Col. David G. McLeod, M.D.
Chief Urology Service
Walter Reed Army Medical Center
For a hearing on
Prostate Cancer Prevention and Treatment
Special Committee on Aging
United States Senate
September 23, 1997
The opinions and assertions
contained herein are the private views of the author and are not
construed as reflecting the views of the U.S. Army or the Department of Defense.
Mr. Chairman and Members of the Committee:
My name is Colonel David G. McLeod, M.D. I am Chief of Urology at Walter Reed Army Medical Center and Director of the Center for Prostate Disease Research at the Uniformed Service University of the Health Sciences.
The Center for Prostate Disease Research (CPDR) was established in 1991 to manage cooperative research efforts of the Tri-Service Medical Centers. The CPDR is currently funded through the U.S. Army Medical Research and Materiel Command and the Henry M. Jackson Foundation for the Advancement of Military Medicine. Over the years, Congress has provided a total of $23 million for CPDR activities. The Center is currently involved in a variety of activities including the implementation of a multi-center data base to analyze treatment outcomes on prostate cancer patients, the establishment of a clinical research center, and establishment of collaborative epidemiological and basic research on prostate cancer. The Center is rapidly becoming a vital resource for the improved understanding of prostate disease.
I am here today to discuss the treatment of prostate cancer and the role that innovations in treatment are playing in improving patient outcomes.
As Doctor Crawford mentioned in his testimonyprostate cancer is very common among older men. One-in-five men will develop prostate cancer in their lifetime. Most prostate cancer patients will be over 65 when they are diagnosed and will survive 10 or more years with the disease. However, a significant percentage will be diagnosed when they are still relatively young. For most prostate cancer patients, their survival will depend on whether they get early detection or treatment. Many patients will be diagnosed late or to have a rapidly-progressing form of the disease.
The good news about prostate cancer is that when detected early in a low stage and grade, it can be effectively "cured" in 80 to 90 percent of patients through surgery or radiation. This is a remarkable result when you think of how rare it is with cancer that we are able to talk about "cures".
There is even more good news: with the advent of the PSA test, a larger proportion of patients is coming to us at earlier stages of the illness. This detection has helped us provide earlier treatment with a greater rate of success. This year, the Congress extended Medicare coverage to early detection of prostate cancer, effective in the year 2000. You and your colleagues are to be commended on this significant step, because it will
make prostate cancer tests completely available to that large portion of men with the disease who are of Medicare age. I only wish that we could advance the date when Medicare will begin paying for these tests.
There is a portion of patients whose treatment will be effective in eliminating the prostate cancer; however, they will have side-effects from treatment that may affect their quality of lifemostly urinary incontinence or impotence. For these reasons, not all patients diagnosed with prostate cancer will choose definitive treatment. For older patients, with less than 10 years of life expectancy or those with serious health problems, it may be more appropriate to monitor the progress of the disease and withhold surgery or radiation if the disease does not appear to progress rapidly. It is particularly important that patients be given information about their treatment options and participate actively in the decision-making.
While there are complications for some patients, treatment outcomes for prostate cancer are improving dramatically. The advances we are making in forms of treatment are improving the effectiveness of treatment while reducing complications for patients. Earlier detection of the disease and better patient outcomes from early treatment are lessening many of the concerns that were raised in the past about prostate cancer detection and treatment.
I would like to start my discussion of treatment advances by describing how we stage and grade prostate cancer and how this information is used to guide the choice of treatment. Doctor Crawford talked about detectionusing the PSA blood test and the digital rectal exam (DRE). A positive result from the PSA and/or DRE is generally followed by a biopsy where we take samples of tissue from the prostate for the pathologist to examine. There are two important questions we need answered in this process:
Well-differentiated cancers which are still confined to the prostate gland have the greatest chance of successful treatment. A recent study published in the Journal of the American Medical Association, for example, showed that 75 to 97 percent of the patients with organ-confined, well-
differentiated cancer were still alive 10 years after radical prostatectomy1. Cancers that have spread beyond the prostate are much less likely to be eradicated. Cancer that has metastasized to the bone will nearly always be fatal.
Once we know the stage and grade of the cancer, as much as can be determined from our clinical evaluation, we discuss treatment options with the patient and his family. There are four basic treatment choices: surgery, radiation, "watchful waiting," and hormonal therapy.
1. Krongrad A, Lai H, Lai S. "Survival after radical prostatectomy," Journal of the American Medical
In a perfect world, we would limit surgery to cases in which we were sure the cancer was entirely confined to the prostate. Unfortunately, we cannot always be sure of the stage prior to surgery. Occasionally we
discover cancer in surrounding tissue or pelvic lymph nodes when we examine the prostate and nodes after surgery. Significant improvements in diagnosis and staging prior to surgery are helping to reduce the number of prostate cancers that are found to extend outside the prostate. For example, laproscopic surgery can now be used in selected patients to remove the pelvic lymph nodes prior to prostatectomy or radiation to determine whether they contain cancer cells. Surgery can be avoided in patients with evidence of cancer in the lymph nodes.
In recent years, we have made a number of significant strides in treating prostate cancer. I would like to briefly describe these for you and then discuss their importance in improving the chances that treatment will be effective in curing the cancer with minimal side effects.
These treatment advances are encouraging, and offer great hope that we can be quite successful in curing prostate cancer for many patients at some point in the not too distant future. Unfortunately, there are a number of government imposed barriers that may stand in our way. Let me discuss a few of these barriers that I am most concerned about.
I commend the Chairman and Senator Shelby, and appreciate the interest other members of the Committee have shown in having this hearing today. I will be pleased to support any activities this Committee can undertake to help us solve the remaining problems in tackling prostate cancer.