An aggressive team and a high-tech machine called Artemis goes beyond 'watchful waiting,' giving many men more confidence in delaying or avoiding invasive treatments.
Peter Schulam, MD, (left) and Preston Sprenkle, MD, discuss results of routine imaging with a patient in the prostate surveillance program.
(April 2013) Brad Davis, a veterinarian with a family history of prostate cancer, got his own diagnosis after he was denied increased life insurance coverage. A blood test he had taken for the insurer showed elevated levels of prostate-specific antigen (PSA), a protein that may indicate the presence of the disease. A biopsy confirmed it.
“This put me in a quandary,” says Davis. Just 54 when he was diagnosed, he knew he had many active years still ahead, and was concerned that surgery or radiation could compromise them. At the same time, he was young enough that the cancer, if left unchecked, could kill him. His choices: watchful waiting; a prostatectomy to remove part of his prostate or all of it; or a relatively new and aggressive middle-of-the-road approach described as “active surveillance.”
Peter Schulam, M.D., who joined Yale from UCLA a year ago to head a newly formed Department of Urology, directs the Yale Cancer Center’s Prostate and Urologic Cancer Program. Borrowing from his experience in California, one of the first things he did at Yale was to assemble a team and high-tech equipment to perform active surveillance.
His active surveillance approach is so new that there aren't yet any national guidelines for the protocol. Patients are referred to Yale’s program after a high PSA or an abnormal digital exam. They have a baseline biopsy, then a repeat biopsy in six months, and a subsequent biopsy every two or three years—or more frequently if indicated.
Dr. Sprenkle and a colleague look at patient's Artemis imaging, which provides the best look yet at the progress of the disease.
The big tool in the program’s arsenal is a multitasking machine called the Artemis device, a 3D imaging navigation system that offers the best look yet at the progress of the disease. The prostate is “the only solid organ in the body in which we can’t image cancer,” Dr. Schulam says. So after an MRI finds suspicious lesions in the prostate, doctors providing active surveillance take a “fusion biopsy.”
“We use Artemis and fusion biopsy to take pictures and overlap them with a real-time ultrasound to help us guide where our needles go,” Yale urologist Preston Sprenkle explains. This allows doctors to take future biopsies in the exact same spot of the prostate as previous lesions were found, allowing them to better monitor the troublesome part of the gland.
The Artemis system shows promise. A UCLA study published in January in the Journal of Urology found that targeted biopsies were three times likelier than conventional biopsies to detect cancer.
Dr. Schulam says urologists need to better differentiate prostate cancer patients who need treatment from those who don't.
Prostate cancer is the second-leading cause of cancer death in American men; the American Cancer Society expects the disease will claim nearly 30,000 lives in 2013. The disease mainly affects older men—the median age of diagnosis is 67—and it’s a slow-growing cancer, so men with the disease are likelier to die with it than from it.
“We overtreat prostate cancer in the United States,” says Dr. Schulam. While most cases are not life-threatening, a vast majority of men undergo aggressive treatments—there are 100,000-120,000 radical prostatectomy surgeries a year in the United States. Last year, the U.S. Preventive Services Task Force recommended against PSA-based screening for prostate cancer, reasoning that too many patients were being treated for asymptomatic disease. The recommendation “charges us as urologists to better differentiate those who need treatment from those who don’t,” Dr. Schulam says.
Patients referred to Yale who benefit most from active surveillance are at a low risk of developing symptoms. Normally, Dr. Sprenkle says he'd recommend radiation or surgery in patients such as Davis who are in their 50s because “the chance their cancer is going to progress over the next 30 to 40 years is very high.” Dr. Schulam says,” Men in their 60s are more likely to find that active surveillance is a treatment, albeit a “deferred” treatment.
Doctors also take a Gleason score, which measures how likely the cancer is to spread based on how it looks under a microscope. Men with a Gleason score of 6 or below and with cancer in only a few samples are also good candidates for active surveillance, says Dr. Sprenkle. Davis says a Gleason score of 6 in only 20 percent of one core biopsy—confirmed in a secondary biopsy with Atermis—contributed to his decision.
Davis, now 55, was the first patient in Yale’s active surveillance program, and he is happy that he had a choice. So far he is symptom-free, his PSA level is at 3 and not a cause for concern, and he has “some benign hyperplasia that’s not real significant. The reality is many men diagnosed in their 60's may have lesions for years like mine before detection,” he says.
Story by John Dillon
Photos by Robert Lisak
Yale Prostate and Urological Cancers Program
Smilow Cancer Hospital at Yale - New Haven
South Frontage Road and Park Street
New Haven, CT 06510
Yale Urology Group
Yale Physicians Building
800 Howard Avenue
New Haven, CT 06519
There are usually no specific signs or symptoms of early prostate cancer. A prostate-specific antigen (PSA) blood test and digital rectal exam can provide the best chance of identifying prostate cancer in its earliest stages, but these tests can have drawbacks. Talk to your doctor about whether prostate cancer screening is right for you.
The following are the most common symptoms of prostate cancer. However, each individual may experience symptoms differently.
The symptoms of prostate cancer may resemble other conditions or medical problems. They may also be due to a benign prostate condition. Always consult your doctor for a diagnosis.