Professor and Chairman,
Department of Urology,
University of Miami School of Medicine

Chairman,
Florida Task Force on Prostate Cancer

HISTORY

This patient was in excellent health and presented with a PSA of 5 ng/mL. He had two positive biopsies, which revealed Gleason 6 prostate cancer. Interestingly, 25 years earlier, he had testicular cancer and was treated with an inguinal orchiectomy followed by a retroperitoneal lymph node resection. Five years later, he developed a second testicular tumor and had an orchiectomy followed by chemotherapy. He was cured of testicular cancer and has been taking intramuscular testosterone since that time.

His consulting surgeon was concerned that the retroperitoneal lymph node surgery may have caused adhesions that would make surgery too difficult. I don’t believe his history would contraindicate surgery, so we’re planning to perform a nerve-sparing radical prostatectomy.

DISCUSSION

The patient temporarily stopped taking testosterone upon diagnosis. But presuming he’s receiving physiologic replacement, continuing it would be no different than in the average patient who has prostate cancer. If we find that his tumor is confined to the prostate and his PSA becomes zero postoperatively and remains zero, we will assume the tumor has been completely removed. We will then monitor the patient’s PSA and re-institute the testosterone, which is important for his quality of life.

I realize that the standard in breast cancer is to stop hormone replacement therapy when a woman is diagnosed. However, in the typical prostate cancer patient, we do not deplete testosterone after prostatectomy. In prostate cancer, I have a large database to tell me that if the tumor was confined to the prostate — negative margins, no capsular penetrations, seminal vesicles and lymph nodes are negative — the patient has greater than a 90 percent chance that he’s going to remain free of cancer.

It’s a fascinating case and I’d be interested to learn what other physicians think about the issue of testosterone replacement after prostatectomy.

HISTORY

This patient presented with a PSA of 3.2 ng/mL. One of the six ultrasound-guided biopsies was positive for a Gleason 6, 3+3, adenocarcinoma of the prostate. The clinical exam was totally normal. He has been HIV-positive for several years and takes a variety of medications, but he has no clinical sequelae of the disease. He had seen a radiation oncologist and two urologists before seeing me.

The radiation oncologist suggested that, given his age, his best chance for cure would be a radical prostatectomy. The message he got from the urologists was that they would not perform a nerve-sparing procedure on him, and I don’t know the reason for that. He prefers surgery, and I recommended a nerve-sparing prostatectomy.

DISCUSSION

I believe radiation oncologists are divided on efficacy of radiation therapy versus surgery in young men. Some feel that beyond 10 years, the data favor radical prostatectomy. In addition, there is the controversial issue of second cancers. I have seen a number of men treated for prostate cancer with external beam radiation who, 7 to 12 years later, developed aggressive, muscle-invasive bladder cancer, which is within the radiation field. It may not be a factor to consider for someone over 70 years of age, but for a 50-year-old patient, I think it needs to be discussed.

The urologists this patient consulted were not prepared to perform a nerve-sparing procedure on him. I don’t know whether that’s because they didn’t feel technically capable of doing the procedure, or whether they wanted to dissuade him from surgery because he was HIV-positive. They may have been concerned for themselves and/or the operating room team, or they may have genuinely felt the survival advantage would not be sufficient to put him through the procedure.

We must always consider whether a patient has a life expectancy sufficient to warrant a major operation. We know there are other treatments for prostate cancer that will allow someone to live 10 years — watchful waiting, initial androgen deprivation, delayed androgen deprivation and various forms of radiation therapy.

But for a patient of this age, the data would suggest that removing the prostate gives him the best chance that he will be free of cancer in 15 years. It’s arguable, but that would be my philosophy based on the literature.