Finding The Medical Oncologist Who Is Right For You: One Specialists Opinion
Some prostate cancer patients may never feel the need to see a medical oncologist others may want an oncology consult soon after diagnosis and a third group of patients may not see an oncologist until other forms of treatment have failed. Many men with prostate cancer are not even sure what role a medical oncologist has in their care. However you get there, when you decide you need to see a medical oncologist, you are going to want to find the right one for you. We asked Andrew Armstrong, MD, MSc to talk about how he would approach this need. Dr. Armstrong is a board-certified medical oncologist and an Assistant Professor of Medicine and Surgery specializing in management of prostate and other genitourinary cancers at the Duke Prostate Center, part of the Duke University Health System in Durham, North Carolina.
Why look at these institutions and why see several physicians? Two reasons.
Having said that, I fully understand that it may be difficult or impossible for every patient to get to one of these specialty centers, and there are many, many community oncologists who provide excellent care for men with prostate cancer based on their years of experience and their dedication to their patients, so let me tell you what would be important for me in any oncologist I was going to select.
So these are my four most important priorities, but other things need to be taken into account too:
Content on this page last reviewed and updated November 25, 2008.
Surgically Removing The Prostate Gland
A radical prostatectomy is the surgical removal of your prostate gland. This treatment is an option for curing prostate cancer that has not spread beyond the prostate or has not spread very far.
Like any operation, this surgery carries some risks, such as urinary incontinence and erectile dysfunction.
In extremely rare cases, problems arising after surgery can be fatal.
It’s possible that prostate cancer can come back again after treatment. Your doctor should be able to explain the risk of your cancer coming back after treatment, based on things like your PSA level and the stage of your cancer.
Studies have shown that radiotherapy after prostate removal surgery may increase the chances of a cure, although research is still being carried out into when it should be used after surgery.
You may want to ask your doctors about storing a sperm sample before the operation so it can be used later for in vitro fertilisation .
Quality Of Life With Advanced Stage Prostate Cancer
Since Huggins and Hodges won a Nobel Prize in 1966 for their work describing the relationship between testosterone and prostate cancer, androgen deprivation has continued to be an important component in the treatment of advanced prostate cancer. It is associated, however, with significant cost in terms of morbidity as well as economics. Side effects of androgen deprivation therapy include hot flashes, osteoporosis, loss of libido or impotence, and psychological effects such as depression, memory difficulties, or emotional lability. Recently Harle and colleagues reported insulin resistance, hyperglycemia, metabolic syndrome, and metabolic complications being associated with castration and thus being responsible for increased cardiovascular mortality in this population.
Because of the palliative nature of androgen ablation, quality of life is an important component of evaluating competing therapies. Intermittent androgen deprivation is one approach to hormonal therapy that has been developed with the aim of minimizing the negative effects of therapy while maximizing clinical benefits and the patients quality of life. It can be used in any clinical situation where continuous androgen deprivation treatment could be applied.
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Resources To Find And Evaluate Doctors
Administrators in Medicine DocFinderInformation on licensing and disciplinary actions taken against doctors in 18 states links to state medical boards of remaining states.
American Board of Medical Specialties Includes a database to find doctors who are ABMS Member Board Certified Specialists, a designation achieved through additional training and education.
American College of SurgeonsInformation about finding surgeons who are Board Certified as well as information about surgical specialties. Includes database of member surgeons.
American Medical Association DoctorFinderEducation, board certification, and hospital admitting privileges for doctors who belong to the AMA.
American Society for Radiation Oncology RT AnswersIncludes searchable database of radiation oncologists.
American Society of Clinical Oncology Cancer.NetOncologist-approved cancer information from the American Society of Clinical Oncology can be found on the site Cancer.Net. This site includes a Find a Cancer Doctor tool with tips on choosing a doctor and a database of oncologists.
Urology Care FoundationSearchable database of member urologists.
Medicare Physician and Other Healthcare Professional DirectoryProvider profiles including specialties, practicing locations, and phone numbers. Other information may also include education, gender, residency, foreign languages spoken, and hospital affiliation.
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Just One Weapon Against Cancer
Before treatment with PLUVICTOTM is recommended, patients undergo a PSMA-PET/CT scan to determine if their tumor contains the PSMA target. If it does not, PLUVICTOTM would not be appropriate, explained Dr. Wong. At Duke we treat you as an individual. Each case is discussed among a multidisciplinary team of surgeons, radiation oncologists, medical oncologists, radiologists, and nuclear medicine specialists. He emphasized that PLUVICTOTM is not for everyone and is just one weapon in the arsenal for fighting cancer. Our team will determine how and if this new option fits in with all the others we offer.
Duke can provide PLUVICTOTM and other novel treatments because it is a Comprehensive Cancer Center with the latest advances in diagnosing and treating prostate cancer. Duke is also recognized as a Comprehensive Radiopharmaceutical Therapy Center of Excellence, which requires strict adherence to safety and treatment criteria that ensures the best care for patients.
