Robotic Surgery may prevent long term complications of hormone therapy for prostate cancer

Robotic surgery is now very well established as a leading treatment option for prostate cancer. In suitable patients, it is likely to provide the best long term quality and quantity of life. Even in men with relatively advanced disease (high risk/locally advanced) prostate cancer, robotic surgery offers a speedy recovery with excellent long term survival. However, a relatively under appreciated advantage of this technique is its ability to delay or avoid the need for hormone therapy in a large number of patients with prostate cancer.

Hormone therapy (androgen deprivation therapy in medical jargon) implies removing the male hormone, testosterone from the body by either removing its site of production (surgical removal of both testes, also called surgical castration) or suppressing it with regular injections (medical castration). Since, prostate cancer cells are dependent on testosterone for their growth and spread, this removal or suppression of testosterone in the body generally brings about a decrease in the amount of cancer and keeps the disease under control for a duration of time ranging from months to a few years.

However, hormone therapy takes a significant toll on the body by way of many short and long term complications. It causes fatigue, loss of muscle mass, loss of bone strength which may cause fractures, depression, loss of sexual function and a general slowdown of physical and mental functions. In the long term, it can lead to an increased susceptibility to develop diabetes, high cholesterol and weight gain. It has also been shown recently to increase the chances of having a heart attack or stroke in the future. In fact, the US Food and Drug Administration (FDA) and American Heart Association (AHA) have issued a warning advising a judicious use of hormone therapy in patients with prostate cancer and weighing the risks and benefits before starting this treatment in all patients.

Patients who undergo radiation therapy for prostate cancer also have to take hormone therapy ranging from 6 months to 3 years depending upon the stage and type (grade) of the disease. This is because radiation alone (without hormone therapy) has much inferior results as compared to surgery in most patients with prostate cancer. This addition of hormone therapy to radiation therapy, unfortunately, exposes patients to the combined onslaught of complications and problems associated with radiation as well as hormone therapy.

For suitable patients, choosing to undergo surgery may be the best way to avoid many of these complications, thereby leading to the best possible preservation of quality and quantity of life. While hormone therapy may need to be given even after surgery in certain situations, it has been shown that even in men with a relatively advanced disease (high risk/locally advanced prostate cancer), hormone therapy can be avoided or delayed in more than 50% of patients by choosing to undergo surgery for prostate cancer. Even if hormone therapy is required after surgery, it can be given in an on-off fashion (intermittent androgen deprivation therapy), thereby avoiding a continuous harmful exposure to the body for a long time.

So, while there will always be certain short term problems and risks associated with undergoing surgery, robotic surgery for prostate cancer may be the best treatment option for most patients with prostate cancer – especially in view of the recent realisation in the medical community that hormone therapy for prostate cancer may not be as innocuous as previously thought by many of us !

Dr Gagan Gautam is the head of urologic oncology and robotic surgery at Max Institute of Cancer Care, New Delhi, India. He is one of the leading specialists for prostate cancer treatment in India and is closely involved in the care, counselling and surgical treatment of patients with this disease.  

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When a doctor becomes a patient – A story of a doctor who underwent robotic surgery for prostate cancer….

I am quite touched by this comprehensive feedback from a senior doctor who was diagnosed with prostate cancer and underwent robotic surgery in my care.

WHEN THE DOCTOR IS THE PATIENT:
PERSONAL ACCOUNT OF TREATMENT OF MY PROSTATE CANCER

I’m writing this piece with the hope that patients diagnosed with prostate cancer will benefit from my experience in accepting the dreadful diagnosis and in choosing the mode of treatment and the doctor (and hospital) to treat me.

My Story: I am 62 year old medical doctor (consultant paediatrician) residing at family house in Hyderabad (AP). Until recently we had been living and working abroad. It has been seven months (today 31st October, 2014) since I had Robotic/Robot-Assisted (da Vinci® ) Radical Prostatectomy (RRP) for Prostate cancer on 31st March 2014 by a team of doctors lead by Dr. Gagan Gautam.

Diagnosis: My story started with occasional dripping of drops of urine after voiding six months prior to my surgery. It was rather a nuisance than a ‘disease’. I mentioned this complaint to a colleague (urologist) in the hospital I was abroad. He advised me to do Prostate Specific Antigen (PSA) as a marker for prostate cancer due to my age rather than a finding of enlarged prostate. We came home for vacation and paediaric conference held in Indore in January this year. Before the conference I saw a urologist at a ‘five-star’ hospital in Hyderabad. He did not think it was necessary to do PSA as he was under the impression that the enlarged prostate was benign (not cancerous); he advised for clinical follow up to monitor the enlargement. However, I personally opted to do the PSA at that hospital on Monday 10th February 2014; it turned out very high (3x upper limit of normal). The following week I went back to the same urologist and showed him the result of the PSA and discussed the next course of action. He then ordered for trans-rectal ultrasound-guided (TRUS) biopsy of the prostate which I underwent in that hospital on Friday 14th February. After two careful reviews of the prostatic tissue in their laboratory the final report was issued out on 24th February as prostate adenocarcinoma (cancer) of intermediate grade.

