A War of Strategy

COMBATING PROSTATE CANCER
TAKES A FULL-COURT PRESS

Today's Tomorrows, Volume 10, Issue 2 - Summer 2002

H. Lee Moffitt Cancer Center and Research Institute Community Newsletter

By Janet Zink

Julio Pow-Sang, M.D., leads the
Genitourinary Oncology Program
at Moffitt

Julio Pow-Sang, M.D. and Bob Samuels have a lot in common when it comes to fighting prostate cancer. They both take an all-out, hands-down, full-court press approach to battling a disease that will claim the lives of more than 30,000 men in 2002.

For Samuels, it's a war of words. The retired banker and two-time cancer survivor spends his days moving mountains of information to the people who need it most men over age 50 who haven't been paying attention to their risk for prostate cancer. (See related story)

For Pow-Sang, it's a war of strategy. The 47-year-old leader of the Genitourinary Oncology Program at Moffitt Cancer Center figures the best offense is to develop as many relevant offensive strategies as possible, thereby creating obstacles at every stage of the disease. It's a game plan that includes:

Prevention and early detection trials that are aimed at helping physicians to catch prostate cancer before it becomes deadly.
Basic research conducted in Moffitt laboratories that provides a foundation for the discovery of causes and cures, and translational research that links laboratory breakthroughs to patient care.
Treatment regimens for metastatic disease that include new advances in hormonal treatment and new chemotherapies.

"We deal with the full spectrum of genitourinary (GU) cancers from prevention to the management of advanced disease, and the research component puts our physicians on the front line in the fight against these diseases," says Pow-Sang. "This means we can offer all the treatment options available and give patients as much information as possible so they can make an informed decision."

Likewise, the GU team is made up of interdisciplinary members who represent a wide range of specialties necessary to treating genitourinary diseases, which include prostate, bladder, kidney, testicular and penile cancers. Specialties include urology, medical oncology, radiation oncology, radiology, nursing, nutrition, pharmacy, clinical research and psychosocial oncology.

High Incidence in Florida

Prostate, bladder, kidney and penile cancers can occur at any age but are far more common in older people. Because Florida has many senior citizens, the incidence of certain urologic cancers is higher than in other areas of the United States. In fact, prostate cancer is the number one diagnosed non-skin cancer in Florida, and the state is number two in prostate cancer incidence and death. California has the highest incidence.

The trend today toward early detection is leading to improved survival rates for prostate cancer. "Once prostate cancer becomes symptomatic, it's terminal. That's why it's important to screen for it," says urologist John Seigne, M.B., B.Ch., who directs the Diagnostic Prostate Clinic at Moffitt's Lifetime Cancer Screening & Diagnostic Center. The clinic's sole purpose is to evaluate men who have had abnormal results from a prostate specific antigen (PSA) blood test or digital rectal examination (DRE).

Seigne recommends that men get screened for prostate cancer starting at age 50. Screenings consist of a DRE and a PSA blood test. When either is abnormal, an evaluation by a urologist should be the next step. Men who are at risk of developing prostate cancer, such as those with a family history of the disease and African-Americans, should start their screenings at age 45.

"African-Americans have the highest incidence of prostate cancer in the nation and the highest death rate from the disease," Seigne says. He attributes the high incidence to a combination of genetics and diet.

Treatment Options Vary

There are five treatment options for prostate cancer, all of which are available at Moffitt under one roof: surgery, radiation, seed implants, external beam radiation, cryosurgery and observation. Pow-Sang says the availability of these state-of-the-art resources and the patient's involvement in his treatment choices, make the program unique to the region.

Because prostate cancer progresses slowly, the stage of the cancer and the age of the patient help determine the best course of treatment, Pow-Sang says. Treatment can sometimes cause incontinence and impotence. However, many older men choose to do nothing, as it's not unusual to live symptom-free with the disease for 20 years.

Surgery involves removal of the prostate via a minimal incision that decreases recovery time and approximates the outcome of laparoscopy, which is a longer and more complicated surgery. External beam radiation therapy is delivered on state-of-the-art equipment by radiation oncologists who are specially trained in prostate cancer. Seed implants (brachytherapy), which are gaining in popularity because of their simplicity, involve placing radioactive pellets directly into the prostate to eliminate the cancer. The process has comparable outcomes to surgery or radiation therapy 10 years after treatment. Cryosurgery, which has undergone improvements in technology, freezes the cancerous tumors with argon gas, producing good outcomes when compared to radiation therapy at five years after treatment. And for metastatic prostate cancer, investigators are evaluating chemotherapy for hormone-refractory prostate cancer.

