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    What PCPs and geriatricians need to know about robotic prostatectomy and organ-confined prostate cancer


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    Dr. Carlucci is a Fellow in the Division of Robotics and Minimally Invasive Surgery, Mount Sinai School of Medicine, New York City.

    Ms. Nabizada-Pace is Program Manager, Division of Robotics and Minimally Invasive Surgery, Mount Sinai School of Medicine, New York City.

    Dr. Samadi is Chief, Division of Robotics and Minimally Invasive Surgery, Mount Sinai School of Medicine, New York City.

    Disclosure: The authors state that they have nothing to disclose.

    Abstract

    Prostate cancer is the most common visceral neoplasm diagnosed in the United States and has gained significant public awareness over the past 20 years as a result of the serum prostate-specific antigen (PSA) screening test. Though there is potentially wide variability in presentation, most patients are diagnosed with organ-confined disease. Treatments for localized prostate cancer include surgery, radiation, and active surveillance. One of the newer surgical modalities is robotic-assisted laparoscopic prostatectomy, which has shown promise in improving cancer control and reducing the morbidity commonly associated with open radical prostatectomy. This article will discuss screening and treatment options for localized prostate cancer, with special focus on robotic prostatectomy and its advantages.

    Carlucci JR, Nabizada-Pace F, Samadi DB. Organ-confined prostate cancer and the emergence of robotic prostatectomy: What primary care physicians and geriatricians need to know. Geriatrics. 2009;64(2):8-14.

    Key words: robotics, prostate cancer, laparoscopy

    Prostate cancer is the fourth most common neoplasm worldwide, and the most common visceral neoplasm in the United States. With the advent of serum prostate-specific antigen (PSA) testing in the late 1980s and increasing awareness of men's health issues, prostate cancer is a primary concern in the minds of many aging males. Though many men are living with prostate cancer (only about 16% of men diagnosed with prostate cancer ultimately die of it), it is important to remember that it is the cause of death in about 3% of the U.S. male population and the second-leading cause of death from cancer in men in the United States.1

    Screening


    Figure 1
    Widespread screening with serum PSA and digital rectal examination (DRE) began in the late 1980s and has allowed earlier detection.2,3 This has resulted in a stage migration such that 91% of cases are now being detected at a clinically localized stage and metastatic disease at the time of diagnosis is now rare in the United States.1,4 However, screening for prostate cancer, as with many aspects of managing this disease, remains a controversial issue. Interpretation of serum PSA results is fraught with uncertainty but a better screening test has yet to be developed. Some of the inherent problems with interpreting PSA levels are that they fluctuate above and below normal levels over time even in healthy men, and that PSA usually increases as a man ages.

    Age-specific PSA cut-offs have been devised which indicate acceptable PSA levels. For stable PSA values, the following age-specific guideline can be used: < 2.5 ng/mL for men up to age 49; < 3.5 ng/mL for men aged 50 to 59; < 4.0 ng/mL for men aged 60 and older. Current American Urological Association guidelines are that men over the age of 50 should be screened with DRE and serum PSA once a year; African-Americans and patients with a family history should begin at 40.

    It now appears likely that PSA velocity (calculated over the course of at least 18 months) is more predictive of prostate cancer than the absolute PSA value. An abnormal PSA according to the above guidelines, a PSA velocity > 0.75ng/ml per year (even if the PSA remains below the age-specific cut-off), or an abnormal DRE warrants a urologic referral. The urologist performs a prostate biopsy under trans-rectal ultrasound guidance. If prostate cancer is found, further staging work-up may include CT scan of the abdomen/pelvis and a bone scan, depending on the aggressiveness and volume of cancer found on biopsy. A clinical stage can then be assigned based on these studies plus the biopsy findings, DRE, and PSA.

    Treatment

    As discussed earlier, most patients are now diagnosed in the early stages of the disease, when the cancer is still organ-confined. There are 3 major treatment options to consider: active surveillance, radiation, or surgery. (Metastatic disease, generally treated with androgen deprivation therapy and chemotherapy, is beyond the scope of this article.)