Dilemma on My Choice of Mode of Treatment: The urologist explained the nature of the disease and the various options for treatment. In his opinion the best and most suitable treatment option for me was radical prostatectomy either by open surgery or by robotic-assisted procedure. Surprisingly what helped me to make up my mind did not come from high peer-reviewed medical journal (even as I am a doctor); it came from a Health & Fitness article (as I am now a patient rather than a doctor). The article that took me to the decision was an online one titled “Robotic Surgery for Prostate Cancer: An Automatic Choice?” by Lisa Farino for MSN Health & Fitness. The key words of the article caught my attention “It’s essential to consider a surgeon’s experience when deciding on treatment”. In this article Farino reviewed a number of issues on RRP including what was ‘robotic’ about prostate surgery, patients’ misconceptions about the procedure, what research said and did not say about open vs robotic prostate surgery and then concluded on the final note on surgeon’s experience. She then wrote, “The bottom line: The biggest factor determining the key outcomes of prostate surgery isn’t whether or not the surgeon uses a robot. With a highly experienced, talented surgeon, both open and robotic prostate surgeries can be performed well. The trick is identifying that highly experienced, talented surgeon who’ll give you the best chance of curing your cancer and preserving your quality of life afterwards.” She concluded by quoting Dr. Eric Klein, M.D., a urologist at the Cleveland Clinic, who said, “The robot is a tool; to have the best outcomes, you want to choose your surgeon, not your tool.”

So I set out to find and decide on the right surgeon.
I flew to Medanta – The Medicity, Gurgaon with my wife and met Dr. Gagan Gautam – Head of Robotic Surgery in his office on Saturday 28th February 2014.
He took history of my condition and examined me. He reviewed the investigations I had done in the Hyderabad hospital. He concurred with diagnosis done there. He took me through the options for treatment taking into consideration my age, my African origin, my good state of health (freedom from co-morbidity like diabetes, hypertension/heart disease) and the stage of the disease (confined to the prostate gland). He did so in great detail with humour and compassion. He agreed with my Hyderabad urologist on the mode of treatment for me. He then asked me to take time the make the decision on mode of my choice; operative treatment is normally done 6 weeks after the biopsy. He however advised that the prostate tissue be re-examined in Medanta to confirm the pathologic diagnosis given at Hyderabad and that I should do MRI of the prostate/pelvis at Hyderabad before my next appointment. I returned home Hyderabad that afternoon. I later obtained my prostate biopsy tissue blocks and slides and mailed them to Medanta hospital; the diagnosis was confirmed there.
After due consultation with my family and my other medical colleagues/friends, I opted for robot assisted radical prostatectomy by Dr. Gautam and his team. As I waited for the 6 week window, I read a lot on prostate cancer, its modes of treatment and in particular the RRP. It was a most trying moment in my life. Waiting for the date of the surgery was like eternity.

Pre-operative Assessment: Eventually the date was fixed on 31st March 2014. I flew with my wife to Gurgaon in the morning of Saturday 29th March. I was reviewed again by Dr. Gautam in his office. He reviewed the MRI examination I did in Hyderabad. It guided him on the tissue planes for the operative dissection. He re-examined me and then explained to me his plans for the operation. Later in the day, I underwent general clinical (heart, vascular & lung functions) and laboratory assessment (esp liver, kidney and blood clotting functions) as outpatient so as to ascertain my fitness to undergo the general anaesthesia, surgery and post-operative convalescence. I was seen by the anaesthetist and cardiologist. The assessment confirmed my state of good health. I was then admitted into the hospital in the morning of Sunday 30th March in readiness for the surgery on the following day.

Admission & Surgery: Early morning of Monday 31st March Dr. Gautam and team visited me and gave me assurance and confidence to face the surgery. That afternoon I was taken, in the company of my wife, to the operating theatre (OT) at around 2.30pm. The moment had come. In transit from the ward to the OT I lay supine watching the ceiling; the lamps therein moved pass me in parallax as I was wheeled on down the corridor. Finally we arrived at the OT and my wife was told to stay back; she bid me good bye. She was hoping, but not quite sure, that she would see me alive again soon. It was an emotional moment. I was taken into the theatre and she departed. I kept on praying. In the next moments the anaesthetists made final assessment of me. Eventually they put a mask on my face and asked me to breath in the gas. That was the last thing I remember as I slept. I woke up in what I came to know to be the recovery ward. The actual operation surgery took about 3 hours (2hrs and 40 minutes console time).

