Prostate Cancer

Prostate Cancer is the most common non-cutaneous human malignancy, with an estimated incidence of 186,320 cases in 2008¹. 28,660 men are predicted to die this year from advanced prostate cancer, the second most common cause of cancer in men (behind lung cancer). These statistics compare favorably to those of 2005, at which time 232,000 men developed the cancer and about 30,300 died from this disease; prostate cancer incidence and death rates have been falling consistently over the last decade¹. About one in six men will be diagnosed with prostate cancer during his lifetime, although only one out of 35 will die from it¹. Currently there are two million men alive with prostate cancer in the United States.

When reviewing nation-wide incidence rates over a 20 year period from 1975 to 1995 a variance in trend over time is seen. The incidence from 1975-1988 rose slightly with a dramatic increase noted from 1988 to 1992, due to the introduction of Prostate Specific Antigen (PSA). A significant decline was noted from 1992 to 1995 with minor further decline from 1995 to 2005. At John Muir Health, we have seen a decreasing incidence of prostate cancer which is consistent with National data comparison from SEER¹. The total number of patients diagnosed in JMH dropped from 2001 to 2005 with an increase seen in 2006 then a continued downward trend observed in 2007 (Table 1). We have a large number of patients diagnosed elsewhere but treated here to due to a large volume of Kaiser patients referred specifically to John Muir Health for radiation therapy (Table 2).

John Muir Health (JMH) Prostate cancer patients tend to be older, with the bulk of patients diagnosed in the sixth and seventh decade of life. The median age of diagnosis is 68 (Table 3). The JMH experience is consistent with the data reported from the National Cancer Data Base (NCDB)² and SEER¹. In our region, most of the patients are Caucasian (Table 4). Most patients are diagnosed at a relatively early stage, before the cancer has spread outside of the prostate gland (Table 5). This correlates to National data as reported by NCDB² and SEER¹. The reason underlying the preponderance of relatively early diagnosis relates to the widespread use of a simple blood test, the PSA, that can detect cancer before any signs or symptoms of the disease are clinically apparent.

Before considering treatment, all patients are biopsied for diagnostic confirmation of disease which also allows stratification into high and low risk categories (Table 6). At JMH, aggressive appearing tumors, termed high grade, with scores of 8-10 on a Gleason Scale of 1-10, especially those with higher PSA's (over 10), tend to be treated immediately and more aggressively than tumors with low Gleason grade (less than 6). Patients that fall into a low risk category (Gleason grade less than 6), depending on other factors such as age, medical co-morbidities and functional level, may be simply observed without any therapy. This is consistent with National Comprehensive Cancer Network (NCCN) practice guidelines³.

The major treatment options for prostate cancer patients at JMH are in keeping with modalities of treatment offered to patients nationwide and consist of surgical extirpation of the prostate gland, using either an open or laproscopic approach (usually with an analysis of regional lymph nodes), or radiation therapy. Radiation therapy can be delivered in several ways including external beam radiation therapy, brachytherapy with seed implants, and high dose after-loading brachytherapy. Sometimes these treatments are administered with the addition of hormonal blocking agents, a therapy which has been shown to improve survival outcomes in certain settings³. At JMH our treatment patterns favor radiation as opposed to surgery, which can be explained by the influx of Kaiser patients diagnosed in that system but referred to John Muir Health for radiation treatment (Table 7).

Prostate cancer has a very long natural history; many of these tumors follow an indolent course. The National Cancer Database (NCDB) five year observed survival rate representing 333,567 cases diagnosed from 1998-2000 for early stage disease (Stage I, II and III),was between 80 - 89%. However, for patients with distant spread of their cancer, termed Stage IV, the NCDB five year observed survival rate decreased to approximately 38%². The five year observed survival rates at John Muir Health for the years 1998-2000, representing 665 analytic cases, closely approximates this national trend. The observed survival rate for Stage I, II and III patients was between 81-90% with survival for Stage IV patients observed to be somewhat better than that reported by NCDB at 42% (Table 8).

Prostate Cancer is an important illness affecting many of the men in our community. John Muir Health has the capability to diagnose and treat this illness, utilizing all of the most advanced techniques. All treatment modalities are available including surgical intervention with either an operative procedure or minimally invasive approach utilizing the daVinci robot assisted procedure, Radiation Therapy or enrolling on a clinical trial. The cancer care team individualizes patient care with outcomes that meet or exceed national outcomes.

1. SEER Stat Fact Sheet - Cancer of the Prostate http://www.seer.cancer.gov/statfacts/html/prost_print.html
2. National Cancer Data Base - http://www.NCDB
3. National Comprehensive Cancer Network - http://www.nccn