Prostate cancer: All hands on deck for treatment success

Prostate cancer is the second-most common cancer among men in the U.S., affecting 13 out of every 100 American men over the course of their lifetime. About two to three men of that 100 will die from the disease. Early detection, monitoring and evolving treatments offer the best outcomes.

“We’re able to detect the spread of prostate cancer better than ever before,” says Providence Swedish radiation oncologist Dr. Vivek Mehta, thanks to new imaging technology and specialized scans. Mehta is director of the Providence Swedish Center for Advanced Targeted Radiotherapies at Swedish Cancer Institute.

The prostate is part of the male reproductive system, just below the bladder and in front of the rectum. Ten years ago, a patient with prostate cancer faced a challenging surgery to remove the prostate and a grueling radiation treatment using an external machine directed at cancer cells. The traditional model involved planning a standard treatment regimen, then attempting to carry that regimen out.

But where the prostate is concerned, a standard regimen is not always achievable. Air or urine can change the rectum or bladder’s shape, Mehta explains, and therefore change the prostate’s position. This can make accurate targeting a challenge.

Exciting new approaches, or modalities, are here — with more on the way, Mehta says. Today, a detailed, personalized treatment plan targets cancer, whether it remains localized or has spread to other parts of the body, while also considering the patient’s quality of life before and after treatment.

“The oncologist’s radiation tools for delivering radiation is evolving by leaps and bounds every five years,” Mehta says. It’s similar to how cellphones were once brick-like items that could only receive or make calls and now are sleek, pocket-size devices that play videos, store massive amounts of data, and pipe the internet to users.

Treatment modalities

In addition to various radiation and surgery approaches, prostate cancer treatment options can include medication-based treatments to address underlying hormones or the immune system, clinical trials, ultrasound, or even freezing and killing cancer cells.

However, most treatment still typically involves surgery or radiation tools — but they’re far more advanced. For example, new radiation tools can now see precisely where cancers are located and deliver radiation to moving areas while sparing damage to surrounding tissues.  

For example, stereotactic radiosurgery — also known as a “CyberKnife” device — delivers high-dose radiation with sophisticated imaging, accurately concentrating radiation on a moving target without impacting non-cancerous tissues.

“CyberKnife is what Providence Swedish is known for,” Mehta says. “Patients seek us out, and we treat more people with that technology than any other health care system in the Northwest.”

Another approach called internal radiation therapy (brachytherapy) implants cancer-destroying sources inside a tumor, which spares nearby healthy tissue and organs.

Overall, new modalities limit in-office time and side effects. “Ten years ago, radiation treatment for prostate cancer might take place Monday through Friday over seven weeks, around 35 visits. We can do the same treatment in just five, 40-minute visits today,” Mehta says. With fewer, more targeted treatments, the prostate cancer patient experiences a lower risk of nausea, diarrhea, bleeding, and bladder complications.

More targeted treatments are improving surgical experiences and outcomes as well. Surgical treatments traditionally remove the prostate (prostatectomy). “The past 20 years have changed the patient experience,” says Dr. James Porter, M.D., medical director for robotic surgery at Swedish Urology First Hill and director of robotics for Providence Health and Services.

As a result of new robotic devices, prostate cancer patients undergoing surgery recover faster, with less pain and blood loss — even going home the same day, in some cases. The new approach decreases the risk of infection, impotence and incontinence.

Porter has completed more than 3,000 da Vinci robotic system procedures. The da Vinci robot has undergone four generations of changes over the years, improving accuracy and control, enhancing vision, and decreasing both the robot’s size and surgical incisions. The high-definition 3D view and micro-instruments allow surgeons to work within small incisions.

Newer technological advances in recent years allow surgeons to pinpoint cancer even more narrowly — only the tumor is treated and destroyed, not the entire prostate. The focal therapies allow surgeons to tailor treatment to target the cancer by size and location.

On the horizon

The next significant modality for prostate cancer treatment is likely radiopharmaceuticals, which target and treat more resistant prostate cancers. These new medications are undergoing trials at places like Providence Swedish.

For example, Providence Swedish participated in trials for the medication Pluvicto, which treats a form of advanced prostate cancer that has already spread to other body parts. Physicians and patients might turn to Pluvicto after unsuccessfully trying other modalities, such as chemotherapy.

The oral medication carries radioactive particles directly to the cancer cell particles to cause cell death. Providence Swedish is among the few health care providers in the Northwest with access to Pluvicto.

Providence Swedish’s involvement in new research trials continues to innovate and improve care for prostate cancer patients. “You can get state-of-the-art treatment now or participate in trials that define the state of the art for tomorrow,” Mehta says.  

However, most of these treatments work best under certain conditions. “New prostate cancer treatments are only helpful if patients are diagnosed early,” he says. Those already showing symptoms likely already have advanced cancer, are harder to treat, and the chance of a cure recedes. “For those late in the disease [trajectory], we have less to offer,” Porter says.

Changing outcomes won’t simply depend on technological advances but more early screening. Men aged 55 to 69 or otherwise at risk can be tested for a prostate-specific antigen, a substance made by the prostate. Many aren’t, at this point. Yet this simple blood test measures how much PSA is in the blood, with higher PSA levels indicating a potential prostate problem — and potential early diagnosis and treatment.  

For this reason, Porter suggests advocating for PSA testing with your primary care provider: “We need to diagnose prostate cancer and get to it before it becomes life threatening.”

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