Center for Screening, Prevention, Detection, Surveillance, and Minimally Invasive and Focal Therapy for Prostate Cancer

Director: Kevin Slawin, M.D.
Physician: Tung Shu, M.D.

Appointments: (713) 366-7847

The Vanguard Center for Screening, Prevention, Detection, Surveillance, and Minimally Invasive and Focal Therapy for Prostate Cancer was developed specifically to bring to bear the entire body of knowledge with respect to these sequential issues during the decision making process between each patient and his physician, and to use the latest online Web-enabled nomograms and other tools, to help men make the best, most well-informed decisions that fits each man’s philosophy and goals with respect to his health and lifestyle.

Rationale - New data from randomized trials performed in this country and in Europe are leading to a sea change in the way we care for men concerned about their risk of prostate cancer and committed to taking the necessary steps to maximize their chances of living a full life with minimal impact from this disease.

Achieving this requires the right balance at every step of the process, including how often to perform PSA-based screening, when to employ methods at prostate cancer prevention and which make the most sense, when to perform a prostate biopsy and when necessary how to perform it, and what to do when prostate cancer is detected and when it is not.

The answers to all of these questions have become more confusing than ever.   Until recently, when guidelines for PSA screening were updated at the Annual Meeting of the American Urologic Association in Chicago, IL, April, 2009, men were encouraged to get an annual screening exam for prostate cancer, including a digital rectal examination and a PSA blood test beginning at age 50 and earlier in men at higher risk for the disease, including African American men and men with a family history of the disease.  PSA levels prompting biopsy, originally set a >= 4.0 in the 1994 when PSA was FDA approved for prostate cancer screening, research from our group and many others demonstrated that by using extended biopsy schemes, the risk of prostate cancer was 25% in men with a PSA between 2.5 and 4.0 ng/mL and prompted decisions to do biopsies in men with these lower PSA levels.  This intensive level of screening has led to a marked increase in the diagnosis of prostate cancer over the last 15 years, and has coincided with a steep decrease in the death rate from prostate cancer over this same period.  Early detection and widespread and improved modalities for the treatment of these cancers during this period, including improved techniques for hormonal therapy, as well as radical prostatectomy and radiation therapy is likely to have played a significant role in the mortality due to prostate cancer.  However, nagging concerns regarding the potential that many of these cancers were not actually life threatening and may have been over-treated, with the accompanying costs and risks of unnecessary morbidities like incontinence and erectile function that often accompany prostate cancer treatment have persisted.

Recently published data from the ERSPC (European Randomized Screening for Prostate Cancer Study), a well performed study examining these issues more closely, as well as from the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial, a more flawed and problematic study performed in this country, and widely reported in the news including the New York Times and the Wall Street Journal, have now quantified more precisely the risks and benefits for men undergoing PSA-base prostate cancer screening.  The good news, downplayed in most of the major news media, is that men randomized to undergo screening for prostate cancer experienced a compliance-adjusted 27% reduction in the risk of dying from prostate cancer within the first 9 years after beginning screening, compared to those men who were not screened for prostate cancer.  This benefit appears likely to increase significantly as the length of follow-up of these patients increase, reflective of the fact that men who ultimately die of prostate cancer often have had the disease for twenty years before succumbing, significantly longer than the period of follow up so far in this study.  Of concern, however, was the finding that it required 48 men diagnosed and treated with prostate cancer for every life saved by prostate cancer screening, suggesting that a significant degree of over-diagnosis and over-treatment may have occurred to achieve this significant and important reduction in mortality.

So for any man contemplating his options with respect to his prostate health, there are many decisions he needs to make which may greatly affect his future length and quality of life as it relates to prostate cancer.  And while there remain many unknowns, these decisions can be well-informed and aided by our current extensive knowledge and informatics tools to assist the decision-making process at every step.  Beginning with the decision of whether and when to start PSA-based screening, the new AUA Guidelines actually suggests beginning screening much earlier, at age 40 years; however further screening tests and the intervals between them are now recommended to be guided by several risk factors, including the PSA level, with some men potentially able to increase the interval between screening tests to more than one year.  Furthermore, in recognition of the potential for overtreatment of certain cancers deemed non-aggressive, the new guidelines stress the dichotomy between diagnosis and treatment, with active surveillance now considered a more viable option for some men diagnosed with non-aggressive disease.

