Mindful meditation helps men cope with active surveillance anxiety in prostate cancer

According to a recently published pilot study from the Northwestern University Feinberg School of Medicine, men with prostate cancer who are under close medical surveillance reported significantly greater resilience and less anxiety over time after receiving an intervention of mindfulness meditation.

Even when there is no sign of tumor progression, the anxiety and uncertainty that men who choose active surveillance experience when diagnosed with prostate cancer causes one in four to receive definitive therapies within one to three years.

One researcher focusing on the emotional stress of active surveillance and how mindfulness training helps alleviate the anxiety is Health psychologist David Victorson, the principal investigator of the study and an associate professor of medical social sciences at Northwestern University Feinberg School of Medicine.

Dating back some 2,500 years, mindfulness meditation is a well-known contemplative awareness practice. This form of meditation is designed to develop the skill of paying attention to patients’ inner and outer experiences with acceptance, patience and compassion.

Victorson said, “It’s very understandable that some men will feel concerned with the knowledge that they indeed have prostate cancer but are asked to NOT do anything to remove it. For many men this can create a great deal of inner turmoil. This turmoil can build up over time and eventually lead to men to seek surgical intervention when it may not ultimately be necessary.”

Now partnering with other academic medical institutions, Victorson and his Northwestern team are conducting a five-year multi-site controlled trial where men and their spouses will be randomized to eight weeks of intensive mindfulness meditation training or an eight-week control group.

According to Mr. Victorson, “I believe we have an opportunity to investigate and equip men with additional tools above and beyond surgical intervention that can help them manage cancer-related uncertainty intolerance.”

Radioactive imaging agent Axumin is approved by FDA for use in recurrent prostate cancer

The radioactive imaging agent, fluciclovine F18 (Axumin), was approved by the FDA for use in positron emission tomography (PET) scans in men with suspected recurrence of prostate cancer whose prostate-specific antigen (PSA) levels rise following prior treatment.

Clinicians now hope to be able to better determine the location of the recurrence in the prostate, as this defines optimal choice of therapy. There is a low diagnostic accuracy with standard imaging tests used to determine identification of sites of recurrence, which is the reason why more accurate techniques are needed.

“When the PSA is at very low levels, imaging tests are not able to determine the location of the recurrent prostate cancer,” said Libero Marzella, MD, PhD, of the FDA’s Center for Drug Evaluation and Research and director of the Division of Medical Imaging Products, in a statement. “Axumin is shown to provide another accurate imaging approach for these patients.”

Experts estimate that up to one-third of patients who receive curative treatment after a diagnosis of primary prostate cancer will experience recurrence within 10 to 15 years following primary treatment.

PET scans are a well-established non-invasive imaging technique that uses the radiotracer [18F]flouro 2-deoxyglucose (FDG) for many tumor types. However, this agent is not widely used in imaging prostate cancer because of poor uptake and high urinary excretion limiting imaging quality.

The other PET radiotracer that is available, C11 choline, has been shown to improve detection in men with biochemical recurrent prostate cancer, but its 20-minute half-life limits use to medical centers with specialized on-site C11 production capability.

Axumin is a synthetic amino acid that is actively transported into prostate cancer cells by amino acid transporters. It is not metabolized, nor is it incorporated into newly synthesized proteins. Imaging studies have demonstrated that Axumin is preferentially taken up into prostate cancer compared with surrounding normal tissue and visualization is not obscured by bladder uptake.

The search continues for foods/substances that may help prevent prostate cancer

Across the nation researchers continue to look for foods (or the substances within them) that can help lower prostate cancer risk. To date scientists have found that some of the substances in tomatoes (lycopenes) and soybeans (isoflavones) might help prevent prostate cancer. New studies are now taking a closer look at the possible effects of these compounds.

Some scientists are also trying to develop related compounds that are even more potent and might be used as dietary supplements. Most of the current research suggests that a balanced diet including these foods as well as other fruits and vegetables is probably more beneficial than taking these substances as dietary supplements.

Vitamin D may prove to be an important in preventative. Some studies have found that men with high levels of vitamin D seem to have a lower risk of developing the more lethal forms of prostate cancer. However, studies have not proved conclusively that vitamin D protects against prostate cancer.

