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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Robotic surgery in India – Challenges and opportunities

There is little doubt that over the past decade, robotic technology has created a mini revolution in surgery. After taking the western world by storm, it is now headed our way, to India. The big question is … are we ready for it?

The scope of robotic surgery in the Indian healthcare scenario seems to be expanding rapidly. Only a few years ago the number of robotic systems in India could be counted off on the fingers of a single hand. However, the number is currently around 25 and is all set to explode in the years to come. It is estimated that over 2500 robotic procedures were performed in India in 2013. However, this is just a small fraction of the number of patients who can benefit from this technology. With rising levels of education and awareness, implementation of cancer screening programs, increasing economic strength, and the availability of modern technology, these numbers are likely to multiply many times over in the coming years.

This technology affords a number of advantages to the surgeon as well as the patient. It is now possible, with robotic technology, to see tissue details in magnified 3-D vision, that were never visualized earlier. Highly miniaturized and dexterous robotic instruments enable the surgeon to perform precise and accurate surgery resulting in excellent outcomes with decreased chances of complications.

However, an under appreciated caveat of this technology is the centralization of major surgical procedures in high volume centers. This is not necessarily a bad thing. Research studies have consistently shown that complex surgical procedures are best performed at tertiary institutions by experienced surgeons dedicated to that particular sub speciality. Not only does this result in optimal surgical outcomes, but also provides opportunities for dedicated follow-up, additional treatments and further research. Robotic technology permits more and more patients to be operated in fewer institutions by a dedicated group of surgeons specialized in the care of these patients. At the same time, robotics has greatly reduced the learning curve of complex surgical procedures, thereby enabling rapid dissemination and assimilation of highly advanced surgical skills by surgeons who are interested in performing robotic surgery.

Every challenge is an opportunity and vice versa. In India, there are certain unique challenges that have to be overcome before robotic surgery becomes widely acceptable. Even if we move beyond the oft cited constraints of cost and prioties in healthcare, availability of trained manpower remains a major issue. Currently, in India, there is a severe deficiency of adequate training facilities for robotic surgery. The establishment of fellowship programs and structured training for entire surgical teams is the need of the hour. Leading robotic programs in India need to take the lead in establishing these training centers. Proctors and preceptors from these Indian institutions need to play a role in helping other surgeons and establishments overcome their learning curve safely and efficiently.

The Da Vinci surgical robot in action

Next generation surgery – The Da Vinci surgical robot in action.

Hopitals and insurance companies need to work together to work out issues regarding financial compensation for robotic surgery. We need to demonstrate definite improvement in patient outcomes, decreased hospitalization and a reduced readmission rate after robotic surgery to encourage insurance companies and government agencies to cover the additional cost of robotic surgery. This can only be achieved by maintaining a robust database for every major procedure done, using the robot.

There is little doubt that India is now ready for a rapid expansion and development of robotic surgery. In fact, due to the combination of a large case mix of complex medical conditions and his/her inherent ability to get comfortable with modern technology, in the times to come, the Indian surgeon may be in a unique position to provide international leadership in certain disciplines of robotic surgery.

[Dr. Gagan Gautam is the Head of Robotic Surgery and Uro Oncology at Max Institute of Cancer Care, New Delhi, India. Though his prime focus is the surgical care of patients with prostate, kidney and urinary bladder cancer, he is also involved in robotic surgery training and counselling and has been pioneering the safe and widespread adoption of robotic surgery in India. He has been invited to a number of national and international workshops and meetings where he has taken lectures and conducted live surgical demonstrations of robotic surgery]

View Dr. Gagan Gautam’s profile or visit his website

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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

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

To read about recovery after robotic surgery, please click here

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