JULY 2012

New Jersey Urology

Saddle Brook Location

Innovative Prostate Cancer Treatment Thats Easy to Live With

New Jersey Urology

By Iris Goldberg According to the New Jersey Department of Health and Senior Services, roughly 7,000 men statewide are diagnosed with prostate cancer each year. Besides certain skin cancers, prostate cancer is the most frequently diagnosed cancer among men in New Jersey and the United States. Upon receiving a prostate cancer diagnosis, many patients are uncertain what the best course of treatment might be. In fact, today, perhaps more than ever before, the questions of how or even whether to treat remain mired in controversy. Consulting with those physicians who have amassed the greatest amount of expertise in treating prostate cancer is the best way for patients to ensure receiving a treatment plan that will produce the most successful outcome in each individual case. For men with prostate cancer who reside in and around the central and southern parts of the state, New Jersey Urology (NJU), located in Bloomfield, focuses solely on treating prostate cancer patients. Glen Gejerman, MD is New Jersey Urologys Medical Director. Dr. Gejerman is board-certified in radiation oncology and specializes exclusively in the treatment of prostate cancer. With greater than 20 years of experience, Dr. Gejerman has treated more prostate cancer patients than most physicians in tri-state area. Additionally, Dr. Gejerman is at the forefront of prostate cancer research, having written numerous articles for prostate cancer research and treatment that have been published in various medical journals. He is a frequent speaker at prostate cancer conferences and symposiums across the country where he is invited to present his work to other physicians. By concentrating prostate cancer care in one center, we have vastly more

Innovative Prostate Cancer Treatment Thats Easy to Live With

Patients who are treated at New Jersey Urology are greeted each day with a smile.

experience, Dr. Gejerman states. In fact, Dr. Gejerman, who personally evaluates each and every patient that comes to NJU for treatment, estimates the facility is handling two to three times the volume (100 patients a day) of prostate cancer patients seen in non-specialized cancer centers. This is all we do constantly, he emphasizes. And that makes a big difference. Perhaps the most unique aspect of New Jersey Urology is that it is all inclusive in terms of the treatment modalities offered. We work with many of the premier urologists throughout the state and because there are so many treatment options, some with equivalent efficacy, it is important that when a patient comes in for consultation, we dont direct him down one path but rather, lay out all of those options, Dr. Gejerman strongly believes.

When patients come to see me, I do a complete history and physicaI exam and review all of their medical records, he states. Based on those findings, well talk about what makes the most sense, relates Dr. Gejerman. And very often, its not really up to me. Once patients are educated and fully understand their options, I find that patients are much more comfortable with the decision they make, he shares. When it comes to deciding whether to have surgery or undergo radiation therapy, for example, each patients individual circumstances and personal preferences are fully explored. In this way, we can properly direct patients, explains Dr. Gejerman. This is, I think, the most uniquely qualifying factor for New Jersey Urology in terms of really offering patients with prostate cancer the very best care, he adds.

For appropriate patients who choose to undergo a surgical procedure to remove the cancerous prostate (prostatectomy), NJU has a number of outstanding surgeons on staff with significant expertise in the robotic approach. The da Vinci robotic prostatectomy is a minimally invasive procedure involving less blood loss and a faster recovery time than traditional open surgery. To treat those patients who prefer, or whose prostate cancers are more amenable to a non-surgical approach, New Jersey Urology offers the innovative Varian Image-Guided Radiation Therapy (IGRT) system. IGRT technology provides precise and exact information on the specific location of the tumor. By precisely tracking cancer, IGRT uses a smaller radiation field, sparing healthy tissue, decreasing side effects and improving outcomes. At the onset of the patients course of radiation treatments, a fiducial gold marker is implanted in the prostate, which helps in the image-guided process by providing image fusion. Before the patient starts treatment, a CT scan is performed whereby the computer can download three dimensional images that are used to outline or contour the target, which is the prostate. Also, the bladder and rectum are marked so that they can be avoided. When patients arrive for their daily treatment they first undergo CT imaging of the prostate gland with the gold markers. The fusion is based on the two gold markers as well as the bony anatomy and the soft tissue, which is an exact way of lining up the prostate. The benefit of IGRT is particularly significant for prostate cancer patients. As the bladder fills and empties, the prostate gets pushed and pulled and will not be in the same position each time a patient receives his radiation treatment. Similarly, the rectum can be empty or full (with gas or stool) and can cause a shift in the location of the prostate as well. Without IGRT, the radiation field must be made large enough to incorporate wherever the prostate might be on a day to day basis. This means that more healthy tissue is being irradiated than necessary. IGRT technology pinpoints the exact location of the prostate at all times, making the radiation field smaller

NJU patients can enjoy a comfortable waiting area complete with flat screen TV, fireplace, a quiet reading area and plenty of snacks.