People often assume that vitamins and other natural substances are completely safe to take, but recent research has shown that high doses of some may be harmful, including those in supplements marketed specifically for prostate cancer. For example, one study found that men who take more than 7 multivitamin tablets per week may have an increased risk of developing advanced prostate cancer. Another study showed a higher risk of prostate cancer in men who had high blood levels of omega-3 fatty acids. Fish oil capsules, which some people take to help with their heart, contain large amounts of omega-3 fatty acids.

Some research has suggested that men who take a daily aspirin for a long time might have a lower risk of getting and dying from prostate cancer. Still, more research is needed to confirm this, and to confirm that any benefit outweighs potential risks, such as bleeding.

Scientists have also tested certain hormonal medicines called 5-alpha reductase inhibitors as a way of reducing prostate cancer risk. Studies like all of these mentioned here could prove to be very beneficial for men in the future.

Dr. Christopher Knoedler and Dr. Robert Gaertner visit Intuitive Surgical® in Sunnyvale California to give their input on a new robot in development.

As recognized and respected leaders in the field of da Vinci® Robotic Surgery for prostate cancer, Dr. Christopher Knoedler and Dr. Robert Gaertner stay on top of the latest developments in their field. Recently they flew out to the headquarters of Intuitive Surgical in Sunnyvale, California to be introduced to a new robotic surgery prototype.

The doctors were asked to visit the headquarters of Intuitive Surgical to see the newest robot that is currently in development. They engaged with the engineers on a back and forth with their own ideas and suggestions on the new (were asked to help engineers trouble-shoot and refine this new) high tech piece of surgical equipment.

Currently when performing robotic prostate surgery, Drs. Knoedler and Gaertner create six small incisions. The new robot would reduce the number of sites that the instruments need to pass through from six to either two or three. When surgeries become less invasive it benefits patients with quicker recovery times.

The new version of the robot also allows the surgeons easy visual access to all four quadrants of the abdomen and allows them to operate in all four areas as well.

Dr. Knoedler and Dr. Gaertner are pioneers in the utilization of da Vinci Robotic Surgery and have trained hundreds of physicians in the use of this revolutionary technology. They were among the first doctors in the region to routinely use this robotic surgery system and have led the way in using it to improve the extremely challenging surgical procedure to remove the prostate gland (Prostatectomy). To date this team has performed more than 3,000 robotic surgeries.

In 1999 Intuitive Surgical introduced the da Vinci® Surgical System and today they are the global leaders in robotic-assisted minimally invasive surgery. This technology features a 3D high definition vision system for a clean and magnified view inside the patient’s body. The instruments used bend and rotate far greater than the human wrist. The surgeon controls the system which translates hand movements into smaller, more precise movements of tiny instruments inside the patient’s body. This technology allows surgeons to perform complex procedures through a few small openings.

A recent study finds that there are large cost savings and many economic benefits associated with robotic-assisted laparoscopic prostatectomy.

A study titled “A Multidimensional Analysis of Prostate Surgery Costs in the United States: Robotic-Assisted versus Retropubic Radical Prostatectomy,” was recently published in Value in Health.

In the United States, prostate cancer is the most commonly diagnosed cancer among men and accounts for 27 percent of all cancer diagnoses. With the estimated direct costs of cancer diagnoses totaling over $125 billion, and more than 80 percent of prostate cancer surgeries done by robotic-assisted Laparoscopic Prostatectomy (RALP), the financial impact of prostatectomies on the healthcare economy is enormous.

In this study, researchers examined the financial impact of RALP versus Retropubic Radical Prostatectomy (RRP) for each radical prostatectomy by performing a systematic peer-reviewed literature search for clinical outcomes and by creating cost models for three different ways to assess the costs: hospital costs, payers’ expenditure and society’s expenses.

The results of the study revealed cost savings for hospitals, payers and society, when RALP surgeries are performed with da Vinci® Surgical Systems compared to RRP surgeries. Statistical analyses showed a clear cost savings with RALP for payers (99%) and society (83%) and for the individual hospital 38 to 79 percent of the time.3 While previous research has been limited to a single cost model, often direct hospital and robotic system costs, this study included multiple ways to assess the costs, reporting cost savings of $1,451 per patient for the payer and $1,202 per patient in societal savings.