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Different Approaches To Starting Hormone Therapy
Experts debate how early treatment with hormone therapy should be started. Some argue that the benefits of hormone therapy for prostate cancer should be offered to men earlier in the course of the disease. Others assert that theres little evidence that getting treatment early is better than getting it later.
Unfortunately, there are still some doctors who are offering hormonal therapy earlier in the course of the disease than is commonly recommended, Brooks says. Given that the side effects can be serious, Brooks argues that starting treatment with hormone therapy so early may not be a good idea.
However, Holden argues that early treatment may be helpful. I think one of the reasons that the death rate from prostate cancer is going down is that were using hormone therapy early, he tells WebMD. We havent proved that early treatment improves overall survival yet, but I think we will.
Researchers are also looking at intermittent therapy, starting and stopping hormone treatment for months at a time. The big advantage is that men could go off therapy temporarily and thus be free of the side effects. Early study results have been promising.
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Radiation Therapy For Prostate Cancer
Radiation therapy uses high-energy rays or particles to kill cancer cells. Depending on the stage of the prostate cancer and other factors, radiation therapy might be used:
- As the first treatment for cancer that is still just in the prostate gland and is low grade. Cure rates for men with these types of cancers are about the same as those for men treated with radical prostatectomy.
- As part of the first treatment for cancers that have grown outside the prostate gland and into nearby tissues.
- If the cancer is not removed completely or comes back in the area of the prostate after surgery.
- If the cancer is advanced, to help keep the cancer under control for as long as possible and to help prevent or relieve symptoms.
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Hormone Sensitive Advanced Pca After Prior Local Therapy
Patients treated with prior local therapy may have relapsed disease. The first step is to assess the disease burden. Asymptomatic patients with a rising PSA and no evidence of radiographic metastasis are said to have BCR. Asymptomatic men may initially be observed, as toxicity of systemic ADT may outweigh benefits depending on a variety of factors and incorporating estimated life expectancy. Patients with oligometastatic disease recurrence may be considered for metastatectomy or radiation therapy to sites of disease.4 This may be associated with a survival benefit and role for these therapies continues to be evaluated. Most men with radiographic evidence of disease will need ADT. Whether ADT should be indefinite or intermittent remains an open question.5 Non-inferiority studies did not reach statistical significance but were associated with a better quality of life . However, the consensus remains that patients with high risk/high volume disease are more likely to benefit from continuous ADT.
Remission And The Chance Of Recurrence
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having no evidence of disease or NED.
A remission can be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. Although there are treatments to help prevent a recurrence, such as hormonal therapy and radiation therapy, it is important to talk with your doctor about the possibility of the cancer returning. There are tools your doctor can use, called nomograms, to estimate someone’s risk of recurrence. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.
In general, following surgery or radiation therapy, the PSA level in the blood usually drops. If the PSA level starts to rise again, it may be a sign that the cancer has come back. If the cancer returns after the original treatment, it is called recurrent cancer.
When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence, including where the recurrence is located. The cancer may come back in the prostate , in the tissues or lymph nodes near the prostate , or in another part of the body, such as the bones, lungs, or liver . Sometimes the doctor cannot find a tumor even though the PSA level has increased. This is known as a PSA recurrence or biochemical recurrence.
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What Happens If I Stop Lupron Depot
If Lupron treatment is stopped, testosterone levels can rise and your cancer may worsen. Do not discontinue Lupron Depot unless your doctor tells you to stop treatment.
In men, testosterone is reduced to castrate concentrations with Lupron Depot treatment. This is called medical castration, as opposed to surgical castration when the testicles are removed surgically. The testicles make most of the testosterone in a man, about 95%. The adrenal glands above the kidney also produce a small amount of testosterone.
In patients with advanced prostate cancer, you may also receive other medicines along with Lupron Depot. These may include chemotherapy drugs, immunotherapy or targeted drug treatments, or corticosteroids depending upon your stage of cancer.
You may experience side effects with Lupron Depot treatment such as:
- hot flashes or sweats
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Your Cancer Care Team
People with cancer should be cared for by a multidisciplinary team . This is a team of specialists who work together to provide the best care and treatment.
The team often consists of specialist cancer surgeons, oncologists , radiologists, pathologists, radiographers and specialist nurses.
Other members may include physiotherapists, dietitians and occupational therapists. You may also have access to clinical psychology support.
When deciding what treatment is best for you, your doctors will consider:
- the type and size of the cancer
- what grade it is
- whether the cancer has spread to other parts of your body
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Most Common Options For Treating Prostate Cancer
Prostate cancer treatments have come a long way in a very short amount of time, allowing men to choose from a wide variety of treatments tailored to their specific situation. Learn more about some of the most common options for treating prostate cancer.
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If you or a loved one has been diagnosed with prostate cancer, its important to research all of your treatment options. What worked for a friend may not be right for you, and you should choose a treatment that will provide you with the best outcome and quality of life.