I made good and quick recovery and was discharged with urinary (Foley’s) catheter in place on the 3rd day after the operation (Thursday 3rd April). I was given appointment to return to the hospital for assessment and removal of the catheter on 8th April, eight days after the operation. I was given the necessary medicines to use and was instructed on the care of the catheter, the need to ambulate and do respiratory exercises. I stayed in a paying guest house across the road from the hospital. My stay in the house was uneventful and I made speedy recovery. The urine being drained into a bag has become grossly clear of blood by the 4th day. On the appointed date, I was re-admitted into the hospital’s urology day-care-ward. The urinary catheter was removed. I was instructed on how to do (Kegel) exercise to improve my external sphincter (pelvic floor, pubococcygeal) muscles in order to enhance voluntary control of urine voiding; I had already known how to do this even before the operation. Thereafter underwent simple ultrasound examination of the urinary bladder to determine residual urine volume after voluntary voiding of the bladder; it showed only 12mL which indicate good voiding. I was discharged later in the afternoon after about five hours of admission. Over the next several weeks I made good recovery. Within two weeks I was able to control my urination voluntarily such that I rarely wet my pants. I was able to hold urine well and void voluntarily at regular intervals of two hours.

Seven Months On After Surgery…: After the surgery I remained in my home in Hyderabad with the family until 30th May 2014 when we returned abroad.

Bladder Control: I virtually have full bladder control. I void on urge with good stream and without efforts. I make no conscious control of my liquid intake but I still avoid intake at bed time. I hardly wake up to void until my usual wake up time of 4am. Except when I sneeze or cough I hardly have any spill of urine; when I can anticipate these I can still keep check on it. I go out wearing my regular underpants without pad. Until my return home after the day’s business I do not go to the toilet to void more frequently than ordinary.
Even before surgery I used to void with reasonably good (jet) stream. However, I realize that it now takes me shorter time to completely empty my bladder (with ease). This implies that before the surgery my urine outflow must have been partially compromised even as ultrasound examination showed only small (acceptable) post-voiding residual urine. This was most likely due to the tortuous course of the urethra within the enlarged prostate.
Erectile Function: I am satisfied with the surprising return of the degree of this function within these seven months of the surgery especially in consideration of what I had read of the guarded prognosis on erectile dysfunction post operatively in the initial months.
Prostate Specific Antigen (PSA): the level of this antigen in the body is taken as a diagnostic marker for the risk of prostate cancer and, after prostatectomy, serial levels are used to monitor the prognosis. Before my operation, the first indicator to the diagnosis of cancer, my level was about 3½ times the expected highest normal level. It was usually expected that within six to eight weeks after prostatectomy the level should fall below 0.20ng/mL.
Below were the serial levels of my PSA:
• March 31th (pre-op): 16.85ng/mL
• May 12th (1½ months post op): 0.071ng/mL
• August 12th (4½months post-op): 0.02ng/mL
• October 13th (6½months post-op): ˂ 0.01ng/mL
These results are interpreted to imply successful removal of the prostate/cancer tissue.

