An estimated 220,800 new cases of prostate cancer were diagnosed nationally in 2015.
John Grabowski lies on an operating table at Robert Wood Johnson University Hospital in New Brunswick as eight nurses meticulously prepare him for prostate cancer surgery.
Wearing blue scrubs, face masks, hairnets and gloves, the nurses shave Grabowski's abdomen, clean and sterilize his torso with disinfectant solution and monitor his heart rate and breathing, while a nurse anesthetist administers general anesthesia.
"Everything I read and looked at for my age, everything looked like it would be best for surgery at this point," says John Grabowski, 64, of Toms River, who was diagnosed with prostate cancer in 2015. With Grabowski, 64, soon unconscious on this winter morning, surgeon Isaac Kim, chief of urologic oncology at Rutgers Cancer Institute of New Jersey, uses a ruler to mark six 1/3-inch-long incisions he will make on Grabowski's abdomen. Into the incisions will go three cannulas -- or tubes -- as well as another half-inch port for a 12-milimeter camera.
After nearly 30 minutes of prep, Kim is ready to get started in earnest.
"All righty," he says. "Come in with the robot, please."
With that, a nurse grasps the handles of the da Vinci Surgical System, a futuristic-looking machine with spider-like arms hanging down in the front. The nurse maneuvers the blocky robot until the arms hover over Grabowski, allowing the other nurses to connect them to the cannulas.
"All righty," Kim says again. He then kicks off his shoes, plops into a leather chair and presses his face into the da Vinci's console. This is where Kim will operate, about 5 feet away from his patient, never actually touching Grabowski with his own hands.
Through two eye holes, Kim peers directly into Grabowski's abdomen in high definition.
The surgeon wraps his fingers around the console's two joysticks, which effectively become his hands, allowing him to move and manipulate the surgical instruments -- monopolar curved scissors, prograsp forceps and PK dissecting forceps -- inside Grabowski. Kim carefully begins cutting and using an electrical current to coagulate through tissue. He clanks on the machine's six pedals, zooming in and out on the camera and switching through his tools. It almost looks as if Kim is playing a video game.
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Robotic prostatectomy with the da Vinci is one of the latest surgical innovations used to treat prostate cancer. Sixteen years ago, the da Vinci became the first robotic surgery system to be approved by the Food and Drug Administration, and doctors today consider the procedure to be less traumatic and minimally invasive compared to traditional open surgery for prostate cancer, which carries the risk of excessive blood loss, post-surgery infections and larger incisions.
Surgical innovations have become crucial with prostate cancer, the second most common cancer found in American men (behind skin cancer), according to the American Cancer Society. In fact, an estimated 220,800 new cases of prostate cancer were diagnosed nationally in 2015, the ACS says.
As common as prostate cancer is, the greatest point of contention continues to be screening recommendations, with experts and doctors failing to come up with a consistent baseline. At the same time, other prostate cancer innovations are being made in hormone therapy and medicines used to treat the disease, as scientists study how gene patterns and even diet can impact the disease.
Mark Stein, a medical oncologist in the prostate cancer program at Rutgers Cancer Institute of New Jersey, calls some of those findings during the past five years "game-changers."
Meanwhile, on the surgical side, the use of the da Vinci machine has also been
groundbreaking. As of March, Kim had performed more than 1,400 prostate cancer surgeries with the robot, which typically involves dissecting along the anatomical plane around the prostate and removing the entire organ intact. Kim says the da Vinci allows him to see better than the naked eye, thanks to the camera's 3-D, fiber-optic quality.
Isaac Kim, chief of urologic oncology at Rutgers Cancer Institute of New Jersey, manipulates the controls of the daVinci Surgical System as he performs robotic prostate surgery at Robert Wood Johnson University Hospital in New Brunswick. "It just gives me a technical advantage that I don't have when I do an open surgery," says Kim, who treats patients and conducts clinical research at Rutgers Cancer Institute, but performs surgeries at RWJU Hospital. "It's more the comfort of the surgeon, and from my perspective, I feel so much more comfortable with the robot."
Robotic prostatectomy is one of several newer developments in the constantly evolving world of prostate cancer, which now is so common that nearly one in every seven men will be diagnosed during his lifetime, according to the ACS. Although prostate cancer killed about 27,500 Americans in 2015, most men diagnosed do not die from it, which has generated hearty debate in the medical world about whether the disease is overtreated.
"The concern is that we're treating a lot of patients who, if you left them alone, the cancer would never hurt them," Kim says. "That was the whole premise."
The ACS recommends men "make an informed decision" with their doctors about whether to be screened for prostate cancer. The most common screening methods are a digital rectal exam and a blood test called a prostate-specific antigen test or PSA. The ACS suggests men who are at average risk begin the screening discussion at age 50, while men at a higher risk -- meaning those with more than one first relative who had prostate cancer at an early
age -- start exploring screening possibilities at age 40.
The American Urological Association suggests beginning PSA tests at age 55, while the U.S. Preventive Services Task Force recommends against having a PSA screening altogether for men who do not display prostate cancer symptoms. The task force concluded the potential harms of PSA screening are greater than the potential benefit. In simple terms: A high PSA result could prompt men who don't necessarily need it to seek out prostate cancer surgery or hormonal treatment, which carry significant risks of erectile dysfunction, urinary incontinence and problems with bowel control.