Most cancers are graded from stage 1 to 4 in level of severity, but prostate cancer uses a different system called the Gleason score. In the Gleason system, prostate cancer is graded using numbers from 1 to 5. Often, prostate cancer has sections with different grades, so those grades are added together to calculate the Gleason score. The highest number on the Gleason score is 10. Your Gleason score helps determine what treatment options are possible.
Standards Of Care In Hormone Therapy
Most doctors agree that hormone therapy is the most effective treatment available for patients with advanced prostate cancer. However, there is disagreement on exactly how and when hormone therapy should be used. Here are a few issues regarding standards of care:
Timing of Cancer Treatment
The disagreement is due to conflicting beliefs. One is that hormone therapy should begin only after symptoms from the metastases, like bone pain, occur. The counter belief is that hormone therapy should start before symptoms occur. Earlier treatment of prostate cancer is associated with a lower incidence of spinal cord compression, obstructive urinary problems, and skeletal fractures. However, survival is not different whether treatment is started early, or deferred.
The only exception to the above, is in lymph node-positive, post-prostatectomy patients, given androgen deprivation as an adjuvant immediately after surgery. In this situation, immediate therapy resulted in a significant improvement in progression free survival, prostate cancer specific survival, and overall survival.
Length of Cancer Treatment
The disagreement in this situation is between continuous androgen deprivation and intermittent androgen deprivation.
Combination vs. Single-Drug Therapy
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Treatment Of Advanced Prostate Cancer Requires Strong Experience
Widespread prostate cancer can be effectively treated today. The latest, yet experimental, treatments for 177-lutetium-PSMA and 225-actinium-PSMA have been shown to be effective in treating both skeletal and non-skeletal prostate cancer.
The key to treating patients with advanced prostate cancer is an individualized treatment program. The front-line treatment of metastatic prostate cancer always includes medical treatments , most commonly hormone therapy and chemotherapy, or a combination. If cancer has metastasized to the bones, a medication to strenghten them is often administered.
Radiotherapy can be included in treatment with special techniques, even if there are extensive metastases. If remission of prostate cancer is achieved by means of medical treatment, we at the Docrates Cancer Center always consider adding localized radiation therapy. This has been shown to be effective in the treatment of advanced prostate cancer. Irradiating of the prostate may also prevent urinary retention later on.
Hormonal treatments and chemotherapy can remain effective for long periods but usually lose their efficacy over time.
A Multidisciplinary Model For Prostate Cancer
To receive the best care possible for prostate cancer, you should seek care from a multidisciplinary medical team. This means that a group of health care professionals from different specialties work together to decide how best to prolong the length and quality of your life. To know if your medical providers are truly working as a team to help you stay as healthy as possible, ask if they hold regularly scheduled meetings that include all team members to discuss your status. You may want to attend such a meeting or ask for a briefing on it.
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Multimodality Strategy For Advanced Prostate Canceris The Future Here Yet
Recent results have encouraged exploration of a multimodal strategy in oligometastatic advanced prostate cancer, especially because studies suggest that each modality contributes to further disease debulking and, thus, disease control . Several studies are evaluating this strategy, including PEACE1 , MetaCure , and the radiotherapy arm of MRC STAMPEDE.
Targeted Prostate Cancer Treatment Options Designed To Help Patients Outperform Standardizedtreatment Models
If you have prostate cancer you understand like we do that your cancer can be extremely difficult to treat andlasting results can be scarce. Stage four prostate cancer is known for having an extremely low five-year survival ratewhen being treated by standard oncology. Even patients who catch their prostate cancer early and have their prostateremoved may still experience elevated PSA levels and micrometastasis with no actual tumor to be found. Either way,many prostate cancer patients do not easily achieve remission with standard chemotherapy regimens andtestosterone-blocking agents, but why? Why are late-stage and recurrent prostate cancer patients less likely torespond when standard protocols have been apparently successful in treating prostate cancer in the earlier stages ofthe disease?
Envita Medical Centers doesnt make any guarantee of outcomes. Results are not typical and will varyfromperson to person and should not be expected.
Envita is an integrative center of excellence for personalized oncology and specializes in developing world-classintegrative cancer treatments that utilize your unique genetic make-up in combination with immunotherapy and amultifaceted targeted approach to provide high-quality personalized care. With nearly two decades of research andclinical experience, Envita has been advancing medical technology to help our patients achieve favorable outcomes.
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Do We Know Which Treatment Is Best For Prostate Cancer Brachytherapy Or External Beam Radiation
Its not a question of which type of radiation therapy is best in general, but rather which therapy is best for the patients specific disease and quality-of-life concerns. We want to use the most tailored, pinpointed radiation to treat the prostate tumor effectively while minimizing side effects. This can depend on the tumors size and stage as well as other patient characteristics and even a patients individual preferences.