Avoiding Overtreatment of Prostate Cancer
By BECKY GILLETTE
Urologist Ronald Kuhn touts trend of active surveillance and genetic testing
LITTLE ROCK--In recent years there has been controversy over the PSA test for prostate cancer and concerns that, in many cases, prostate cancer was being overtreated because, in some men, it would be so slow growing that it would never cause problems. That has led to a shift for additional testing to identify if the patients with a high PSA test have a tumor that is likely to be aggressive, said Ronald Kuhn, MD, who practices at Arkansas Urology and performs surgery three days a week at Baptist Health Medical Center-North Little Rock.
"In past years, I think there was the conception that the PSA test we use to screen for prostate cancer was perfect," said Kuhn, who earlier in his career was chief resident of urology for the University of Arkansas for Medical Sciences (UAMS). "But, if you talk to any urologist, we all know it is not a perfect test. You cannot generalize the 'normal' for the whole population."
Some experts have suggested since it isn't perfect, the PSA test shouldn't be used at all. But Kuhn still does PSA tests and prostate exams. When a PSA test is high, he recommends a biopsy that is then sent off for DNA analysis to determine if the tumor is likely to be aggressive or non-aggressive.
"For about 30 to 40 percent of patients, the DNA test shows that they are likely to have this cancer the rest of their lives, but it will not cause them any problems," Kuhn said. "The big push with the American Urology Association in those cases is active surveillance with a non-treatment management course. A prostate MRI can also help us sort out who will have a problem and who will not."
Kuhn said considering the number of patients with a high PSA test who don't have an aggressive tumor, some might question if a biopsy is needed. But Kuhn said the way they do biopsies these days, the risk of infections is much reduced.
"I tell a lot of my patients when we are trying to decide to do a biopsy that it is like looking both ways before you cross the road," Kuhn said.
Another relatively new development is the Provenge vaccine. It involves blood apheresis. The patient's blood is removed, the Provenge vaccine added and the blood returned to the patient's body.
"It is immunotherapy," Kuhn said. "It works best with low volume metastatic prostate cancer. It is not a miracle drug. There is no such thing. But it is really good for early advanced prostate cancer patients. We are more aggressive in trying to identify patients who had progression of cancer with traditional treatments. They are going to do best with the Provenge vaccine. With metastatic or advanced prostate cancer, you layer the cancer treatments. You don't start one and end another; you layer one on top of another. As a person progresses over the years with prostate cancer, if you start seeing failure with one treatment, you layer another treatment over that."
Kuhn uses the da Vinci® Surgical System for five or six surgeries a week.
"There is better visualization of the anatomy than when we do open surgery," he said. "A lot of things we do with prostate and kidney surgery are in relatively small areas and small spaces. The da Vinci® has ten-x magnification. You are really on top of the anatomy. The other thing about the da Vinci® is that the instruments are wristed. You can rotate it just like your hand. Actually, you get more rotation than with your hand. You can get into any space and any configuration needed to do the surgery."
In addition to prostate surgeries, he finds robotic surgery useful for kidney surgery.
"In the past if there was a kidney tumor, you would just take the whole kidney out," Kuhn said. "Now the evolution in urology with the aid of the Da Vinci® is to take the tumor out and preserve the kidney. As you age, the more renal mass you have, the better chance of avoiding complications and dialysis."
Kuhn grew up in El Dorado, went to Rhodes College in Memphis, Tenn., where he majored in biology. He did research at St. Jude Children's Research Hospital in Memphis a couple of semesters. That solidified his interest in medicine. He went on to earn his medical degree from UAMS. He thought he was going to specialize in internal medicine.
"I spent six weeks with an internist I really admired, but I thought, 'This is not for me'," Kuhn said. "I went back to medical school and had a talk with the dean of the Medical School, Dr. Dick Wheeler. He recommended I go hang out with these urologists. I did a rotation in urology and that is what did it for me."
One thing he likes about urology is having a real office practice. In general surgery, often when you operate on somebody, you may not see a lot of them again. But in urology, patients are followed for years.
"When you start practicing as a urologist, you see and do everything," Kuhn said. "As you get older and the practice matures, you can kind of get into the nook of what you want to practice. My practice has really evolved into robotics and mainly oncology. I focus more on the surgical aspects of cancer. It took me 20 years to get to that point."
Before joining Arkansas Urology in 1999, Kuhn was associated with the Urology Group in Baton Rouge, La. While at UAMS he was named the Pfizer Outstanding Urology Resident.
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