Dr. Gagan Gautam: I am a fellow of, trainer/teacher and examiner in, two regional postgraduate medical colleges abroad, each with structured 4year training programmes. Most of my clinical/academic practice at home and abroad, since my medical graduation in 1978, has been in teaching and specialist tertiary hospitals. I have had the opportunity to head a largest state government-owned (1000-bed) hospital. I have also been appointed by both these colleges and national medical regulatory council to assess and accredit hospitals for postgraduate training across the country. I am therefore in good position to recognise a good hospital and to identify exceptionally talented doctors.
Dr. Gautam is a good doctor, an excellent clinician and a fine surgeon. He gave me good impression of himself from the very moment I first met him in his office on Saturday 28th February. In the course of his interviewing me, my wife and I sat across his desk. He took detailed history of my condition and made careful, thorough and relevant examination of me in a basic and professional manner. After the clinic examination he reviewed the laboratory investigation I had in Hyderabad. He then summarized his evaluation of, and opinion on, my case in a lucid and unassuming manner. He described the disease, its risks, modes of treatment and prognosis as was specifically relevant to me. He left open the choice of options of the treatment to me. In the course of the discussion, he made direct eye contact with us. I observed his good knowledge of the issues on the disease and his confidence in his competence to deal with its management. I also observed his calmness and composure. He moved his hands only when necessary and his fingers showed no tremors – features of a good surgeon. His humility as a doctor and respect for his patient and colleague (me) were obvious. We were satisfied with him and by the time we concluded the consultation we believed that we made the right choice of the surgeon I needed.
My second visit to his office was a day prior to my admission for the operation. He reviewed the MRI films and report done in my Hyderabad hospital. He re-examined me again and then made and explained his plan and extent of the surgery he will do for me. Even though the procedure for the operation is fairly standardized, the plan he prepared for me was customized to my condition. He was to remove all the prostate en-bloc including the regional lymph tissue while carefully sparing and preserving the nerves that regulate for bladder sphincter control and conserve erectile function. This tight-roped plan is aimed at removing (all or as much of as is possible and feasible) the cancer tissue leading to cure and ensuring good quality; the universal goals of the treatment are, first, to cure the patient (i.e., the prostate cancer is removed completely) and, secondly, to help the patient maintain urinary control (or continence, the absence of urinary leakage), and erectile function.
He performed my operation very well and successfully. My family and I appreciate the precision with which he did this. The serial level of my PSA over the past seven months is testimony to the success of the procedure. It is hoped that this marker will remain undetectable over time indicative of my cure. The overall quality of my life after the operation is beyond my expectation. I have been in close contact with him and he has remained consistent in his care and humility. I shall live the rest of my life appreciating how the operation he performed has turned around my life after the dreadful diagnosis. Medanta hospital is lucky to have him; he is a great asset.
I will not hesitate to recommend him to any patient on personal and professional grounds.

Sincerely,
Dr. B.A.U

Prostate cancer treatment in India – A personal experience..

Making a decision regarding the best treatment option for prostate cancer is a difficult task. Every individual with this disease is unique and the ideal treatment for one may not be so for another. However, it does help to learn about other people’s experiences so that one can get to know the expected outcomes of treatment by any particular technique or technology…

Here is a real life account of a gentleman who underwent robotic surgery for prostate cancer in my care. I am grateful to his daughter (who has penned this down) for sharing the intricacies of the decision making process…something that will strike a chord with so many gentlemen and their loved ones who happen to be in the same situation as this family was just a few months ago…

Posting real life experience of my father, a Prostate Cancer patient who under went RARP under the able hands of Dr. Gagan. [Posting from my Dad’s account]

===========================================
“Cancer” the word itself strikes fear. We hear it happening all around and somehow think we and our near and dear ones are impervious to it.

….and then it hits you or a family member out of nowhere. In our case my father who had just turned 60 few months back was diagnosed with Prostate Cancer in Jan 2014. No symptoms, no health issues just underwent routine health checkup and he was diagnosed with elevated PSA of 24. A rectal biopsy followed which confirmed the cancer with a Gleason Score of 3+4.

Our search for a doctor along with state of art medical facilities led us to Dr. Gagan Gautam at Medanta. At the time we were evaluating Surgery vs. Cyberknife (a focused radiation based approach where prostrate is not removed). We first fixed an appointment with Dr. Gautam and four of us literally spent close to 2 hours with him asking him questions and discussing the whole thing. The patience, grace and humbleness with which he attended to us and assuaged all our fears was really amazing. My Father (actually the whole family) was completely sold on the idea that he should be our doctor and that if surgery is to be done then he is the doctor who should do it.

We shelved our Cyberknife plans and decided to undergo simple and effective RARP surgery through Dr. Gagan. On the appointed day my Dad was taken in for surgery around 7 am and was wheeled back to his room by 3:30 pm. We spent a total of 3 nights in hospital and were home just around lunch time on day 4. My dad had his catheter removed in exactly a week’s time. His first month PSA was less than .02 which indicated the disease was controlled via the operation. 3 months down the road he does not use pads; his urine control is good, enjoys playing with his grandson and drives himself 25km one way to his work. I don’t think we could have asked for anything more. All thanks to Dr. Gagan Gautam.

PS: 
We decided on RARP because it was the latest treatment, less painful (only 5 holes ), has been in practice for close to a decade, recovery after surgery was fastest and chances of my dad having normal life like before were the best. Plus we did not want to keep the infected organ inside the body considering the age of my father, hence Cyberknife was a ruled out.

Cancer is a complicated disease and my father did have some lymph node spread as shown by the final biopsy which is done on the removed organ and tissue, thankfully the margins were clear. Also, the staging of cancer tends to change what started as 3+4 Gleason score for us was finally a 4 +4 after the final biopsy (cancer staging changed as well). In course of cancer treatment there will be good days, bad days and even more bad days, I think best we can do is to keep having faith and positivity. After God’s will, I attribute my Dad getting well to not only a highly skilled doctor, but also his own resolve and will to get better.