The Vanguard Center for Screening, Prevention, Detection, Surveillance, and Minimally Invasive and Focal Therapy for Prostate Cancer was developed specifically to bring to bear the entire body of knowledge with respect to these issues during the decision making process between each patient and his physician, and to use the latest online Web-enabled nomograms and other tools, to help men make the best, most well-informed decisions that fits each man's philosophy and goals with respect to his health.

Our Center will provide patients with guidance in the following areas:

1.       Screening

a.       When and if to start

i.      Current guidelines

b.      How and how often

i.      PSA, free PSA, PSA-velocity, proPSA

c.       Use of digital capture and analysis of serial PSA history and electronic nomograms to monitor progress

d.      Creation of an individualized plan for each patient with respect to the intensity of future screening

2.       Prevention

a.       Options, Risks and Benefits of Available Strategies

i.      Diet and Exercise

ii.      Finasteride/Dutasteride

1.       Review of the randomized trials for both agents for prostate cancer prevention

iii.      Selenium/Vit E

1.       Review of the randomized trial for both agents for prostate cancer prevention

iv.      Statins/Cholesterol

1.       Review the increasing body of knowledge with respect to statins and prostate cancer prevention

v.      Testosterone Replacement Therapy in Aging Men and the impact on the risk of future prostate cancer

1.       Guidelines on when and how to use, and the available agents

3.       Detection

a.       Prostate Biopsy

i.      When, how, how many cores, how often

ii.      Transrectal extended versus Transperineal Saturation and Mapping

iii.      Robotic biopsy technology

iv.      Imaging

1.       Digital-doppler enhanced Transrectal Ultrasound

2.       Tranrectal ultrasound Histomapping (experimental)

3.       3 Tesla MRI/MRIS imaging in select cases (available soon)

4.       MRI/TRUS fusion image guided biopsies (experimental)

4.       Treatment Options

a.       Surveillance

i.      Review of surveillance strategies from leading centers from around the world

1.       Nomogram analysis of clinical parameters including PSA, Gleason Score, number and percent of cores positive, other factors to determine the appropriateness of entering a surveillance protocol for prostate cancer

2.       Review of parameters that would trigger a change to active treatment for prostate cancer

3.       Individualized planning for each patient who opts for this choice of management

b.      Minimally Invasive Therapy

i.      Da Vinci Robotic Assisted Laparoscopic Prostatectomy

1.       Individualized planning and performance of prostatectomy (surgery to completely remove the prostate) by surgeons with extensive experience in both open and robotic prostatectomy to maximize the chance of achieving a negative surgical margin that indicates the best chance of cancer cure, along with maximizing the chances of preserving both continence and erectile function.  Techniques that focus exclusively on preserving erectile and urinary function increase the risk of leaving cancer behind, especially in men with intermediate and higher risk disease.

2.       Selective application of specialized surgical techniques in these patients, including "en bloc" resection of the bladder neck, and performance of nerve grafting,  to decrease cancer recurrence rates while optimizing quality of life outcomes in these patients.

3.       Monitoring of cancer control using ultrasensitive PSA beginning 6 weeks after surgery, which can identify patients with a 99.2% chance of long-term cure with just a single test result that falls to <= 0.01 ng/mL.

ii.      Cryotherapy - Our physicians have extensive experience performing prostate cryotherapy.

iii.      HIFU - This option is not FDA approved in the United States pending the results of Phase III clinical trials currently ongoing.  However, patients who opt for this mode of therapy can be treated outside the United States, with the most accessible centers located in Cancun or Puerto Vallarta, Mexcio, Nassau, Bahamas or Toronto, Canada.

c.    Radiation Therapy

i.      Image Guided Radiation Therapy (IGRT) - Follow this link to learn more about this state-of-the-art treatment for prostate cancer

ii.     Brachytherapy

iii.    Proton Beam EBRT

d.       Focal Therapy - This refers to therapy, usually ablative, using minimally invasive therapy to freeze or heat the cancer, avoiding treatment of the remainder of the prostate gland and thus theoretically minimizing side effects like incontinence and impotence that can occur with both surgery and radiation therapy of the prostate.  This approach is currently experimental but remains an area of extreme interest and clinical development.   Highly motivated patients may opt for this modality after a full understanding of the risks and benefits.  Focal therapy is currently practiced using either cryotherapy or, preferably, HIFU.

e.       Progressive and Advanced Disease - We are currently offering a number of clinical trials of the most advanced technologies and concepts for these patients.