(Focus-India)
According to World Cancer Research Fund International, Prostate cancer is the 2nd most commonly occurring cancer in men and the 4th most common cancer overall. These statistics go beyond mere numbers; they urgently highlight the need for awareness and action. As we step into September, recognized as Prostate Cancer Awareness Month, we embark on a journey to explore the essentials – from early detection and accurate diagnosis to evolving treatment landscapes.
In recent years, technological advancements have greatly impacted treatment options for prostate cancer. Notably, the introduction of robotic surgery has revolutionized the field. With enhanced precision and minimal invasiveness, this approach offers improved outcomes, shorter recovery times, and reduced post-operative discomfort.
In this edition, we have had the privilege of interviewing Dr. Mahesh Desai, a renowned urologist from India, who shares invaluable insights into the diagnosis, treatment, and the role of robotic surgery in providing patients with more effective and patient-friendly options. Dr. Mahesh also sheds light on the challenges in diagnosis, the opportunities that technology presents, and the journey of hope that each patient embarks upon.
Through this interview, we invite you to discover the power of knowledge and the potential for progress in the realm of prostate cancer care.
Dr. Mahesh Desai is a Consultant Urologist and Managing Trustee currently serving at Muljibhai Patel Urological Hospital, Gujarat, India.
The challenge lies in distinguishing between non-progressive microscopic cancer that does not require treatment, early cancer with a potential for progression, and cancer that is already advancing. This can be determined through various methods, including PSA levels, MRI, biomarkers, genomic analysis, family history, and PSMA scan.
In the U.S., the average 5-year survival rate for prostate cancer is between 95% and 100% for men aged 40-80 years. However, for younger men, the 5-year survival rate is lower (For men age 25-34 years, it’s 80%. For men age 20-29 years, it’s 50%. For men age 15-25 years, it’s 30%). Do you observe a similar pattern in your practice? And, what is the main reason for this difference?[1],[2]
Dr. Mahesh - Well, it depends upon when you diagnose and at what stage you diagnose. India is little different from the USA. We did an epidemiological study in the district of Kheda and found that the average size of the prostate in rural areas is approximately 12 grams, while in trading villages it is around 22-23 grams. When prostate cancer develops, the process of spreading beyond the capsule becomes more significant. Therefore, our cutoff value for detection is not 4 ng/dl but 2.5 ng/dl. In our camps, we prioritize early detection because timely identification allows for curative surgical treatment if the cancer has not spread beyond the organ.
However, it is not uncommon to miss the diagnosis. If you diagnose patient between 45 and 50 years of age and operate, overall survival is very high, more than 80-90%. But diagnosing between the ages of 50 and 60 years, with a Gleason Score of 7-8 or higher, presents greater challenges. Out of the 82% prostate cancer cases we operated with a preoperative diagnosis of localized prostate cancer, we discovered that 48% of patients had organ-confined cancer, while the rest showed capsular infiltration or a little spread outside capsule. In such cases, there is a progression, and patients require hormonal therapy and radiotherapy. In these instances, if the prostate is small but not extensively spread, we primarily treat it with medication rather than surgery. If the gland shrinks adequately, we may perform surgery followed by radiotherapy, resulting in improved overall survival. However, once the cancer becomes metastatic, survival without treatment was previously around 8-9 to 12 months. With the current availability of multiple treatment options, survival has extended to more than three years. Nevertheless, survival still depends on the stage on diagnosis, tumor grade, and metastatic status.
In a normal individual of middle age, around 50 years old, approximately 30% may have microscopic evidence of prostate cancer, which might not progress. In the United States, post-mortem studies have shown that around >80% of elderly patients have microscopic evidence of prostate cancer without clinical manifestation. Therefore, the challenge lies in distinguishing between non-progressive microscopic cancer that does not require treatment, early cancer with a potential for progression, and cancer that is already advancing. This can be determined through various methods, including PSA levels, MRI, biomarkers, genomic analysis, family history, and PSMA scan.
Studies have indicated that the Prostate Specific Antigen (PSA) test, currently employed for prostate cancer diagnosis, exhibits inaccuracies in the form of both false positive and false negative outcomes. [3] Have there been any notable breakthroughs in the early and accurate detection of prostate cancer?
Dr. Mahesh - PSA is prostate-specific, not cancer-specific. Its levels can rise due to infections and non-cancerous conditions. To increase sensitivity and specificity, we have additional markers to supplement PSA testing, such as PSA density, PSA velocity, Free PSA levels, and combinations of markers, such as PHI Scores.
PSA levels can increase if the prostate gland is large, making it difficult to determine if there is cancer. However, in cases where the prostate gland is enlarged, determining the appropriate biopsy size becomes challenging. Fortunately, there is a specialized agent that can distinguish between benign and malignant tissues, although it is not currently available in India. Additionally, other agents like 68Ga can be sensitive in detecting primary and secondary cancers. Therefore, it is crucial to understand how cancer progression is detected. If the stage of the disease is accurately determined at the time of diagnosis, the treatment can be tailored accordingly, leading to better effectiveness. Treating cancer as organ-confined when it is metastatic will render it ineffective.
When conducting a PSMA scan, a pharmaceutical agent or a radio nuclear test is administered to detect prostate cancer, specifically targeting the prostate-specific membrane antigen. However, not all agents used in the scan possess the desired sensitivity and specificity. Some of these agents have received FDA approval but have not yet been introduced in India. If the PSA levels are elevated, the scan can effectively identify the presence of cancer.
Talking about the treatment of prostate cancer, is robotic surgery being employed as a treatment option for prostate cancer in India?
