Making Prostate Cancer Easier to Understand for Newly Diagnosed Patients

Dr. Ravi Munver explained that, for patients who are recently diagnosed with prostate cancer, it is important to explore treatment option with their care.

It is for patients who are recently diagnosed with prostate cancer to explore all available treatment option with their care team, according to Dr. Ravi Munver, who emphasized understanding each therapies risks and benefits, as well as understanding which treatment is right based on age, health and personal goals.

To further explore this treatment option, Munver sat down for an interview with CURE in which he expanded on the typical treatment options available for this patient population, diving into tactics like radical prostatectomy and radiation therapy, as well as minimally invasive options like cryoablation, high-intensity focused ultrasound (HIFU) and transurethral ultrasound ablation (TULSA).

“A prostate cancer diagnosis can obviously be very devastating, but the nice thing to know is that it's one of the most treatable cancers out there,” he emphasized to patients in the interview.

Munver is the vice chair of Urology, the chief of Minimally Invasive and Robotic Surgery, the director of Robotic Surgery and Minimally Invasive Urological Oncology Fellowship, and the director of the Living Donor Kidney Surgery Program, all at the John Theurer Cancer Center, part of Hackensack Meridian Health, as well as a professor of urology at the School of Medicine and vice chair of the Department of Urology at Hackensack University.

CURE: What questions should patients be asking their care team after a prostate cancer diagnosis?

Munver: A prostate cancer diagnosis can obviously be very devastating, but the nice thing to know is that it's one of the most treatable cancers out there. So, when patients come to see their caregiver to talk about prostate cancer, they should first do their research. There's a lot of research you can do — you can go on the internet, you can talk to friends and family.

However, you really want to specifically ask what the various treatment options for prostate cancer are, because we can treat it in a variety of different ways. Aside from that, you want to specifically ask what the pros and cons of each therapy are. Also, you want to ask what the best therapy is for someone your age, based on your health history and desires, and what you are looking for in terms of an outcome. Those are the really important things to ask, and then the caregiver will generally extrapolate on the different types of treatment options that are available.

The one thing that I caution patients against is asking, “What would you do?” because it's really a shared decision-making process, and that's what we try to iterate with patients — that it's not just what the caregiver offers, but what's available and what the patient wants.

What are the current treatment options for prostate cancer, and how have they evolved in recent years, particularly with minimally invasive techniques?

There are a multitude of treatment options for prostate cancer. If we're talking about prostate cancer in a healthy man who has all options available to him, the gold standard therapies are surgical removal of the prostate, which is called radical prostatectomy, and radiation therapy. There are different types of radiation therapies available. Those are the two therapies with the highest cure rates, looking at 10 years and beyond.

Aside from those therapies, there are also minimally invasive or focal therapies. These include cryoablation, which uses freezing therapy to kill prostate cancer cells. There is something called high-intensity focused ultrasound therapy, or HIFU, which uses ultrasound waves to treat specific areas of the prostate with prostate cancer. Then there are other therapies out there, such as TULSA. TULSA is transurethral ultrasound ablation, which uses ultrasound waves in a different manner than the HIFU therapy, but it can also treat prostate cancer.

There is even a laser therapy called interstitial laser ablation. These are focal therapies. They don't treat the entire prostate, but they treat specific areas of the prostate in men who are looking for a less invasive approach, which may offer fewer side effects compared to radical prostatectomy and radiation therapy, which are typically whole gland therapies, treating the entire prostate.

What should patients know about navigating the side effects or long-term effects that occur when receiving these therapies?

Each of the different prostate cancer therapies has its own set of side effects, and naturally, the most invasive therapies will have the highest number. For example, radical prostatectomy, even when performed minimally invasively with robotic surgery, can still lead to two significant quality-of-life side effects: incontinence (urine leakage after surgery) and erectile dysfunction in men who previously had good erectile function. Most of the time, these side effects from radical prostatectomy are transient, meaning the incontinence and erectile dysfunction are short-lived and typically resolve over a few weeks to a few months. However, sometimes they can be permanent. This doesn't mean men have to live with them, as these side effects can often be treated with other therapies.

Similarly, with radiation therapy, you can experience side effects like incontinence and erectile dysfunction, though typically at a slightly lower rate than with radical prostatectomy. When we consider the minimally invasive or focal therapies—where only part of the prostate is treated, such as cryoablation, high-intensity focused ultrasound therapy, transurethral ultrasound ablation, or interstitial laser ablation — these offer the lowest number of side effects. This means a very low risk of incontinence, a very low risk of erectile dysfunction, and a very low risk of pain or long-term comorbidities that existed preoperatively and might be affected by the therapies themselves.

Again, each of these therapies has its own specific set of side effects. If these side effects occurred in all men, these therapies wouldn't be offered, as you'd be treating the cancer but also creating significant quality-of-life issues afterward.

Why do you think it's important for patients to consider second opinions pertaining to their treatment options when they're first diagnosed?

When I began at Hackensack University Medical Center 23 years ago, three of my first five cancer patients went to other institutions for second opinions. I thought to myself, “I'm never going to succeed as a urologist because I can't convince my patients to stay with me.” They probably looked at me and thought, “Boy, this guy looks really young. I don't know how much experience he has. I'm going to go someplace else.” And they never came back.

Fast forward 23 years, patients ask me all the time about second opinions, and I actually welcome that. So, what do I say about second opinions? I think second opinions are great, but what I tell patients is to get a second opinion from someone who is knowledgeable, not necessarily just someone you find on the internet or someone you heard is good. Try and do some research and find out what that individual's background is in the specific therapy you're looking for.

For example, some urologists will only perform one type of therapy. Well, guess what? If you want a different type of therapy, they may downplay that because they're so good at doing one versus another. So, if you are leaning towards a specific therapy, obviously get a second opinion, but go to someone who has expertise in that therapy.

Someone like me, I have expertise in a lot of these different therapies. I consider myself an overall minimally invasive surgeon, so I can offer focal therapies. I can offer radical prostatectomy, and I work in conjunction with radiation oncologists to discuss different forms of radiation therapy. I think second opinions are great. I don't think anyone should ever get a major operation or a major procedure without getting a second opinion, and the patient doesn't have to feel like they're alienating the first physician they went to by getting one. There's absolutely nothing wrong with that. As a result, I am very supportive of getting second opinions.

I think it's very important for the patient to hear different perspectives, or they may hear the exact same perspective. Then they can make that decision going into that operation or procedure or therapy and say, “I'm very comfortable because I went to different people and they gave me very similar responses, and this is exactly what I was expecting, or this is what I may have read about or heard about.”

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