“It is clear that the adoption of robotic-assisted Laparoscopic Prostatectomy eases the financial burden of prostate cancer on our healthcare system,” said Dr. Ashutosh Tewari, Professor and System Chair of Urology at Mount Sinai Health System. “As the healthcare providers strive to improve both patient outcomes and achieve greater value, this data shows that technologies like the da Vinci Surgical System can simultaneously deliver cost-effective treatment and care that can make surgery easier on patients.”

The study also calculated the costs of the robotic system in two different ways – as hospital overhead including hospital costs, inpatient bed, and inpatient days (resulting in $1,094 in hospital savings) and using the annual volume of robotic procedures ($341 in extra costs). This demonstrates that potentially higher robotic surgical expenditures are counteracted by cost savings due to better clinical outcomes, including reduced complications , improved functional outcomes (e.g. continence and sexual function), and a faster recovery.

“This study further demonstrates that hospital administrators need to look beyond visible operating room costs when analyzing the robotic-assisted surgery value proposition,” said Myriam Curet, M.D., Senior Vice President, Chief Medical Officer at Intuitive Surgical, Inc. “The ability of robotic-assisted surgery to reduce complications and shorten hospital stays, undoubtedly leads to greater value for patients and healthcare providers.”

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Compounds with the potential of fighting prostate cancer have been identified by scientists

Eleven compounds that have the potential to significantly improve the treatment and diagnosis of prostate cancer have recently been identified by a group of scientists, who say the compounds could be used in the future to develop more effective and targeted drugs. Currently prostate cancer is similar to most other types of cancer in that it is fought using drugs that damage healthy cells as well as cancerous ones.

Researchers in four institutions across Russia looked at a cancer marker called the prostate specific membrane antigen (PSMA), to determine whether specific types of molecules can be more selective in the type of cells they target. Prostate cancer tissues have 10 times the level of PSMA proteins. These PSMAs can be a highly effective way of spotting secondary tumors that could be present after the removal of the initial tumor.

Once the PSMA was identified, the scientists evaluated three different groups of molecules capable of binding to it. After a detailed analysis, the team identified ligands as having the best potential to offer a targeted approach to prostate cancer, and the team was able to build on previous work done in this area. The scientists highlighted a set of eleven promising cancer-fighting compounds based on a substance called urea. Urea is a part of urine and has long been of interest to cancer specialists because of the way it can be modified to block DNA replication and thus the division of cancer cells.

The team reported that they have discovered eleven substances that have demonstrated the characteristics necessary. These substances are now being tested in clinical trials and according to the scientists, the results so far are encouraging.

According to the US National Cancer Institute, prostate cancer is the second most common cancer in men after skin cancer, and despite the fact that most men don’t die from the disease, it’s still the second most common cause of cancer-related death in the US after lung cancer.

The study referred to in this article has been published in the Journal of Drug Targeting.

PSA Testing Differs Among Primary Care Doctors, Urologists

When it comes to prostate-specific antigen (PSA) testing, a new study reports that urologists are far more likely than primary care doctors to do perform these prostate cancer screenings.

The test is simple. blood sample is taken and sent to a laboratory to check for levels of a protein produced by cells of the prostate gland.

After the U.S. Preventative Services Task force recommended against routinely screening all men in 2011, PSA testing declined overall. New research shows that the decline in number of men tested was sharper among primary care doctors than urologists.

PSA testing decreased from 36 percent to 16 percent at primary care physician visits between 2010 and 2012. Researchers found that the decline in PSA testing was much smaller in urologist visits, dropping from 39 percent to 34 percent.

This discrepancy may reflect different perceptions of the benefits of the test among doctors, according to a study published online in JAMA Internal Medicine.

This much larger decline in PSA testing among primary care doctors could also stem from conflicting prostate cancer screening guidelines and differences in patients’ demographics or expectations, the study authors suggested.

The research team used the National Ambulatory Medical Care Survey to examine PSA testing one year before and one year after the task force recommendations were issued.

The study involved nearly 1,200 preventive office visits made by men aged 50 to 74 who were not diagnosed with cancer or any other prostate condition. Primary care doctors were seen in 1,100 of these visits. The others were examined by a urologist, a doctor who specializes in the urinary tract.

Prostate Cancer Update: 2016

Prostate cancer is the most common non-cutaneous malignancy diagnosed in men. Last year in the U.S. an estimated 240,000 men were diagnosed with the disease, and 29,000 died because of prostate cancer. Approximately one in six men will be diagnosed with prostate cancer in their lifetime.

