Prostate Cancer
Introduction
Prostate cancer is a very common condition that increases in frequency as men grow older. Although the disease may be very serious and lead to death, most cases are curable if detected early and treated. Many pilots and controllers fear losing their FAA medical certification if they are diagnosed with prostate cancer and put off regular examinations to avoid the requirement to report this to the FAA. We encourage regular evaluations with your physician for this treatable disease.
Approximately 200,000 cases of prostate cancer are diagnosed in American men annually. Nearly 32,000 men will die of this disease each year. However, if detected early, the cure rate for prostate cancer is almost 100%.
The primary risk factor for prostate cancer is increasing age, particularly over age 50, with half of all cancers occurring after age 65. African-American men have twice the rate of prostate cancer as do white American men.
Screening Tests
Two primary tests screen for prostate cancer: the Digital rectal Exam (DRE) or “finger wave” and the Prostate Specific Antigen (PSA) blood test. Neither is adequate alone; the tests are complementary. Most men should be screened by age 50, or sooner if they have a history of prostate cancer in the family.
If a nodule (lump) is detected on DRE or if PSA levels are elevated and/or rising on repeat testing, your physician may recommend a transrectal ultrasound (TRUS) to further define any irregularities that may be prostate cancer.
If a nodule is confirmed or there are other indications of prostate abnormalities, the next step is a biopsy of the prostate. The biopsy is obtained by using a needle inserted in the prostate gland to remove a sample of tissue. This sample is studied by a pathologist who determines if the prostate is normal or if it contains cancer cells. If cancer is found, it is “classified” according to how aggressive it appears using the Gleason scale. Most men describe the biopsy as uncomfortable but not seriously painful.
Other Causes of PSA Elevation
Another common cause of mildly elevated PSA tests and enlargement of the prostate is Benign Prostatic Hypertrophy (BPH). This is a universal condition in older men who may notice a less forceful urine stream, prolonged urination and waking up at night to urinate.
There is some controversy over the relative risks and benefits of screening low risk men for prostate cancer with PSA alone.
Cancer Treatment Options
If prostate cancer is diagnosed, your physician will discuss treatment options with you. One option is watchful waiting with frequent DRE and PSA testing. In many cases, pilots may fly after appropriate reporting to the FAA while under careful observation. Controllers will require specific clearance from the Regional Flight Surgeon. For airmen, in Apr 2013 the FAA delegated authority to the local Aviation Medical Examiner to clear pilots to fly if their prostate cancer is confined to the prostate.
Surgical Options and Staging
Many men with prostate cancer elect to have the prostate removed. The procedure is called prostatectomy. It can be done by several techniques. The major complication from prostatectomy is the possibility of impotence or impaired sexual functioning. A new technique called the “nerve sparing prostatectomy” may decrease this complication rate. At the time of surgery, the surgeon and the pathologist will determine if the cancer is confined to the prostate or has spread to surrounding areas. This process is called “staging”. If the cancer has grown beyond the prostate, but not to isolated and distant areas, this is called local extension. If the prostate cancer has spread to distant areas, the term is “metastatic” cancer. Frequently, if a surgeon suspects distant spread, they may recommend additional blood tests or diagnostics scans, (CT, MRI, radionuclide studies). The results of these tests determine treatment recommendations.
In most cases, the cancer is confined to the prostate and surgery cures the condition. After a recovery period of several weeks, the individual may return to full activity with continued periodic monitoring. Monitoring is frequently done with periodic measurement of PSA levels. At this point, reporting the condition to the AME may begin so that the pilot can obtain clearance to resume flying assuming there is no metastasis beyond the prostate. Controllers have to get clearance through the Regional Flight Surgeon.
Alternatives to Surgery
Several alternatives to surgical treatment exist. Microwave treatment of the prostate is a relatively new treatment option . A probe inserted into the penis can “cook” the cancer in the prostate. Because it is a new treatment, long term success and complications are not yet well documented. A similar investigational treatment is cryosurgery which freezes the prostate using a penile probe similar to the microwave therapy. Both types of treatment may not be covered by insurance companies since they are not yet widely accepted. Both are a viable treatment options allowed by the FAA.
Radiation Therapy – External Beam
Radiation to the prostate cancer is a third treatment option. Frequently radiation is recommended as an adjunct to surgery if the cancer has spread beyond the prostate. Two forms of radiation delivery exist. The first is External Beam radiation (EBR) . This uses radiation “guns” to shoot the prostate through the skin with doses spread over weeks to months. The FAA will not certify pilots to fly or controllers to work while they are undergoing EBR. The major complications are skin irritation and breakdown (painful sitting) and delayed impotence. Proton irradiation may decrease these complications. Proton beam therapy is a newer technology available in a limited number of treatment centers that may have fewer side effects than traditional radiation therapy. It is also acceptable by the FAA for treatment.