NJU offers the innovative Varian image-guided radiation therapy system.

and reducing damage to surrounding normal tissue. The computer system uses RapidArc therapy that comes around the body from different directions and allows the physicians at NJU to design a plan that can properly cover the prostate gland with 100 percent of dose while at the same time minimizing the dose to the bladder and rectum. Because it is delivered with such speed, RapidArc therapy provides maximum targeting precision in that the treatment is started and completed within 60 to 120 seconds, so that it actually decreases the chance that even a minor shift in the prostates position might occur. During RapidArc treatment there are no angles in which the beam stops. The treatment is delivered in one single rotation of the gantry around the body. Therefore, the physicians at New Jersey Urology have nearly unlimited choices and degrees of freedom to design the most sophisticated treatment plan with

less normal, healthy tissue in the highdose treatment fields, resulting in less non-cancerous tissue damage and fewer side effects. In fact, Dr. Gejerman relates that this technology, which provides pinpoint accuracy, completely eliminates the possibility of urinary incontinence as a result of treatment. He further shares that while 20 to 30 percent of patients do experience some degree of temporary erectile dysfunction, in the majority of cases this is effectively managed with medication. Patients are carefully monitored both during and long after their course of radiation therapy in order to minimize the occurrence of any adverse effects. It is important for those who are considering radiotherapy to treat their prostate cancer to understand the differences between the forms of radiation that are available today. When IGRT is compared to some of the newer modalities that patients may hear about,

At the onset of the patients course of radiation treatments, a fiducial gold marker is implanted in the prostate, which helps in the image-guided process by providing image fusion.

This committee is composed of boardcertified radiation oncologists and medical physicists who undergo special training in order to participate. Besides cutting edge technology, New Jersey Urology features a host of amenities that are attractive to patients and therefore, to referring physicians as well. A great deal of thought went into the construction and decoration of the facility so that men would feel comfortable. Its almost like a club, Dr. Gejerman suggests, with a fireplace, large screen TVs and even magazines that are geared towards a male audience, so that men do feel comfortable while theyre waiting to come in for their treatment.and that does facilitate men feeling like theyre in a club, he notes.
CT Scanning is performed to download 3 dimensional images to outline the prostate.

the benefits of IGRT over the others are difficult to ignore. For example, Cyberknife, also known as hypo-fractionation, delivers 5 large doses of radiotherapy instead of the standard 44 doses. At first glance, this might seem to be the more desirable option, with 1 week of treatment instead of 9. However, there isnt any long-term data to determine whether the shorter treatment will achieve long-term cancer control. Also, there is a real concern amongst many radiation oncologists that these few large doses of radiation will have severe long-term consequences with rectal and urinary injury. In fact, unless a patient is enrolled in a clinical trial investigating Cyberknife and understands that there is no long-term efficacy data, the physicians at PCU strongly recommend that patients avoid this technique. Another alternative to IGRT is Proton beam therapy, which is unique in that it has a Bragg peak a sharp dose gradient that can limit radiation that is delivered to normal structures. While Proton beam has been shown to be effective for treating tumors at the base of the skull and for pediatric cancers, it is unclear whether it will work for prostate cancer. Due to the sharp gradient in the beam as well as limitations in image guidance, parts of the prostate may be missed during therapy. A large study recently published in the Journal of the American

Medical Association demonstrated more severe sexual and bowel side effects as a result of Proton beam therapy. There are also concerns about absorbed dose in the hips, which can lead to hip fractures. Additional clinical trials will be required before Proton beam therapy can be considered as good as IGRT. It is an ongoing priority at New Jersey Urology to update equipment as technological advancements become available. So, for example, when Varian introduces improvements to its IGRT and/ or RapidArc systems, NJU will make sure to acquire the newer technology. In this way New Jersey Urology maintains its status as a state-of-the-art facility. This, no doubt, is an integral factor which contributed to its recently receiving the prestigious American College of Radiology (ACR) Certificate of Approval. According to the American College of Radiology, the goals of the accreditation program are: to provide impartial, thirdparty peer review; to recognize quality radiation oncology practices through accreditation; to make recommendations for improvement in practice and patient outcomes according to the recognized standards of the scientific community; and to provide a referral list for patients. In addition, the on-site surveyors act as data collectors and submit their findings to the ACR Committee on Radiation Oncology Practice Accreditation, who makes the final recommendations.