Over the last five to 10 years we have seen dramatic changes in the way prostate cancers are detected and treated. Traditionally, prostate cancer was detected using PSA testing and digital rectal exam with the primary treatments being surgery and/or radiation. For metastatic disease, patients were treated with hormonal therapy and cytotoxic chemotherapy. In this article we will discuss what’s new in prostate cancer screening, diagnosis, and treatment of localized and metastatic disease.


The PSA (prostate specific antigen) blood test is the most widely used screening test for prostate cancer since it first came into use in 1994. Men who are screened for prostate cancer using PSA are more likely to find their cancers earlier and have a higher chance of cancer cure. It is, however, not a perfect test, and many patients and physicians question its role in prostate cancer screening.

First, a PSA test can give both false­positive and false-negative readings. Men with normal PSA readings may have prostate cancer, a false negative. More commonly, men with high PSA readings do not have cancer, a false positive. Men with high readings but without cancer go through unnecessary prostate biopsies and follow-up testing.

Second, prostate cancer in many men is indolent. PSA screening detects non­lethal as well as lethal cancers. One of the key challenges is differentiating those cancers which can be followed via active surveillance and those potentially aggressive cancers that will lead to significant morbidity and mortality. Most experts agree that not every prostate cancer needs to be treated. A significant trend clinically has been the acceptance by patients that not all cancers need immediate, aggressive treatment.

Controversy regarding PSA testing increased substantially after the U.S. Preventative Services Task Force came out with its position statement in 2010, giving the PSA blood test a “D” rating as a screening tool. Although many urologists and oncologists were critical of the rating, many practitioners at the primary care level drastically changed their discussion with patients and practice patterns regarding PSA testing. Patients also became more critical of the test after heavy publicity of the USPSTF rating.

In 2013, the American Urologic Association established its own guidelines. The AUA does not support the USPSTF position on PSA screening. The AUA recommends the omission of PSA screening for men with a life expectancy less than 10 years or those under 40. For all other men the AUA advocates shared decision­making for men and their physician regarding PSA testing; especially those men between ages 55-70 or those with a strong family history of disease.
Shared decision-making relies heavily on the guidance of a medical practitioner looking out for the best interest of the patient. We would encourage you to review the AUA guidelines at: www.auanet.org/education/guidelines/prostate-cancer-detection.cfm
As urologists we strongly advocate for prostate cancer screening. In 2015 the current standard is the PSA test; in the future we hope a more cancer-specific test will emerge.


The PSA is a basic screening test. It is often a starting point with patients as we discuss whether to perform a prostate biopsy, and, if a cancer is found, whether treatment or surveillance is most appropriate. Here we have also seen advances.

There are new genetic and biomarker studies which have added to our ability to find prostate cancers.
Examples include the PHI (Prostate Health Index) or a 4Kscore- measures 3 or 4 different types of PSA kallikreins in the blood, and the PCA3; a urine test that looks for a protein that is produced by prostate cancer cells. These tests are used to predict risk of high grade cancer prior to a patient having a biopsy. Advances in genetic testing allow us to better determine which cancers should be treated. Examples of this include the Oncotype DX and Prolaris-genetic tests run on a biopsy specimen to help determine if the biopsy sample represents low or higher risk disease.

Recent advances in MRI of the prostate have improved our ability to identify prostate cancers and, in some cases, differentiating indolent from aggressive tumors. Urologists traditionally use trans-rectal ultrasound as a guide during a prostate biopsy, but the ultrasound is a low-resolution image. We now have software that can fuse a fixed MRI image with real time ultra­sonography. The radiologists reading the MRI will draw out specific areas requiring biopsy; the urologist can “fuse” that image with the ultrasound and insure that those specific areas are biopsied. This sequence creates a more targeted biopsy, detecting cancers we may have otherwise missed.

Treatment of Localized Disease

There is an increasing interest in active surveillance for low-grade prostate cancers. Active surveillance is a close monitoring process that typically involves frequent PSA testing and rectal exams, repeat prostate biopsies, and imaging studies such as MRI to try to detect progression of disease. While active surveillance is gaining traction, the gold standard for treatment of prostate cancer remains radical prostatectomy. Over the last decade daVinci robotic radical prostatectomy has emerged as the preferred surgical approach in the overwhelming majority of hospitals and centers of excellence. Robotic prostatectomy has shortened recovery times, decreased blood loss and, in experienced hands, improved outcomes.

