It has been widely reported in the media that Jerry Brown, governor of the state of California, has just completed radiation treatment for early prostate cancer. When I saw him on television recently, he looked fit, alert, and vigorous and bore no apparent adverse effects from his treatment.
Although the details of the governor’s illness have not been released, it seems apparent that his diagnosis was initially made because his PSA (prostate-specific antigen) level was elevated. The controversy surrounding the efficacy of PSA testing in a man 74 years old has been hotly debated, but in this case, the test seems justified.
Governor Brown’s oncologist was quoted as saying that “fortunately, this is early stage localized prostate cancer, which is being treated with a short course of conventional radiotherapy. The prognosis is excellent, and there are not expected to be any significant side effects.” This statement also indicated that the governor was “continuing a full work schedule.”
The only reliable way of diagnosing early-stage localized prostate cancer is with a PSA blood test. The digital rectal exam will almost always pick up a lesion in the prostate at an advanced stage but may not detect the type of lesion diagnosed in the governor. Although lesions detected in early-stage prostate cancer are often not treated but carefully monitored in a program called active surveillance, the governor’s urologist decided to proceed with radiation therapy. Both active surveillance and localized radiation therapy are treatment options that need to be carefully monitored. Active surveillance is increasingly favored for older men because prostate cancers tend to be very slow growing.
In my estimate, the reason Brown’s physicians chose to be a bit aggressive with limited radiation therapy despite his age is that the governor is healthy, he is in excellent physical shape, and his actuarial life expectancy is probably longer than that of the average 74-year-old. In addition, the side effects of the modern delivery system of radiation are very minimal, and survival data, which goes out about 15 years, is extremely favorable and compares to a more aggressive surgical approach as treatment.
According to Dr. Christopher Rose, a radiation oncologist at the Center for Radiation Therapy of Beverly Hills, “Conventional radiotherapy implies external beam radiation therapy, and is generally offered in a course of treatment lasting anywhere from 5 1/2 to nine weeks. However, accelerated treatments exist in which five treatments are delivered over the course of eight days.”
In describing the technical features of the treatment, Dr. Rose noted that “a three-dimensional model of the prostate—as well as organs that the oncologist wants to avoid—is pieced together using CT scans. The patient lies on his back and a 360-degree radiation source delivers beams of radiation to the patient in a way that targets the prostate but avoids other structures as much as possible. The beams can be delivered at differing degrees of intensity and in a concave shape so that the rectal tissues, lying near the walnut-shaped prostate, are avoided.”
Dr. Rose explained that “other advances allow a CT scan to be taken at each treatment session and lined up with the initial map so that the patient can be precisely positioned and the same tissue volume irradiated each time” and that “with these advances, the potential for a cure goes up and the potential for injuring adjacent organs goes down.”
Rose also noted that “with conventional radiation treatment, each session takes a matter of minutes and is performed on an outpatient basis. My patients all work through their treatments. Sometimes, 1 in 4 suffer fatigue but that usually occurs at the end of the day. Gov. Brown seems at the top of his game, and it probably won’t interfere with activities of daily life.”
The prognosis for the type of cancer that the governor apparently has is extremely favorable. His condition will be followed by monitoring the blood levels of PSA and perhaps performing biopsies in the future.
The takeaway message is that most men diagnosed with early-stage localized prostate cancer who choose either the active surveillance program or localized radiation treatment, as in the case of Governor Brown, die of something other than prostate cancer.
Dudley S. Danoff, MD, FACS is the attending urologic surgeon and founder/president of the Cedars-Sinai Medical Center Tower Urology Group in Los Angeles, California. He is the author of Penis Power: The Ultimate Guide To Male Sexual Health (Del Monaco Press, 2011) and Superpotency (Warner Books).
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