Research Focusing on New Treatments

"Research is the best hope for making new inroads in the treatment, early detection and prevention of prostate cancer," says Pow-Sang. An emphasis on "traditional" research at Moffitt Cancer Center takes discoveries made in the laboratory and fast-tracks their translation into improved patient care in the clinic.

Scientific investigators at Moffitt who are exploring answers to prostate cancer include:

Raoul Salup, M.D., who is investigating the potential of DNA vaccines to boost immune response against proteins that are over-expressed in many prostate and breast cancer specimens. Salup also is studying tumor-induced damage to cells required for the generation of specific immune responses.
Linda Mora, M.D., who is exploring specific proteins that might contribute to prostate cancer and uncovering ways to block them.
Dietitian Nagi Kumar, R.D., Ph.D., who is leading two studies on prevention of the progression of prostate cancer. She has begun recruiting men for a National Cancer Institute (NCI)-funded study of the effect of soy supplements on prostate cancer. The study will determine if taking 80 mg of soy supplements for three months reduces PSA levels. In the second study, men diagnosed with prostate cancer are given either soy or lycopene, a tomato product, before having their prostates removed. After surgery, researchers will analyze the tumors to determine if the dietary supplements reduced or slowed their progression. "Lycopene and soy are very promising agents that have been shown in laboratory studies to reduce proliferation and increase cell death in cancer," Kumar says.

Moffitt also is one of 400 sites in the U.S., Puerto Rico and Canada working in conjunction with the NCI to recruit participants for the Selenium and Vitamin E Cancer Prevention Trial (SELECT). The study will examine the direct relationship between prostate cancer and certain dietary supplements. More than 32,000 men will be enrolled in the study, which will take up to 12 years to complete. The goal for enrollment at Moffitt is 150 men over a five-year period.

"The research our team members are conducting on GU cancers brings the scope of our program full circle," Pow-Sang says. "The work we do gives patients access to the most current information on the best methods for prevention and treatment."

Bob Samuels is a former Moffitt Cancer Center patient who became an activist.

Eight years ago, Samuels, 63, was treated with external beam radiation for prostate cancer at Moffitt. So far, the disease hasn't recurred. But his experience prompted him to champion awareness of the disease.

Samuels, now a member of the Moffitt Hospital Board of Directors, founded the National Prostate Cancer Coalition in 1996 and runs the Florida Prostate Cancer Network (www.florida-prostate-cancer.org), which he founded in 1997.

While survivors and supporters have rallied to boost research on breast cancer and AIDS, a similar movement has been slow to develop around prostate cancer, Samuels says, even thought it's a major health issue in Florida and across the country.

"Men are too macho," Samuels says. "They don't want to talk about health issues, especially this one."

Under Samuels' leadership and with the help of Moffitt administrators and physicians, such prominent figures as Norman Schwarzkopf, Bob Dole, Rudolph Giuliani and New York Yankees manager Joe Torre have become vocal proponents of prostate cancer education and research.

"The key is early detection," Samuels says. "The earlier you catch it the more likely you are to cure it."

Samuels' encounter with the disease began shortly after he retired from his job at Chase Manhattan Bank in 1992 and came to Florida to "do nothing," he says.

Two years later,, a friend mentioned at lunch that he had been diagnosed with prostate cancer. Samuels asked his friend the signs and symptoms and was told there are none. Although he had had a physical just a few months earlier, Samuels' doctor hadn't screened him for prostate cancer.

"At the end of the lunch I called the doctor," he recalls. Blood tests revealed that Samuels' prostate specific antigen levels were 47. Normal levels are between 0 and 4.

"I was stunned. Everything worked. I had no symptoms. And suddenly I was being told you have this cancer and you have these choices of treatment. Which do you want?"

He learned everything he could about the disease and treatment options.

"At that time it was difficult to come by the information. It's like you go to a foreign country when you get the diagnosis and you don't speak the language and you don't have a map" he says. "I thought, this is so crazy. So many people have it, but no one talks about it, and them not talking is going to kill the rest of us."

He decided if he survived, he was going to start talking.

And that's just what he's doing.

His organization encourages research and education and offers information and support to men diagnosed with the disease.

:We are survivors," he says. "We've lived through this stuff."

Prostate Cancer Signs And Symptoms

Weak or interrupted urine flow; inability to urinate, or difficulty starting or stopping the urine flow
The need to urinate frequently, especially at night
Blood in the urine
Pain or burning on urination
Continual pain in lower back, pelvis, or upper thighs

Most of these symptoms are nonspecific and are similar to those caused by benign conditions

Source: American Cancer Society, Cancer Facts & Figures 2002