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    Dr. Carlucci is a Fellow in the Division of Robotics and Minimally Invasive Surgery, Mount Sinai School of Medicine, New York City.

    Ms. Nabizada-Pace is Program Manager, Division of Robotics and Minimally Invasive Surgery, Mount Sinai School of Medicine, New York City.

    Dr. Samadi is Chief, Division of Robotics and Minimally Invasive Surgery, Mount Sinai School of Medicine, New York City.

    Disclosure: The authors state that they have nothing to disclose.

    Abstract

    Prostate cancer is the most common visceral neoplasm diagnosed in the United States and has gained significant public awareness over the past 20 years as a result of the serum prostate-specific antigen (PSA) screening test. Though there is potentially wide variability in presentation, most patients are diagnosed with organ-confined disease. Treatments for localized prostate cancer include surgery, radiation, and active surveillance. One of the newer surgical modalities is robotic-assisted laparoscopic prostatectomy, which has shown promise in improving cancer control and reducing the morbidity commonly associated with open radical prostatectomy. This article will discuss screening and treatment options for localized prostate cancer, with special focus on robotic prostatectomy and its advantages.

    Carlucci JR, Nabizada-Pace F, Samadi DB. Organ-confined prostate cancer and the emergence of robotic prostatectomy: What primary care physicians and geriatricians need to know. Geriatrics. 2009;64(2):8-14.

    Key words: robotics, prostate cancer, laparoscopy

    Prostate cancer is the fourth most common neoplasm worldwide, and the most common visceral neoplasm in the United States. With the advent of serum prostate-specific antigen (PSA) testing in the late 1980s and increasing awareness of men's health issues, prostate cancer is a primary concern in the minds of many aging males. Though many men are living with prostate cancer (only about 16% of men diagnosed with prostate cancer ultimately die of it), it is important to remember that it is the cause of death in about 3% of the U.S. male population and the second-leading cause of death from cancer in men in the United States.1

    Screening


    Figure 1
    Widespread screening with serum PSA and digital rectal examination (DRE) began in the late 1980s and has allowed earlier detection.2,3 This has resulted in a stage migration such that 91% of cases are now being detected at a clinically localized stage and metastatic disease at the time of diagnosis is now rare in the United States.1,4 However, screening for prostate cancer, as with many aspects of managing this disease, remains a controversial issue. Interpretation of serum PSA results is fraught with uncertainty but a better screening test has yet to be developed. Some of the inherent problems with interpreting PSA levels are that they fluctuate above and below normal levels over time even in healthy men, and that PSA usually increases as a man ages.

    Age-specific PSA cut-offs have been devised which indicate acceptable PSA levels. For stable PSA values, the following age-specific guideline can be used: < 2.5 ng/mL for men up to age 49; < 3.5 ng/mL for men aged 50 to 59; < 4.0 ng/mL for men aged 60 and older. Current American Urological Association guidelines are that men over the age of 50 should be screened with DRE and serum PSA once a year; African-Americans and patients with a family history should begin at 40.

    It now appears likely that PSA velocity (calculated over the course of at least 18 months) is more predictive of prostate cancer than the absolute PSA value. An abnormal PSA according to the above guidelines, a PSA velocity > 0.75ng/ml per year (even if the PSA remains below the age-specific cut-off), or an abnormal DRE warrants a urologic referral. The urologist performs a prostate biopsy under trans-rectal ultrasound guidance. If prostate cancer is found, further staging work-up may include CT scan of the abdomen/pelvis and a bone scan, depending on the aggressiveness and volume of cancer found on biopsy. A clinical stage can then be assigned based on these studies plus the biopsy findings, DRE, and PSA.

    Treatment

    As discussed earlier, most patients are now diagnosed in the early stages of the disease, when the cancer is still organ-confined. There are 3 major treatment options to consider: active surveillance, radiation, or surgery. (Metastatic disease, generally treated with androgen deprivation therapy and chemotherapy, is beyond the scope of this article.)

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