CCE Prostate Cancer: Cleveland Clinic

March 6, 2009
Heide Aungst
Heide Aungst

The Cleveland Clinic has a long history of pioneering innovation and leading-edge research in urology.

Cleveland Clinic
Cleveland, Ohio

The Cleveland Clinic has a long history of pioneering innovation and leading-edge research in urology.

In the 1920s, William Lower, MD, the Clinic’s first urologist and one of its four founders, was among the first surgeons to perform a suprapubic prostatectomy. In 2008, Jihad Kaouk, MD, performed the world’s first robotic single-port prostatectomy.

“Our philosophy for prostate cancer is that there isn’t one single best treatment,” says Eric Klein, MD, chairman of the Glickman Urological & Kidney Institute at the Cleveland Clinic. “We offer all available therapies: open surgery, laparoscopic surgery, robotic surgery, brachytherapy, and cryotherapy. And, we have one of the world’s largest comparative database of cure rates for all of those treatments since 1987.”

Cleveland Clinic physician Andrew Stephenson, MD, director of the Center for Urologic Oncology, is lead author of a study under review at the Journal of the American Medical Association that analyzes radical prostatectomy outcomes from pooled data on 22,000 patients at five major institutions. By charting outcomes with a nomogram, urologists can predict the patient’s likelihood of recurrent prostate cancer within 15 years.

“That allows us to reassure the vast, vast, vast amount [of patients] who are cured by surgery that they are cured. They don’t need to worry about it, and they don’t need additional treatment,” Klein says. “And it allows us to identify the relatively small number of patients who, even though they had surgery, had microscopic metastatic disease outside the prostate and give them additional treatment. It’s one of the best tools that has ever been developed.”

Stephenson and Cleveland Clinic researcher Michael Kattan, PhD, are now at work mapping out a similar nomogram to help predict brachytherapy outcomes. Brachytherapy is the implantation of radioactive seeds in the tumor.

Although that nomogram will look at data from other institutions, along with that from the Cleveland Clinic, the Clinic boasts one of the largest brachytherapy programs in the country. Since the treatment became routine in 1996, Cleveland Clinic urologists have treated more than 2,000 men with brachytherapy.

Richard Nord, MD, a partner in the Advanced Urology Inc., with offices in the Youngstown, Ohio, area, diagnoses and treats men with prostate cancer. His group of four urologists offers patients almost all of the same treatments available at a larger medical center.

Still, he often sends patients to the Cleveland Clinic.

“We actively encourage it because with a cancer like prostate cancer, there’s certainly different ways to approach it,” Nord says. “Many, many times, particularly in early prostate cancer-which we see so much more nowadays-there are different approaches in managing it, different options for the patient. And, as part of their due diligence, many patients wish to go to a tertiary center like the Cleveland Clinic.”

Another type of patient that Nord sends to the Cleveland Clinic is a younger man with high-risk prostate cancer who might need a multimodal treatment approach. “Those patients really should be enrolled in a clinical study-if they’re willing to-and that’s something we have the ability to offer them through the Clinic that’s not going to be ongoing on a local basis,” he points out.

In addition to comprehensive treatment protocols, the Cleveland Clinic is involved in cutting-edge research and drug trials for the treatment of prostate cancer. They receive more than $9 million annually in funding just from the National Institutes of Health.

In the area of tracking down the cause of prostate cancer, Klein and researcher Robert Silverman, PhD, of the Clinic’s Lerner Research Institute, have identified the xenotropic murine leukemia related virus (XMRV), a gamma retrovirus that can be found in the prostate. Since 2006, Clinic researchers have been studying whether prostate cancer might be caused by this virus.

“The rest of our work now is to find out how XMRV might-and I emphasize the word might-cause prostate cancer,” Klein stresses. “And, if it does, develop a vaccine to prevent it, just like there’s a vaccine that prevents cervical cancer.”

The American Cancer Society estimates that up to 20 percent of cancers might be caused by viruses.

One prominent study that the Clinic participated in was the Selenium and Vitamin E Cancer Prevention Trial (SELECT) to determine if the nutrients vitamin E and selenium prevent prostate cancer. Klein co-chaired the multi-center study, which included more than 35,000 men. It showed that neither would help.

“The results were disappointing, but it was still an incredibly important trial,” Klein says. “The science was terrific. We designed a great trial. It was run well, and we can have real confidence in the results that these agents are not helpful. We have confidence that they’re not very harmful, either.”

Today, Cleveland Clinic researchers, led by Robert Dreicer, MD, of the Clinic’s Taussig Cancer Center, are conducting a Phase 1 study of a lyase inhibitor that blocks steroid production and appears to work for men not helped by other prostate cancer treatments.

“That’s an example of using a new drug in a setting where there aren’t any cures,” Klein says. “For existing drugs, we’ve had a very leading-edge program here in giving patients systemic treatments prior to surgery to see if we can kill off some of the micrometastatic disease that some patients have.”

Another area of leadership is the Minority Men’s Health Center. Since minority men get prostate cancer at a higher rate than Caucasians, Charles Modlin, MD, and his group have gone into the community to screen and treat men, including the uninsured in urban areas, for prostate cancer, who may also have other health risks.