We really dont want it to feel like a clinical situation, Dr. Gejerman explains. Patients come for treatment every weekday for nine weeks, he adds, reiterating the importance of having a pleasant environment for the men who are undergoing radiation therapy to spend that time in. The physicians and staff at New Jersey

Skilled technicians guide the patient through each treatment.

and they always catered to me. I had a very good time there, he is pleased to share. As far as the facility itself, Mr. Chimento thought it was very impressive. Everything is clean and neat, he describes. Very modern, Mr. Chimento adds. In the control area, the treatment is carefully monitored. There was always Urology have been so successful at something to drink and TV to watch, making patients feel at home that many he relates. While he found the waiting times, at the four month follow-up visit, area to be extremely comfortable, Mr. patients share with Dr. Gejerman how Chimento was pleased with the fact much they actually miss coming for that his treatments always began on treatment and seeing the team. From schedule. the moment they first arrive at our front Speaking of the technicians who desk, everyone they encounter is upbeat, delivered his treatment, Mr Chimento warm and friendly, he says. says, They were tremendous people in In fact, during the nine week course every way possible their personalities, of treatment, staff members learn the work process everything they did much about the patients during their was excellent. In fact, Mr. Chimento was conversations with them. They inquire so satisfied with the care he received at about their children and grandchildren New Jersey Urology that he has already and know about upcoming special recommended the facility to others. occasions. This is how our staff is trained, Like I said, it was perfect in every way. Dr. Gejerman continues. And the men Fifty-four year old Peter Kelly decided really appreciate the opportunity to to undergo radiation at New Jersey socialize, he adds. Urology for his prostate cancer after In terms of accessibility to patients, consulting with Dr. Gejerman, on the there is always a physician available to recommendation of his urologist. Dr. answer any questions. In case a patient Gejerman was very helpful. He explained encounters a problem while away from everything to me, Mr. Kelly remembers. the facility, Dr. Gejerman provides his cell For Mr. Kelly, having phone number so that he can be reached treatment for his at all times. It is very important for cancer in a nonpatients to know that we are very much hospital setting invested in their care and if anything was beneficial. It comes up, we want to know about it, he was much easier emphatically states. to digest, he says, Frank Chimento is sixty-six years old. He was diagnosed with prostate cancer earlier this year after undergoing a biopsy of his prostate gland. After the results were received, Mr. Chimentos urologist recommended that he begin treatment at New Jersey Urology. He was quite taken with the respectful way he was treated by the entire staff. Being handicapped and confined to a wheelchair, Mr. Chimento had concerns about how things would be handled. They helped me out of my wheelchair explaining that he didnt actually feel ill and going to a hospital each day might have been somewhat depressing for him. As far as the actual delivery of treatment, Mr. Kelly was very pleased. He found the staff to be extremely

accommodating. When he expressed a desire to come earlier each day than when he was originally scheduled, he was worked into an earlier slot within a short amount of time. Perhaps the most positive aspect of Mr. Kellys experience at NJU was the opportunity to meet and speak with other men who were dealing with the same situation. Talking with the doctors and the technicians is very helpful but theyre not going through it, Mr. Kelly notes. You could compare notes with somebody else. If you feel soreness or tiredness and you hear that others are going through the same thing, its very reassuring, he explains. While prostate cancer continues to be the most prevalent cancer affecting men in New Jersey, innovations in diagnosis and treatment offer promise for increasingly more successful outcomes. For referring physicians and their patients throughout the state, New Jersey Urology serves as a valuable resource, providing access to the highest level of care and treatment of prostate cancer available today. New Jersey Urology is located at 160 Pehle Avenue, Saddle Brook, NJ 07663. For more information or to schedule an appointment, please call (201) 881-1000, Ext. 1 photography by Michael Goldberg
Glen Gegerman, MD, Medical Director of New Jersey Urology, personally evaluates every patient.