Good Luck!

To read the original post, please visit http://www.facebook.com/roboticsurgerydelhi/posts/635216833226179

Dr. Gagan Gautam is the head of robotic surgery and urologic oncology at Max Institute of Cancer Care, New Delhi, India. He is India’s leading expert in robotic surgery for prostate cancer and is closely involved in the counselling and management of patients with this disease. To know more about him, please click here or visit his website, http://www.roboticsurgerydelhi.com

To seek an appointment or to contact Dr. Gautam, please click here

To read his other blogs on prostate cancer treatment please click on the links below:

What is the best prostate cancer treatment in India?

Robotic surgery for prostate cancer in India – A video demonstration

Cost of prostate cancer treatment in India

Watchful waiting and active surveillance for prostate cancer

Recovery after robotic surgery for prostate cancer – What to expect?

 

 

Recovery after robotic surgery for prostate cancer – What to expect?

‘Is this a big operation?’ ‘How much time will it take for me to recover completely?’ ‘Will it be painful?’ ‘How many days will I have to stay in the hospital after the surgery?’ ‘Will I be able to climb stairs after I am discharged?’ ‘When can I drive? Go for a walk….?’

These are some very practical questions that I am asked almost everyday during my initial counselNurse at Patient Cart da Vinci Siling sessions with gentlemen who have been diagnosed with prostate cancer and are considering robotic prostatectomy (robotic surgery for prostate cancer). Fortunately, the answers to these common questions are almost always better than what they expect to hear!

Robotic surgery has had such a positive impact on postoperative recovery that it is sometimes hard to believe that it still is ….and will always remain…. a major cancer operation.

When I talk to my patients about this, I just tell them the sequence of events that they are likely to go through before, during and after the surgery. I tell them that there is a 95% chance that they will be able to stick to this pathway. Roughly, a 5% chance does exist, for having some problems or complications during the recovery phase. However, the vast majority of these can be managed effectively, albeit, with extra medications or procedures and hospital stay.

What follows is a step by step description of what to expect after robotic surgery for prostate cancer:

Step 1: Admission

You will be admitted to the hospital the evening prior to the date of surgery. In some circumstances you may be asked to come in the same day early in the morning. Before admission, all the relevant investigations are reviewed and a clearance for surgery is taken from the anesthesiologists. This is called the pre-anesthesia check up or PAC. At this time, if necessary, further advice and clearance may be sought from other specialists like cardiology, endocrinology etc. This is to ensure that all potential risk factors are assessed and mitigated prior to the surgery. This is done with the sole intention of keeping you safe during and after surgery. The night before the surgery you will be provided a normal dinner and some medications to help you have a relaxing sleep before the day of the surgery. You will be asked not to eat or drink anything after midnight and will be requested to sign the consent form for the operation.

Step 2: The operation

You will be moved to the preoperative holding area about an hour prior to the time of surgery. Here you will receive antibiotics to decrease chances of infection and will be reviewed by anesthesiologists. You will then be moved to the main operating room and anesthesia will be administered. Robotic prostate cancer surgery, on an average, takes about 3-4 hours to complete.

Step 3: After the surgery (Postop day 0)

After surgery, your surgeon will meet your next of kin and provide them with information about your surgery and expected recovery. You will be able to meet your loved ones in the post operative recovery room after 1 or 2 hours when you have recovered from the effects of anesthesia. Thereafter, you will be moved to your room. You will be able to have a full liquid diet starting 4 hours after the completion of your operation, although some fluids will also be given intravenously for support. You will be encouraged to move all your limbs and do deep breathing exercises. You would be expected to be reasonably comfortable with the help of painkillers that would be administered to you. At this time you would have a urinary tube and a thin abdominal drain to remove fluids from the body.

Step 4: The day after surgery (Postop day 1)

On the day after the operation, you will be served a normal diet for breakfast and intravenous fluids will be discontinued. You will be encouraged to walk about outside your room for a total of 60 minutes during the day, in splits of about 10 minutes each. The abdominal drain will be removed and medications tapered down. Deep breathing exercises (incentive spirometry) and steam inhalation are very important components of your ‘home work’ on this day. This keeps your lungs healthy and prevents infection. You should be quite comfortable with the help of medications.

