DUDLEY SETH DANOFF, M.D., F.A.C.S.
It has been widely reported in the media that California Governor Jerry Brown has just completed radiation treatment for the early diagnosis of prostate cancer. When I saw him on TV this past week, he looked fit, alert, vigorous and bearing no apparent adverse effects from his treatment.
Although the details of his illness have not been released, as a long-time practicing urologist surgeon, it seems apparent that his diagnosis was initially made because his PSA (prostate-specific antigen) blood test was elevated. The controversy surrounding the efficacy of PSA in a man 74 years old has been hotly debated, but the in this case, seems justified.
Governor Brown’s UC San Francisco oncologist was quoted as saying that “fortunately, this is early-stage localized prostate cancer, which has been treated with a short course of conventional radiation therapy. The prognosis is excellent, and there are not expected to be any significant side effects.” This statement also indicated that the governor was “continuing a full work schedule.”
The only reliable way of truly diagnosing early-stage localized prostate cancer is with a PSA blood test. The digital rectal exam, though important, will almost always pick up a lesion in the prostate at a more advanced stage than the lesion diagnosed in the governor. Although lesions of this type are often not treated but carefully monitored in a program called “active surveillance,” the governor’s urologist decided to proceed with radiation therapy. Both “active surveillance” and localized radiation therapy are treatment options which need to be carefully monitored. “Active surveillance” is increasingly favored for older men because prostate cancers tend to be very slow-growing.
In my estimate, the reason Governor Brown’s physicians chose to be a bit more aggressive with limited radiation therapy in spite of his age of 74 is the fact that he is vigorous, healthy, and in excellent physical shape, and his actuarial life expectancy is probably longer than an average person age 74.
Given the modern delivery system of radiation (IMRT), the side effects are very minimal and survival data, which goes out about 15 years, is extremely favorable and compares to a more aggressive surgical approach as treatment.
According to Dr. Christopher Rose, a radiation oncologist at the Center for Radiation Therapy of Beverly Hills, “Conventional radiotherapy implies external beam radiation therapy, and it is generally offered in a course of treatment lasting anywhere from 5-1/2 to nine weeks. However, accelerated treatments exist in which five treatments are delivered over a course of eight days and are very well tolerated.” In describing the technical features of the treatment, Dr. Rose noted “a three-dimensional model of the prostate – as well as organs that the oncologist wants to avoid – is pieced together using CT scans. The patient lies on his back and a 360-degree radiation source delivers beams of radiation to the patient in a way that targets the prostate but avoids other structures as much as possible. The beams can be delivered at differing degrees of intensity and in a concave shape so that the rectal tissues, lying near the walnut-shaped prostate, are avoided. Other advances allow a CT scan to be taken at each treatment session and lined up with the initial map so that the patient can be precisely positioned and the same tissue volume irradiated each time, and with these advances, the potential for a cure goes up and the potential for injury to adjacent organs goes down” said Dr. Rose. He also noted that “with conventional radiation treatment, each session takes a matter of minutes and is performed on an outpatient basis.” He noted that “most patients work all through their treatments and occasionally suffer minor fatigue that usually occurs at the end of the day. Governor Brown seems at the top of his game, and it probably won’t interfere with his activities of life.”
The prognosis for the type of cancer that Governor Brown apparently has is extremely favorable. He will be followed by monitoring the blood levels of prostate-specific antigen (PSA) and perhaps repeat biopsies in the future.
The take-away message is that most men diagnosed with early, localized prostate cancer who enter either the “active surveillance” program or localized radiation treatment, as in the case of Governor Brown, die of something other than prostate cancer.