before proceeding with robotic surgery."

Technology advancements have made prostate cancer diagnosis more accurate and treatment options are more technically advanced to minimize side-effects. Robotic technology enhances precision during surgery.

"Done in experienced hands, surgery with robotic technology has an excellent chance of curing patients, decreasing possible side effects of incontinence and impotence," says Dr. Ramin. "From a physician's perspective, the robotic surgery is more technically difficult than open surgery, but it gives the patient the chance for a better outcome."

In the future, Dr. Ramin would like to see randomized studies looking at active surveillance compared to surgery or radiation treatment.

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