Step 5: The next day (Postop day 2)

This is the day you go home! You will be relatively pain free such that you can manage easily on oral medications, without the need for any injections. Your confidence in moving about and doing all your daily activities should be back. You can take regular meals, travel in a car, go for a walk and climb stairs. You can also take a shower on this day. You will be discharged with clear instructions on how to manage the urinary tube, which would be removed after 1 week. You will be prescribed some medications to ease your visit to the washroom and to keep you comfortable. Although you would likely have passed some wind by now, passage of stools may take another day or two in the course of a normal recovery.

Step 6: A week later 

You will be asked to come into the hospital and stay there for 3 – 4 hours in the daycare ward. Here your urinary tube (catheter) will be removed. You will be taught pelvic floor exercises (Kegel exercises) to promote early recovery of full urinary control. You will be advised on the proper use of continence pads, water intake etc. and sent home on the same day after you have comfortably passed urine a few times. If the pathology (biopsy) report from the surgery is available by that day, your doctor will discuss the findings with you. After this time, you should be well on your way to a full recovery. You can rejoin your work in about 2 -3 weeks. Most men are comfortable enough to start driving around the same time.

Step 7: A month later 

You will likely have fully recovered by now, except that you may be needing a couple of pads to control leakage. Even this is likely to rapidly improve in the coming few weeks. You should get your first PSA test 1 month after the day of your surgery. This will give you and your doctor an excellent idea about the control of the disease and the chances of requiring further treatment, if any. You will need to be in regular follow up with your doctor to ensure that you remain trouble free. Initially it will be once every 3 months. As the years go by, you are likely to require a visit to the clinic only once in a year.

I hope that you found this blog useful. I wish you a speedy recovery!

 

Dr. Gagan Gautam is the head of robotic surgery for prostate, kidney and urinary bladder cancer at Max Institute of Cancer Care, New Delhi, India. Besides being one of the leading specialists for prostate cancer in India, he is also an expert in nerve sparing robotic prostate cancer surgery, which has been shown to result in a faster recovery of urinary control and potency after prostate operation. To know more about him, please click here or visit his website http://www.roboticsurgerydelhi.com.

To read a patient’s first hand account on the experience of undergoing robotic prostate surgery, please click here.

To contact Dr. Gautam or to seek an appointment, please click here.

To view his video on robotic prostate cancer surgery, please click here.

To read his blog on the cost of prostate cancer treatment in India, please click here.

To read his blog on robotic prostatectomy, please click here.

To read his blog on watchful waiting and active surveillance for prostate cancer, please click here. 

Watchful waiting and Active surveillance for prostate cancer

Contrary to what a lot of people believe, prostate cancer treatment options do not start and end with surgery, radiation or hormone therapy. There are two other treatment options for prostate cancer that need to be discussed and evaluated in almost every newly diagnosed gentleman with this disease. And these are – Watchful waiting and Active surveillance.

Watchful waiting implies withholding active treatment for prostate cancer (surgery, radiation or hormone therapy) in men with advanced age or multiple medical problems till they develop significant symptoms from the disease. It is considered in men with early prostate cancer, who have a limited life expectancy of less than 5 to 10 years and have not yet developed significant symptoms from their disease. It is based on the premise that a significant proportion of men with prostate cancer have slow growing disease and hence will not be affected by it in their expected lifetime. It is very important to note that AGE should not be the sole criterion for applying watchful waiting in patients. I have come across many patients even in their late 70s who enjoy excellent health and have a life expectancy of at least 10 to 15 years and more. These are the patients who are very likely to benefit from active treatment for prostate cancer with surgery or radiation.

Active surveillance, on the other hand, is a treatment option for very early stage of prostate cancer which is expected to be localised within the prostate and has not spread beyond it. It can be applied to men with less aggressive types of this disease and can be recommended as an alternative to immediate treatment with radiation or surgery. For active surveillance to be considered, ALL of the following conditions should me met in the evaluation of the patient:

  • PSA should be less than 10 ng/ml
  • Gleason score in the biopsy should be 3+3 = 6; Men with Gleason 7 or above prostate cancer are not good candidates for active surveillance in most circumstances
  • In the biopsy report, not more than 2 cores should be positive for prostate cancer
  • There should not be an involvement of more than 50% of any core with prostate cancer
  • Clinical stage should be T2a or less (This is determined by your doctor on physical examination of the prostate)

If all the above criteria are met, a serious thought should be given to proceeding with active surveillance and withholding immediate treatment for prostate cancer. Active surveillance involves regular physical examination and PSA tests every 3 months, and a prostate biopsy repeated every year to ensure that the cancer is not becoming more aggressive. In case it is found that the cancer is increasing in volume or aggressiveness, immediate treatment is indicated. It has been found that by following this strategy, up to 70% of patients fulfilling the above criteria can safely avoid surgery, radiation or hormone therapy for prolonged periods of time with attendant benefits in terms of improved quality of life and decreased complications.