Radiation, brachytherapy seed placement, cryotherapy (freezing), and a recently FDA approved treatment, high­intensity focused ultrasound (HIFU), are also options for treatment of localized prostate cancer. Traditionally we treat or remove the entire prostate, even the benign ti ssue.

A different and developing strategy is focal therapy. Using some of the newer technology such as HIFU or cryotherapy we can ablate only the cancerous lesion while leaving the normal prostate intact. While focal therapy is not yet considered standard of care, improving imaging with MRI and other means of identifying the tumor location within the prostate will likely make focal therapy a more common and standard option in the near future.

Treatment of Advanced Disease

Prostate cancer is hormone sensitive and creating castrate levels of testosterone can help control the disease. Androgen deprivation therapy (ADT) uses either surgical castration, medical castration, and/or combined androgen blockade with the use of anti-androgens.

Despite initial tumor response to ADT, most cases will become resistant over time. Historically once the cancer became castrate resistant (CRPC) the only options were cytotoxic chemotherapy. Newer treatments have shown improved survival.

Abiraterone acetate (Zytiga) and Enzalutamide (Xtandi) are second-line inhibitors of androgen activity in the body either by reducing production (Ztytiga) or by androgen receptor blockage (Xtandi). Both are being used commonly by urologists and oncologists for treatment after failure of initial ADT. Both show very good response and extension of survival.

Sipuleucel-T (Provenge) was a first of its kind cancer vaccine. It involves the autologous infusion of patient’s own blood cells after they are exposed to the prostate cancer antigen in a lab. It has been shown to extend overall survival as well.

Radium 223 (Xofigo) is a radioactive agent used to target bone metastases. It is especially useful for men with late stage, painful bony metastatic disease.


The landscape of prostate cancer diagnosis and treatment continues to evolve and improve. We believe this will help the lives of the many men diagnosed with prostate cancer. As urologists who are part of a larger practice, Metro Urology, that focuses on prostate cancer we see the benefit of adopting and employing these new technologies. We are excited about the future of prostate cancer care.

Todd Brandt, MD, has practiced with Metro Urology since 2000, focusing on prostate cancer and men’s health.

Basir Tareen, MD, is a fellowship-trained urologic oncologist. He has practiced with Metro Urology since 2011.

New Research Into The Prevention Of Prostate Cancer

Researchers continue to look for foods (or substances in them) that can help lower prostate cancer risk. Scientists have found some substances in tomatoes (lycopenes) and soybeans (isoflavones) that might help prevent prostate cancer. Studies are now looking at the possible effects of these compounds more closely. Scientists are also trying to develop related compounds that are even more potent and might be used as dietary supplements. So far, most research suggests that a balanced diet including these foods as well as other fruits and vegetables is of greater benefit than taking these substances as dietary supplements.

Some studies have suggested that certain vitamin and mineral supplements (such as vitamin E and selenium) might lower prostate cancer risk. But a large study of this issue, called the Selenium and Vitamin E Cancer Prevention Trial (SELECT), found that neither vitamin E nor selenium supplements lowered prostate cancer risk after daily use for about 5 years. In fact, men taking the vitamin E supplements were later found to have a slightly higher risk of prostate cancer.

Another vitamin that may be important is vitamin D. Some studies have found that men with high levels of vitamin D seem to have a lower risk of developing the more lethal forms of prostate cancer. Overall though, studies have not found that vitamin D protects against prostate cancer.
Many people assume that vitamins and other natural substances cause no harm, but recent research has shown that high doses may be harmful, including those in supplements marketed specifically for prostate cancer. For example, one study found that men who take more than 7 multivitamin tablets per week may have an increased risk of developing advanced prostate cancer. Another study showed a higher risk of prostate cancer in men who had high blood levels of omega-3 fatty acids. Fish oil capsules, which some people take to help with their heart, contain large amounts of omega-3 fatty acids.

Some research has suggested that men who take aspirin daily for a long time might have a lower risk of getting and dying from prostate cancer, but more research is needed to confirm this.
Scientists have also tested certain hormonal medicines called 5-alpha reductase inhibitors as a way of reducing prostate cancer risk.