PSA screening was introduced in 1986 and, immediately, the overall incidence of prostate cancer rose significantly, peaking in 1992 at 237 cases per 100,000 men, according to a study published by the Journal of the National Cancer Institute. The study also determined that between 1986 and 2005, an estimated additional 1.3 million men were diagnosed with prostate cancer, prompting more than a million of them to seek treatment.
Most prostate cancers grow slowly, and autopsy studies dating to 1935 have shown many older men who died of other causes also had prostate cancer that never affected them during their lives, according to the ACS.
"Clearly, a lot of men die with prostate cancer -- not because of it," Kim says.
Hundreds of thousands of men are still diagnosed each year and seek treatment, which has led researchers and scientists to zero in on screening recommendations. Today, they tend to very from doctor to doctor. Kim, for instance, says high-risk patients should begin having their PSA checked at age 40 or 45. If there are no close relatives with prostate cancer, he suggests starting at age 50.
"Until we figure out a better alternative, I'm not sure abandoning the current care is the best approach," he says.
Kim also says the increased attention to overdiagnosing has allowed prostate cancer doctors to better divide their patients based on risk factors and risk profile. He says for a "significant" number of his prostate cancer patients, he recommends "surveillance" -- monitoring the disease with regular check-ups and PSA tests.
"Right now, in my practice, roughly one in five cases will not have anything done for their prostate cancer," Kim says. "I just recommend, 'Let's just watch this.' We're becoming much more conservative in managing our patients now."
Many patients don't always wait to treat their prostate cancer, doctors say. When some learn they have the disease, the initial shock and fear can lead them to seek immediate remedies, even when it's not necessary.
Notoriously, surgery for prostate cancer can affect urinary and sexual function, and cause some men to suffer emotionally from diminished sex lives. In fact, a study published in 2008 in the medical journal European Urology found that one in five men who had prostate cancer surgery regretted the decision.
Grabowski says he was diagnosed in July 2015 and, after learning half of his prostate was cancerous, he opted for surgery. Kim said Grabowski's case posed an "intermediate" risk.
"Everything I read and looked at for my age, everything looked like it would be best for surgery at this point," Grabowski says.
In addition to the risk of surgical side effects, prostate cancer needs testosterone to grow, so doctors often prescribe hormonal therapy to decrease the synthesis of testosterone in the body. But the decrease of the hormone can have major impacts on how some men feel from day to day.
"Men are really a difficult population to treat because hormonal therapy has impacts on energy, sexual function, libido," says Stein, the medical oncologist at Rutgers Cancer Institute. "Certainly, creating a supportive environment and being able to discuss not just treatment, but side effects of treatment, is an important part of what we do here as a comprehensive center."
Stein adds that a colleague is working on a program that studies how exercise can eliminate some side effects of hormonal therapy.
"There's such a stigma (associated with prostate cancer)," Stein says. "You've met countless people (who) are receiving hormonal therapy and you never knew it. I have patients who don't want to talk to their children or their spouses about the treatment. Because people don't talk about it, prostate cancer is underappreciated as a real public health issue."
Stein says some of the research "that makes me get out of bed in the morning" centers around trying to find other types of treatments so doctors don't have to rely on depleting testosterone.
"The big picture, and what we'd ultimately like to do, is either figure out how to treat patients without having to go down this road of hormonal therapy at all," Stein says, "or perhaps we could just use it for a finer period of time, and then stop and say that somebody's cured."
Part of the research entails examining if life-prolonging drugs can become curative if given to more recently diagnosed patients, or seeing if targeted therapies can be given to turn off certain proteins in a tumor and stop cancer cells from growing, even if the testosterone levels are normal. Stein says he's also working to determine if combining chemotherapy with other types of medicine can improve outcomes for patients.
"We're trying to figure out novel ways to push off starting hormonal therapy for as long as possible," Stein says. "Are there ways of doing that? That's an important research question."
On a national level, research on gene changes linked to prostate cancer is helping scientists have a better understanding of how the disease develops, according to the ACS.
Researchers, for instance, have found that some substances in tomatoes and soybeans, and certain vitamin and mineral supplements, could help prevent the disease.
Several newer forms of hormonal therapy also continue to be developed by major drug companies, although the number of drugs approved for prostate cancer remains relatively small.
"There are a lot of exciting things going on in the medicine world right now," Stein says.
Back in the operating room, Kim is working his way through Grabowski's surgery. He carves around the prostate, stomping on his pedals to zoom in tighter or farther out when necessary.
"This camera zooming in is something you can't get without the robot," he says.
Kim peels off spiderweb-like nerves, sews sutures in areas to control bleeding, uses an irrigation instrument to spit water, and continues snipping and coagulating. His intricate work plays out on six television screens stationed around the room.
Toward the end of surgery, Kim has carved out the entire prostate and, in one quick motion, scoops the organ into an entrapment bag inside Grabowski's abdomen. Kim then starts adding more sutures to curb the bleeding.
Soon, Kim will be finished. Then it's on to the next prostate cancer surgery later in the afternoon.
"All that experience comes to help you in the next case," Kim says. "I'm better every time I do this because I've seen one other case, and again, that just helps you."
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