In summary, it is important to have a discussion with your doctor about all the treatment options for prostate cancer including active surveillance and watchful waiting. It is also a good idea to seek a second opinion from another source to increase your knowledge and reach an appropriate decision for individualizing treatment for prostate cancer depending on the person’s medical conditions, disease status and preferences.

This article has been written by Dr. Gagan Gautam, Head of Urologic Oncology & Robotic Surgery at Max Institute of Cancer Care, New Delhi, India. Besides being India’s leading robotic surgery expert  for prostate cancer, Dr. Gautam is also closely involved in the counselling and individualised care of men afflicted with this disease. His major focus is directed towards helping men in selecting and receiving the best treatment option for prostate cancer based on their personal medical conditions and preferences.

View Dr. Gautam’s profile here

If you are seeking an appointment, please click here

To read about robotic surgery for prostate cancer, please click here

To read about recovery after robotic surgery, please click here

To read a patient’s first hand account on the experience of undergoing robotic prostate surgery, please click here

To see a video of robotic surgery for prostate cancer, please click here

To read about the cost of prostate cancer treatment in India, please click here  

Cost of prostate cancer treatment in India

Being told by a doctor that you have been diagnosed with prostate cancer is probably one of the most traumatic experiences that anyone can have. The road ahead becomes uncertain and every step seems tricky and arduous. There is little doubt that prostate cancer extracts a psychological cost from the person it afflicts and also from his near and dear ones. This impact can be lessened by a compassionate and confident healthcare provider and perhaps more so, by caring and understanding family members.

The next step ideally involves an informative exchange of information amongst all stakeholders to ascertain a coherent plan of treatment. One of the major realities that one has to face in this situation is the cost of prostate cancer treatment, specially since this financial burden is often unexpected and unplanned for in a country like India, where the vast majority of population does not have medical insurance. What follows are a few important pieces of information about the expected cost of prostate cancer treatment in India, which fortunately, is still way below that seen in most parts of the world.

I shall be covering three established prostate cancer treatment options – Surgery, Radiation therapy and Hormone therapy. Other treatment options like HIFU, Cryotherapy and Cyberknife cannot be routinely recommended for the treatment of prostate cancer in India currently, since they are in an early phase of adoption with little information available about their long term outcomes and complications. Moreover, the discussion on how to choose the right treatment for prostate cancer is beyond the scope of this blog and will be addressed in another post.

Hormone therapy: Hormone therapy or Androgen Deprivation Therapy (ADT) as it is called in medical terminology implies the use of injections to suppress the level of Testosterone (male hormone) in the body to near – zero levels. This acts to decrease the growth and spread of prostate cancer for a duration of time ranging from a few months to a few years. While it is the mainstay of treatment for prostate cancer which has spread to other parts of the body (stage 4 or metastatic cancer), it is NOT recommended as the ONLY treatment for most cases of prostate cancer which is limited to the prostate region (localized prostate cancer) since it does not cure the disease but only controls it for some time. Invariably, with time the cancer starts becoming resistant to hormone therapy and starts spreading after that. The cost of hormone therapy ranges from 16,000 – 30,000 INR for an injection, which is to be given every 3 months. Some of the brands available in India are Zoladex®, Lucrin®, Eligard® and Pamorelin®.

Important points to discuss with your doctor:

  • A more expensive injection is not necessarily more effective. One should go for a cheaper, yet trusted brand to ensure that adequate effectiveness is achieved without excessive financial burden.
  • An injection imported from outside India is not necessarily more effective than an indigenous version.
  • You can often get these injections at up to 20% less than the MRP if you directly purchase it from the company representative. Your doctor should be able to provide you with the contact details.
  • Be careful about the storage requirements of the injection. Some of these require to be kept refrigerated during transportation and storage to maintain effectiveness.
  • A longer acting version (6 months) may be a cheaper option than two 3 monthly injections.
  • Removal of testes (surgical castration or bilateral orchidectomy) is a less expensive alternative to injections in the long run but is associated with an adverse psychological impact due to changes related to body image.

