For decades, the fear of becoming impotent and incontinent as a result of surgery for prostate cancer kept many men from undergoing screening and treatment, leading to many deaths that might have been prevented. This situation has changed
For decades, the fear of becoming impotent and incontinent asa result of surgery for prostate cancer kept many men from undergoingscreening and treatment, leading to many deaths that might havebeen prevented. This situation has changed drastically in recentyears, with the use of new surgical approaches to removing theprostate that spare nerves and tissues in the area and can avoidthe dreaded side effects. In addition, many men once thought tobe "incurable" are now able to avoid surgery altogetherand live longer lives with more effective radiation therapy.
The two physicians who pioneered those treatments and were instrumentalin changing prostate cancer treatment--Dr. Patrick C. Walsh, directorof the Department of Urology at Johns Hopkins University, andDr. Malcolm A. Bagshaw, Professor Emeritus of Cancer Biology atStanford University--shared the 1996 Charles F. Kettering Prizefor outstanding contributions to the treatment of cancer, awardedby the General Motors Cancer Research Foundation.
A Unique Route to Less Fearsome Surgery
In an era of "high-tech" medicine and imaging, it wasthe old-fashioned learning tools of anatomic studies and cadaverdissection that led to an new anatomic approach to radical retropubicprostatectomy, which not only spares the nerves that supply thepenis but also can greatly reduce incontinence and severe intraoperativebleeding.
In the 1970s, Dr. Patrick Walsh embarked on a series of anatomicstudies to delineate the structures surrounding the prostate,in an effort to prevent these problems. Initially, he mapped theanatomy of the dorsal vein complex around the prostate, and wasable to eliminate the severe bleeding that typically hamperedsurgery. After noting that one of his patients was fully potentafter the improved surgery, Dr. Walsh set out to find out whymost men became impotent. By dissecting infant cadavers, in whichpelvic nerves and tissues are more clearly seen, he was able tolocate the nerves that supply the corpora cavernosa and give riseto erections. "These nerves had never been charted. It wasassumed that these nerves ran through the prostate, but it turnedout that they ran outside the prostate," said Dr. Walsh.By not cutting or only removing nerves on one side, he was ableto preserve potency.
In 1990, Dr. Walsh charted the anatomy of the striated sphincter(which controls urine retention) and refined the surgery furtherto avoid damage to the bladder neck and urethra, preventing incontinence."It is now possible to remove the prostate with excellenttumor control and improve the quality of life in carefully selectedpatients," he commented.
Dr. Walsh has made other important contributions to the field,including the characterization of familial and genetic factorsresponsible for prostate cancer. He has established the largestregistry of men with hereditary prostate cancer and has improvedthe use of prostate-specific antigen (PSA) testing in the earlydiagnosis and staging of the cancer.
Demonstrating the Efficacy of Radiation Therapy
Radiation therapy is now the treatment of choice for many menwith both early-stage and even more advanced prostate cancers.But that wasn't always the case. Before Dr. Malcolm Bagshaw'spioneering work, prostate cancer was considered by many to bea radioresistant tumor.
Dr. Bagshaw and collaborators at Stanford University showed thathigh-dose, small-field radiation could allow selected patientsto undergo potentially curative therapy without the need for surgery.Moreover, radiation therapy was associated with an extremely lowincidence of urinary incontinence and the preservation of sexualpotency in over 50% of patients treated. This is especially importantsince the incidence of prostate cancer rises with age, and manyelderly men have coexisting medical problems that may make surgeryrisky.
"We have done the largest single series, 1,400 patients treatedwith external beam radiation for prostate cancer, some were intheir 40s but others were in their 80s when treated," saysDr. Bagshaw. "In the early stages of the disease, we showedthat radiation provides a high likelihood of tumor control andthe same life expectancy as a man who doesn't have prostate cancer.This is true regardless of the age of the patient."
His work also resulted in replacement of cobalt-60 megavoltagetherapy with the linear accelerator for the treatment of locallyadvanced cancer. Other innovations by Dr. Bagshaw include thedevelopment of techniques to identify and shield the rectum, analcanal and sphincter, small bowel, and pubic bone, as well as uninvolvedportions of the urethra, from radiation. "Radiotherapy techniquesfor localized prostate cancer devised by Dr. Bagshaw have becomean important standard of care throughout the country," remarkedJoseph G. Fortner, md, President of the General Motors CancerResearch Foundation.
In the era before PSA testing was able to detect prostate cancerin its earliest stages, Dr. Bagshaw carried out a number of importantstudies to refine radiation treatment. One series of studies "mapped"the spread of prostate cancer to the lymph nodes, showing a progressivespread from the nodes nearest to the gland to the para-aorticnodes, and led to modification of the radiation field to includeall of the potentially affected nodes. Other studies defined therole of preoperative testing and exploratory laparotomy for patientswith apparent localized disease. His work has also helped definethe natural history of prostate cancer.
Lifetimes of Achievement
Drs. Bagshaw and Walsh have each published over 100 papers andnumerous book chapters on prostate cancer, as well as edited severaltextbooks.
Dr. Walsh is the author of The Prostate: A Guide for Men andthe Women who Love Them (Johns Hopkins Press, 1995), aimedat the lay public. He earned both his undergraduate (1960) andmedical degrees (1964) from Case Western Reserve University inCleveland, Ohio. Dr. Walsh joined the Johns Hopkins faculty in1974 as Chairman of Urology. His first paper on impotence followingradical prostatectomy was published in 1982.
Dr. Bagshaw's first major study on the role of radiotherapy inprostate cancer was published in 1965. He received his undergraduatedegree from Wesleyan University in Middletown, Connecticut andhis md from Yale University School of Medicine in 1950. Dr. Bagshawjoined the Stanford University faculty in 1956, where he becamethe first Henry S. Kaplan and Harry Lebeson Professor in CancerBiology in 1992.