Patients with prostate cancer have many options


 By HOWARD COHEN
 THE MIAMI HERALD

 The detection and treatment of pros-
tate cancer is getting high tech.
 New sophisticated screenings, better
tests for evaluating biopsied tissue
and use of MRI-ultrasound fusion to
accurately map prostate cancer are the
latest advancements in detecting and
treating the disease.
 "These are the things that are new
and exciting," said Dr. Dipen Parekh,
professor and chairman of the depart-
ment of urology and director of robotic
surgery at the University of Miami
Miller School of Medicine. "If you do
get a diagnosis of prostate cancer, if
you seek out treatment with the right
people, and you are in the right hands,
you should expect an excellent future
course."
 In addition, robotic-assisted laparo-
scopic prostatetectomy continues to
advance as a surgical tool, along with
radiation therapy or brachytherapy,
which uses radioactive seeds to kill
cancer cells. Still others undergo a
radical prostatectomy, the removal of
a cancerous prostate and its surround-
ing tissue.
 Pre- and post-surgical pelvic floor
physical therapy, a series of exercises
under the guidance of a therapist, can
also strengthen pelvic areas to end
incontinence, said Louise Gleason, a
physical therapist with South Miami
Hospital's Pelvic Floor Center.
 And, for those for whom prostate
cancer has become too advanced and


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who are not candidates for surgery,
Provenge, a restorative treatment of
cellular immunotherapy, made from
a patient's own immune cells, can
stimulate a patient's immune system
to identify and target prostate cancer
cells, thus prolonging life, said Dr.
Michael Cusnir, an oncologist at
Mount Sinai Medical Center in Miami
Beach.
 Guidelines for screenings of the
prostate, a walnut-sized portion of a
man's reproductive system that wraps
around the urethra, the tube that
carries urine out of the body, have
changed since May 2013.
 "Instead of every man over 40 get-
ting a PSA (prostate-specific antigen
blood test), now it's more focused on
screening for patients with a high risk
for prostate cancer, those who have
a family history, or who are African
American," said Parekh.
 MRI-ultrasound fusion, adopted
early by the University of Miami's
Sylvester Comprehensive Cancer
Center, can result in more accurate
prostate biopsies than ultrasound
alone or digital rectal exams.
 The American Cancer Society rec-
ommends that at age 50, men who are
at an average risk of prostate cancer
have a discussion about the risks and
potential benefits of a screening with
their doctor.
 The screening discussion can start at
45 for men at higher risk of developing
prostate cancer, which, according
to the American Cancer Society, will
impact one out of seven men in the


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United States though only one out
of 36 will die from the disease. Most
older men who have been diagnosed
with prostate cancer will die from
other causes before succumbing to the
cancer.
 At-risk men would include African
Americans, who have a higher instance
of prostate cancer compared with their
white and Hispanic counterparts, or
men who have an immediate relative
such as a father, brother or son who
was diagnosed with prostate cancer
before age 65.
 Those who have had more than one
immediate relative with the disease at
an early age should begin discussions
with their doctors even earlier, at age
40.
 Prostate cancer is the second most
common cause of cancer death in
men, behind lung cancer and ahead of
colon cancer.
 About 233,000 new cases of prostate
cancer will be diagnosed nationwide in
2014, and 29,480 men will eventually
die from it, according to the American
Cancer Society. The upshot: More
than 2.5 million men in the United
States who have been diagnosed with
prostate cancer at some point the
average age at the time of diagnosis is
66 are still alive. Active surveillance,
or monitoring the disease with doctor
and patient working in tandem, can
also improve quality of life.
 Robotic surgery, guided by infra-
red vision, is a preferred treatment
because blood loss is minimized as
is the risk of damaging blood vessels
and nerve bundles that are respon-
sible for blood flow to the penis that
allows a man to achieve an erection.
The image-guided surgery is also less
traumatic.
 Most patients go home within a day
or two with a catheter, for about a
week, to help drain the bladder until
the sutures heal. Normal continence
resumes for 95 percent of patients
within the first six months.
 For patients who need help dealing
with issues of incontinence, which can
occur before or after prostate cancer
surgery, or from an enlarged prostate
as a man gets older, therapeutic
exercises can be a remedy.
 The Pelvic Floor Center at South
Miami Hospital focuses on a ring of
bones that includes the sacrum at
the bottom of the spinal column and
the pelvic bone on either side. At the
base of that bone structure lie muscles
that hang like a hammock from the
tailbone to the pubic bone, supporting


the pelvis. These muscles are volun-
tarily controlled, like the biceps or
triceps, and are used to control the
passage of waste from the body.
 "I gear my physical therapy to-
ward the muscles and bones of the
pelvis to see if we can help patients
restore that function after whatever
procedure they have," Gleason said.
"When these muscles are weak, or not
working properly, they can't close that
urethra to hold that urine back and
that's where I come in. I assign people
exercises based on the strength they
already have so as to maximize their
improvement," she said.
 In general, it takes about a month
before a patient will see real strength-
ening, Gleason said.
 Typical sessions run once a week for
about six to eight weeks with home ex-
ercises suggested afterward. A simple
exercise might go like this: Recline on
the floor with knees bent, a hand on
the belly, another on a leg. Tighten up
around the anal area as if holding back
gas. Release and repeat.
 "The first goal is to isolate the
pelvic floor and be able to recognize
when they are using it," Gleason said.
"From there, you can begin to exercise
because you are using the correct
muscle."
 Still other therapies can utilize elec-
trodes placed on the skin to measure
activity in the muscles to train the
muscles to contract and strengthen.
If the incontinence or sexual dys-
function is muscular related, these
exercise combinations can be effective,
Gleason said.
 In some cases, prostate cancer has
advanced beyond surgical solutions.
Provenge, a therapeutic class of cellu-
lar immunotherapies, is not curative.
But this nonsurgical alternative to
prostate cancer treatment can improve
the survival rate of patients for months
or years.
 Patients' cells are collected, infused
with an antigen that helps activate the
patient's T-cells to help fight the cancer
cells, and then placed back into the
patient's body intravenously.
 'Almost like a blood transfusion,"
explained Mount Sinai's Cusnir. "We
almost train the patient's own immune
system to recognize the cancer cells
and fight them on their own."
 The process is repeated three times
in two-week intervals.
 "We're still looking for a big change,"
Cusnir said about the treatment of
prostate cancer, "but at least we keep
improving survival."


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