Radiation therapy: Radiation treatment is an alternative to surgery in patients who have prostate cancer that is localized to the area of the prostate and has not spread to other parts of the body. In most circumstances, radiation therapy needs to be combined with hormone therapy for 2 to 3 years in order for it to come close to the effectiveness and cure rates of surgery alone. Image Guided Radiation Therapy (IGRT) is currently the standard benchmark for the radiation treatment of prostate cancer in India. It is delivered over 6 to 8 weeks with 5 daily sessions in a week. The cost ranges from 2.0 – 2.5 lacs (200,000 to 250,000 INR) in most private institutions in the country with advanced radiation facilities. The addition of hormone therapy to this treatment increases the cost by about 65,000 to 1,20,000 INR per year bringing the total cost of treatment to about 4.0 to 6.0 lacs (400,000 – 600,000 INR), albeit spread over 2 to 3 years.

Brachytherapy, which is a form of radiation for early prostate cancer, involves the placement of radioactive ‘seeds’ in the prostate under the guidance of an ultrasound machine. These seeds need to be imported from abroad and the treatment can cost anywhere from 5.0 – 8.0 lacs (500,000 – 800,000 INR) depending on the number of seeds required and the prevailing currency exchange rate. It is one of the more expensive options for treatment, especially if it is combined with hormone therapy.

Surgery: The complete removal of the prostate, along with the adjoining structures (seminal vesicles, lymph nodes etc.) done with an intention to cure a patient of prostate cancer is called Radical prostatectomy. It can be performed in an open conventional manner or with laparoscopy or robotic surgery. Robotic surgery for prostate cancer is now available in the country and is currently considered by many to be the best treatment for prostate cancer in India. It has the advantages of a faster recovery, greater precision and lesser complications as compared to conventional surgery for prostate cancer. The cost of robotic prostate cancer surgery in India is usually in the range of 3.5 to 4.0 lacs (350,000 – 400,000). While this cost is about 30% more than that of conventional surgery, some of this gets offset by the earlier discharge from hospital, less medication use and decreased chances of additional treatment due to decreased complication rates with robotic surgery.

In summary, while the ideal treatment for prostate cancer in a particular patient differs from individual to individual based on their age, overall health status and stage of the disease, cost considerations do play a major role in the decision making process. All these implications should be discussed with your doctor in order to arrive at the most suitable decision.

This article has been written by Dr. Gagan Gautam, who is the head of urological cancer surgery and robotic surgery at Max Institute of Cancer Care, New Delhi, India. He is fellowship trained in robotic cancer surgery from the University of Chicago Medical Center, USA and is currently the leading robotic surgeon for prostate, kidney and bladder cancer in India. His institution, Max Hospitals, Saket, New Delhi is an 800 bedded tertiary hospital located just 20 min away from the International airport. It is an NABH accredited institution and is recognised as one of the best hospitals for prostate cancer treatment in India. It is equipped with state of the art diagnostic and therapeutic infrastructure including the Da Vinci Xi HD robotic surgical system, which is used by Dr. Gautam to perform robotic surgery on his patients who travel from all over India and other parts of the world.   

 To know more about his work, please visit www.roboticsurgerydelhi.com

To view Dr. Gautam’s profile, please click here

 If you would like to submit a query or seek an appointment with Dr. Gautam, please click here

 To know more about robotic surgery for prostate cancer, please click here

 To watch a video demonstration of robotic prostate cancer surgery, please click here

To read about the expected course of recovery after robotic surgery, please click here

To read a patient’s first hand account on the experience of undergoing robotic prostate surgery, please click here

To read about active surveillance and watchful waiting for prostate cancer, please click here

Robotic surgery for prostate cancer in India – A video demonstration

Dr Gagan Gautam, head of robotic surgery and urologic cancer surgery at Max Institute of Cancer Care, New Delhi, India, demonstrates the tips and tricks of robotic surgery for prostate cancer. A systematic and simplified approach decreases complications and enhances the recovery after robotic surgery for prostate cancer. By reducing the duration of surgery and stay in the hospital, it also serves to decrease the cost of prostate cancer treatment in India which offsets the cost of robotic surgery to a large extent.

Max Hospital, Saket is one of the best hospitals for prostate cancer treatment in India and provides specialist services for the treatment for all stages of prostate cancer. Robotic surgery for prostate cancer is a state of the art technique which improves recovery, decreases complications and provides excellent survival benefits to patients with stages 1 to 3 prostate cancer.

To know more about his work, please visit http://www.roboticsurgerydelhi.com

To view Dr. Gautam’s profile, please click here

If you would like to seek an appointment with Dr. Gautam, please click here

To know more about robotic prostate cancer surgery at Max Hospital, New Delhi, please click here

To read about the expected recovery after this surgery, please click here.

To read a patient’s first hand account on the experience of undergoing robotic prostate surgery, please click here

To read about the cost of prostate cancer treatment in India, please click here

To read about active surveillance and watchful waiting for prostate cancer, please click here