Dr. Mahesh - We have performed approximately 900 cases of robotic-assisted surgeries at MPUH, which has become the preferred approach. Open surgery was commonly performed in the past, but it had more complications, longer hospital stays, and increased issues with incontinence. Robotic surgery, on the other hand, is a form of laparoscopic-assisted surgery that offers advantages such as magnification. The image can be zoomed in up to 30 times, allowing for better visualization of different tissues, particularly for nerve-sparing procedures. The precision achieved with robotic surgery is significantly higher. Since 2010, we have been performing robotic surgery for prostate cancer, and our outcomes have been very promising.
In 1987, biopsy procedures were introduced, followed by the invention of PSA testing in 1989. Our hospital in India was among the first to implement PSA testing. With the combination of PSA and ultrasound, we began diagnosing and staging prostate cancer, although MRI was not available then. However, with the advent of MRI, local staging became more accurate. The introduction of PSMA PET imaging and other advancements followed within the next ten years that helped to detect progression and proper staging. Molecular biology would hold the key to diagnosing and treating prostate cancer.
Last year, the FDA approved a new drug called Pluvicto for someone with prostate cancer that has spread to other areas of the body. What are your thoughts on this new treatment option? [4]
Dr. Mahesh - I believe it is a significant advancement. When dealing with metastatic prostate cancer, it is important to determine whether it is castrate-sensitive or castrate-resistant. Depending on the classification, we have a range of medications available for treatment. We had limited options in the past, but now we can incorporate different drugs. However, not all of these drugs are accessible in our country, and the cost is also a factor to consider. Life expectancy has increased in our country, and the aging population contributes to a higher incidence of prostate cancer.
Using metastatic drugs can extend life expectancy by an additional three to four years, but the monthly cost can range from 2,50,000 to 300,000 Lakh INR per cycle. Consequently, these medications are prescribed to those who can afford them, while others are offered simpler alternatives.
How do you envision the treatment landscape for prostate cancer evolving in the next 10 years?
Dr. Mahesh - I'm 79-year-old and let me share my own journey as an example. Back in 1985, when I had to do a digital rectal examination and find a hard nodule, we did acid phosphatase and blood tests, did the orchiectomy, and then hormone stilbestrol treatment. With the introduction of ultrasound for kidney stone examination, we started doing Transrectal ultrasound of the prostate, which increases the ability to examine the prostate gland, including cancerous nodules, became possible.
In 1987, biopsy procedures were introduced, followed by the invention of PSA testing in 1989. Our hospital in India was among the first to implement PSA testing. With the combination of PSA and ultrasound, we began diagnosing and staging prostate cancer, although MRI was not available then. However, with the advent of MRI, local staging became more accurate. The introduction of PSMA PET imaging and other advancements followed within the next ten years that helped to detect progression and proper staging. Molecular biology would hold the key to diagnosing and treating prostate cancer.
As we started diagnosing prostate cancer earlier, we started doing open surgery. We did 36 open surgeries and then came the laparoscopy. Then, in 2001, we began utilizing laparoscopy for prostate surgeries, drawing inspiration from its success in nephrectomy and transplantation procedures. From 2001 to 2010, we conducted 94 laparoscopic radical prostatectomies.
The introduction of robotic surgery came next, but it was expensive and cost 11 Crore rupees. We acquired the robotic system in 2010 through charitable donations. So, we started diagnosing and staging the tumor early. We have done about 35 camps around the Kheda district and have performed over 870 robotic radical prostatectomies. The robotic approach has proven to be superior to open surgery. The laparoscopy stands on the shoulder of the open surgery, while the robot stands on the shoulder of the laparoscopic
surgery.
Furthermore, we are in the process of acquiring an MRI fusion machine, which will further enhance our capabilities. Presently, the outlook for Indian patients appears promising, as many centers in India offer robotic and laparoscopic prostatectomy procedures. Additionally, there is an upcoming meeting in Australia where seven new robotic equipment will be showcased at a price significantly lower than the current cost. An Indian company named SS Innovations has launched a cost-effective robot named SS Mantra which will benefit Indian patients. This indicates technological advancements within the field of robotics. Moving forward, technology will continue to play a crucial role in saving lives through early detection and providing appropriate treatment.
Thank you for sharing your experiences and knowledge spanning from 1985, doctor. To conclude our session, what do you suggest to prostate cancer patients and their caregivers to effectively manage their disease?
Dr. Mahesh - Treating prostate cancer according to its stage is crucial, but it's particularly important to consider a patient's family history of breast or ovarian cancer, as it can aid in detecting prostate cancer. Therefore, screening should start between the ages of 40 and 45, with PSA tests potentially detecting 4% to 5% of cases early, especially in those with a family history. Individuals without risk factors should begin screening between 45 and 50, monitoring PSA levels and conducting follow-ups every two to four years if the PSA is below 2.5, and if subsequent tests remain normal, extending the follow-up intervals to four years initially, and then five to seven years after two to three consecutive normal reports.
In the presence of a family history, waiting for two years and closely monitoring the PSA levels is advisable. If the PSA shows a trend of increasing by 0.75 ng/dl per year, further investigations, such as an MRI, should be considered. And if the PSA jumps from two to five or five to ten within a couple of years, you should get a full workup. Once diagnosed, treat it accordingly. When it comes to treating the metastatic tumor in patients around the age of 75, the good news is that the current drugs offer an excellent quality of life; however, the main hurdle we face is the cost, but I make every effort to assist them in any way I can.
Thank you so much for the enlightening discussion!
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