Radiation Therapy- Seed Implantation
The second form of radiation delivery, also known as brachytherapy, is radium seed implantation. These are “splinters” of a radioactive material that are inserted into the prostate similar to a biopsy technique. They deliver radiation to the prostate over extended periods of time. Again, impotence is a potential complication but skin breakdown is less common. The FAA has certified pilots to fly while the have Radium seed implants to treat an otherwise controlled cancer. Again since Apr 2013, AME’s can clear airmen to flying if cancer is confined to prostate. Controllers require specific clearance from the Regional Flight Surgeon.
High-Dose Rate Brachytherapy
A third form of radiation delivery is high-dose rate (HDR) brachytherapy. In this form of treatment, a highly radioactive Iridium-192 source is welded to a wire used inside of a catheter. The Iriduim source is advanced in half centimeter increments directly within the tumor. Because of the high dose, only a few minutes of exposure are required in 3-10 sessions for treatment. The wire is withdrawn at the end of each treatment, thus the individual has no permanent radiation source as with radium seed implants. Radiation damage to surrounding healthy tissues is minimized.
High-Intensity Focused Ultrasound
HIFU (or sometimes FUS for Focused UltraSound) is a highly precise medical procedure that applies high-intensity focused ultrasound energy to locally heat and destroy diseased or damaged tissue through ablation.
Chemotherapy
Chemotherapy used toxic medications to attempt to kill cancer cells. Chemotherapy is not very successful in prostate cancer and is not used as the only treatment for the condition. It may be used as an “adjunct” or additional therapy to surgery or radiation. Because it is not tolerated very well by those who are candidates for this treatment, the FAA generally does not waive pilots to fly or controllers to control when they are on this treatment. Other forms of medications are better tolerated in prostate cancer and potentially more effective. They are directed at manipulating hormone levels that may slow the progression of prostate cancer.
Hormone Therapy
The final therapy for prostate cancer involves hormone therapy. Hormones that inhibit testosterone block a stimulus for prostate growth. They include Casodex (bicalutamide) and Eulexin (flutamide). Other hormones inhibit the release of hormones that stimulate testosterone. They include Lupron (leuprolide) and Zoladex (goseralen). Usually hormones from each category are given simultaneously. The major side effects include hot flashes and sweating. The FAA will recertify airmen and controllers taking hormones for this condition.
Watchful Waiting
Prostate cancer is the most common cancer in adult men, but is not the most common cause of cancer deaths. Some cases are relatively slow growing and pose little immediate risk to an individual. These cases may not require immediate treatment, but can be followed with careful monitoring. This approach, termed “ Watchful Waiting”, is sometimes recommended in early stages of low grade, slow growing prostate cancer and in older gentlemen. This may reduce the risk of impaired sexual function and loss of bladder control some men experience with other treatments for prostate cancer. Monitoring of the PSA level on a frequent basis is critical for this approach. A rise in the PSA may signal a transition to a more aggressive type of cancer or spread of the cancer.
Again since Apr 2013, AME’s can clear airmen to flying if cancer is confined to prostate. There is some confusion whether or not watchful waiting is included in this policy since it isn’t specially addressed in the Guide to Aviation Medical Examiners. However, the Manager of Aeromedical Certification in Oklahoma City has confirmed that the intent is to allow AMEs to clear watchful waiting as long as cancer is confined to the prostate. Controllers require specific clearance from the Regional Flight Surgeon.
FAA Certification
FAA certification after diagnosis of prostate cancer generally requires the operative report and hospital discharge summary (if any), pathology and laboratory reports, the results of any scans or tests for metastatic disease and a statement from the treating physician that the pilot may return to full activity. The physician statement should mention what follow-up evaluations are scheduled and the dosages of any medications.
As of 9 Apr 2013, the FAA modified its policy to allow the Aviation Medical Examiner (AME) to clear airmen with prostate cancer that was confined to the prostate. If spread beyond the prostate, then the case continues to require Special Issuance. This documentation can be submitted directly to the FAA or the AME, but pilots and controllers are cautioned that most clinical specialists are not trained to recognize all of the aeromedically relevant aspects of a case. Erroneous or incomplete information can result in significant delays in certification. Once an airman or controller is returned to duty, the FAA will generally require a Current Status Report from your treating physician at the time of your next FAA medical examination.
AMAS Aeromedical Assistance
For a more specific personal explanation to your questions or those concerning aeromedical certification, contact AMAS for a private consultation. For help in reporting treatment for and obtaining clearance from the FAA to fly or control with these conditions, refer to the AMAS Confidential Questionnaire. If you are an AMAS Corporate Member, these services are FREE to you.