Q&A with Herbert Lepor, M.D.
Chairman of Urology
In 2008 prostate cancer is expected to strike over 186,000 American men, and will cause some 29,000 fatalities. PSA testing is the main tool used to screen for prostate cancer. So it was something of a surprise when the U.S. Preventive Services Task Force recently recommended that men older than 75 no longer get screened annually. Dr. Herbert Lepor discusses this issue and others.
Q: Is the medical community giving up on older men with prostate cancer?
A: This was a recommendation, not a medical guideline. Since many prostate cancers progress slowly, some older men diagnosed through screening won’t benefit from treatment. What really matters is your life expectancy and overall health. Plenty of healthy men in their 70s with a long life expectancy are well served by screening.
Q: Every man dreads hearing that his PSA level is in the danger zone. Is this fear justified?
A: Getting an annual PSA test and digital rectal exam actually should allay these fears. You should be reassured if your PSA score remains favorable. And if it starts to climb, this provides the opportunity to detect prostate cancer early, when it’s far more likely to be cured.
Q: Many men with prostate cancer panic about becoming incontinent and impotent. How do you reassure them?
A: Advances in treatment have reduced the risk of these side effects. Radical prostatectomy — surgical removal of the prostate — is the most effective treatment, but the surgeon’s experience and expertise are key to achieving optimal outcomes. I’ve performed almost 4,000 radical prostatectomies, and our outcomes are among the world’s best. Some 97 percent of our patients remain continent.
One common side effect of surgery is erectile dysfunction. While a resident at Johns Hopkins, I co-developed the nerve-sparing radical open prostatectomy, designed to preserve erectile function. For men who are potent going in, our overall postoperative potency rate is 60 percent. Individual results depend on age, whether one or both nerve bundles were preserved, the quality of erections before surgery, and prior history of diabetes or cardiovascular disease. For a 50-year-old with a good erection, our postoperative potency rate is 80 to 90 percent.
Robot-assisted prostatectomy has gained popularity, but studies show it has no real advantages over the open approach as far as erectile quality or other important outcomes. Some men prefer this alternative, and it’s now available at NYU Langone. We recently recruited Dr. Mani Menon, the most experienced robotic prostate cancer surgeon in the world. He and Dr. Michael Stifelman, our director of robotic surgery, offer this approach.
Q: What about radiation?
A: My feeling — although many radiotherapists may not necessarily agree — is that radiation therapy, which includes external beam radiation and radioactive seeds (brachytherapy), isn’t as effective as surgery in totally eradicating prostate cancer and offers no fewer complications. But it’s certainly an option, particularly when surgery fails to get all the cancer, or in older men for whom surgery may be problematic.
Q: If, God forbid, you were diagnosed with this disease yourself, which treatment would you opt for?
A: I have a family history of prostate cancer, so my PSA is closely followed. Hopefully the disease would be found early and I would proceed with a prostatectomy. It’s a better way to cure cancer.
Q: We’ve been hearing a lot about focal therapy, which targets small parts of the prostate. Are you excited about this development?
A: I believe these minimally-invasive ablative treatments represent the future of prostate cancer therapy. They could offer a middle ground for men with very small cancers who may not require a prostatectomy or radiation therapy. Just how effective they are remains to be seen, however. NYU is a leader in investigating two such approaches. One is high-intensity, focused ultrasound (HIFU) where an ultrasound energy beam is used to destroy prostate tissue with minimal damage to the bladder and nerves. Six to eight centers around the country will be testing it, including NYU. The other is photodynamic therapy, where photosensitive bacteria are injected into the bloodstream, then excited by a certain wavelength of energy to cause tissue damage. It appears the prostate is more susceptible to this damage than the adjacent nerves that mediate erections. FDA trials should start soon, and NYU will be one of the leading sites.
To enhance these treatments, we also need to get better at mapping tumors. Dr. Samir Taneja is heading our research on new detection methods like the TargetScan device, which employs computer technology to guide biopsy procedures. As a world leader in both radical prostatectomy and research into possible alternatives, we’re beautifully positioned to help develop these exciting options, which we hope will greatly improve our ability to cure prostate cancer while minimizing the risks of side effects.