As divided as it is on other issues, the urology community should unite around one: A Gleason score 6 tumor should not be considered cancer. Uniting on that one issue will save many of our patients from unnecessary treatment.— Bert Vorstman, MD, MS, FAAP, FRACS, FACS
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Diagnosis and treatment of prostate cancer have been the source of heated debate for decades, most of which has centered on the clinical value of the prostate-specific antigen (PSA) test. In 2012, the U.S Preventive Services Task Force (USPSTF) gave the PSA test a D grade, which discourages many physicians from providing this service. The urology community immediately fired back, contending that the USPSTF recommendation would stifle lifesaving early detection of prostate cancer. Early detection leads to diagnosis and treatment of prostate cancer, which also draw differing opinions. To shed light on these issues from one perspective, The ASCO Post recently spoke with noted urologic surgeon Bert Vorstman, MD, MS, FAAP, FRACS, FACS.
From New Zealand to Florida
Please tell our readers a bit about your background.
I grew up in New Zealand. After training at the University of Otago Dunedin School of Medicine in New Zealand, I completed a urology residency at Auckland Hospital in New Zealand. I did a fellowship in adult and pediatric reconstructive urology at the Eastern Virginia Medical School in Norfolk, Virginia. I was part of [National Institutes of Health]–sponsored pioneering research on urinary bladder reinnervation, after which I earned a Master of Surgery from the University of Otago in 1988. I was was a faculty member at the University of Miami, Jackson Memorial Hospital, Miami, Florida, and then went on to found the Florida Urological Associates, a busy urology practice in Coral Springs, Florida.
Gleason 6: Mislabeled as Cancer
Some physicians believe a Gleason 6 prostate tumor should not be called a cancer, obviating the need for treatment. What’s your opinion on this issue?
Larry Klotz, MD, and others have shown irrefutably that the very common Gleason 6 prostate “cancer” is a not a real cancer for two fundamental reasons: First, no man has died of this disease, and second, this so-called cancer lacks a number of molecular biologic mechanisms necessary for it to behave as cancerous.
Additionally, unlike a typical cancer cell, this cell has a very long doubling time at 475 ± 56 days, so from mutation to a growth of about 1 cm (smaller than half an inch) in diameter takes some 40 years. Therefore, because a Gleason 6 tumor lacks the hallmarks of a cancer, it is not a health risk, needs no detection, and does not require treatment. The Gleason 6 is a pseudo-cancer mislabeled as a cancer.
The PSA Controversy
As a urologist, what’s your feeling about the PSA controversy?
The D grade by the USPSTF and its recommendation against the PSA-based prostate cancer screening are correct. The risk-to-reward ratio weighs heavily against the use of a detection tool that leads to an overwhelming amount of unnecessary procedures.
Dangers of Robotic Prostatectomy
Robotic surgery has become the favored procedure for radical prostatectomy. As a surgeon, what is your opinion of robotic surgery?
Surprisingly, radical prostatectomy is based only on a simple treatment philosophy, which, for a number of reasons, went from being a procedure based upon tradition to becoming fully transformed as an ideology into standard practice. Although now considered standard practice, this procedure had its origins in ancient times as a crude and often deadly approach to removing bladder stones. Over time, and through unbridled trial and error human medical experimentation involving multiple academics worldwide, surgery for bladder stones gradually morphed into surgery for removing cancerous prostates. Fully aware of the many dangers associated with their radical prostatectomy, treatment urologists kept devising improvements for lessening hemorrhaging, incontinence, impotence, and general debilitation.
From various refinements to open approaches, urologists went on to experiment with other techniques including laparoscopy and robotics. Surprisingly, the advent of robotics simply added a raft of new complications to the already monumental list of troubles associated with radical prostatectomy. Disappointingly, urologists were never able to prove through scientific evidence–based medicine studies that radical prostatectomy was safe and effective. In fact, the FDA’s [U.S. Food and Drug Administration’s] Manufacturer and User Facility Device Experience (MAUDE) site has pages of serious adverse events associated with robotic prostatectomy.
Spread of Cancer Cells Through Surgery
Another little discussed issue that sparks varying viewpoints is the potential danger posed by needle-tract seeding during biopsy. What are your thoughts on this?
There is not much in the literature about needle-tract seeding in biopsy; however, many studies using sophisticated staining techniques have documented clearly that tumor handling during radical prostatectomy results in a 30% to 80% rise in the number of circulating prostate cancer cells.1
Surprisingly, the spread of cancer cells from a cancerous organ because of surgical manipulation may not be immediate but may take several days to occur. Such an event may occur even if the cancer was removed completely or not, whether a conventional surgical approach was used, whether a no-touch surgical technique was adopted, or whether robotics was employed. Furthermore, these released malignant cells can be in the circulation for several years, undetectable by conventional imaging means such as bone scans, magnetic resonance imaging, and positron-emission tomography scans.
Despite the finding of malignant cells in the bloodstream and bone marrow from a cancerous organ before any surgical manipulation and, the increased number of these cancer cells in the circulation after surgical manipulation, the natural history of these dispersed cancer cells is uncertain but worrisome. Also, the mere demonstration of these cancer cells in the circulation does not necessarily mean development of a clinically metastatic deposit is inevitable or, if a relapse occurs, whether it originated from a preexisting circulating cancer cell or from one released by surgical manipulation.
However, these dispersed malignant cells can survive and exist dormant in various areas of the body for at least several years. And, in one study, the detection of prostate cancer cells in the blood of some men after radical prostatectomy correlated with a rising PSA during follow-up and therefore failure to achieve a cure.
Furthermore, this study has mirrored my experience in managing many men who had radical prostatectomy for seemingly localized disease only to see a rising PSA value some 5 to 15 or more years later. Again, these clinical events underscore the concern that prostate cancer cells spread inadvertently by surgical treatment may exist dormant before reactivation and recurrence of disease years later.
High-Intensity–Focused Ultrasound
Last year, the FDA finally approved the first high-intensity–focused ultrasound system in prostate cancer. What’s your opinion on this system?
High-intensity–focused ultrasound uses acoustic energy to deliver cancer-killing heat at a focal point within the prostate in an outpatient setting. Like other minimally invasive, focal options of prostate cancer treatment, high-intensity–focused ultrasound is associated with considerably less debilitation than is either robotics or radiation therapy and may be reasonable for treating the few localized, high-grade, high-risk prostate cancers.
Saving Patients From Unnecessary Surgery
Would you like to share any closing thoughts?
As a urologist running a very busy community practice, I often see men who underwent unnecessary treatment due to an improper Gleason scoring. As divided as it is on other issues, the urology community should unite around one: A Gleason score 6 tumor should not be considered cancer. Uniting on that one issue will save many of our patients from unnecessary treatment.
For more of Dr. Vorstman's thoughts on prostate cancer, visit www.urologyweb.com. ■
Disclosure: Dr. Vorstman owns shares in an outpatient surgery center, health-care mutual funds, and Sonablate.
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