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Old 01-15-2009, 05:46 PM   #16
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Re: Diagnostic bone and CT scans: worthwhile?

Hi David,

I'm inserting some comments in green. I found this older thread with your question because of your current post. I was checking to see where you were before answering. One of the things I do is review prostate cancer research proposals for the "Prostate Cancer Research Program", which is part of the "Congressionally Directed Medical Research Program," in other words, funded by US tax payers. As I recall I had 18 proposals to review fairly thoroughly so I could make written comments along with two other reviewers for each, and another 20 or so for general familiarity. (Together with similar review panels, we were charged with recommending awards totalling $80,000,000.) I spent most of August doing that and almost nothing else, so I missed your post and evidently did not pick it up when I tried to catch up in September. Jim

Quote:
Originally Posted by Exflyboy View Post
Hi IADT.....think I picked up something in one of your earlier posts, suggesting that you are (were?) on active surveillance, and seemed to be one of those relatively few people supporting that option, whereas majority opinion seems to be against it, in favour of positive intervention.

I have been very interested in active surveillance, but not for myself; it just makes great sense to me for the right kind of case. My own therapy, for a very challenging case (first ever PSA 113.6, all biopsy cores positive, Gleason 3+4=7, etc.) has been intermittent hormonal therapy, which evolved in the first year to triple therapy (Lupron, Casodex, finasteride, with either Fosamax (earlier) or Boniva (now) in support, as well as diet/nutrition/supplements, exercise, and stress reduction (and prayer). I am now into my tenth year as a survivor and am doing very well as I'm getting into my third round of hormonal blockade, with a four month PSA test and another Lupron shot tomorrow.

There have been scattered posts about active surveillance, but I started a thread on it that gave some key references and statistics on January 5, 2008, about a year ago. Some of the top prostate cancer research institutions in the US have vigorous active surveillance programs, and there are highly regarded AS programs in Canada and the Netherlands as well. A lot of encouraging research is being published on their results. I just saw that Dr. Klotz, who heads arguably the premier program in the world in Toronto, Canada, has 65% of his program's patients still able to defer therapy, now with quite a few years under their belts. The site [url]www.pubmed.gov[/url] is outstanding for checking this research and getting leads.


I joined the site just a few days ago and posted an outline of my recent-diagnosis, and was looking for comments for/against surveillance. Anything you can add onto that thread would be much appreciated - sorry, no intent to be a thread-hijacker !

I've reviewed your other posts, and I'll respond to the latest from today.

Take care,

Jim


Cheers / David

 
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Old 01-16-2009, 03:15 AM   #17
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Re: Diagnostic bone and CT scans: worthwhile?

Jim....just a very quick 'thank-you' , from somebody else's computer. I'm very grateful for all the time you have taken to provide both direct information and leads elsewhere.....it is very evident that you are an invaluable asset to this community.

Since I'm not even required to pay US taxes, almost feels like I'm getting a range of support we Scots aren't even entitled to.....that's an awful lot of research money that you are helping to disburse !

Thanks for the highly specific encouragement in my case, and please do keep it up within this wider community (where do you find the time ?!).

Cheers / David

 
Old 01-19-2009, 09:25 AM   #18
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Re: Diagnostic bone and CT scans: worthwhile?

Hi Jim,

You make a good point about whether these scans are really necessary. I personally don't think that they are, at least in my case, but nevertheless, the fact that they are being done anyway gives one a sense of reassurance. My oncologist told me that at this stage ( psa being very low, less than 0.2 ) that the scans would probably not show anything at all, but he wanted me to have them regardless. I just finished a bone scan ( don't know the results, but I'm sure I would have heard something if it was positive ) and I had a CT scan to set up for radiation. I'm scheduled to have an MRI on Feb 11. This will be after the radiation has started, which is tomorrow ( Jan 20 ).

It makes me wonder why all these scans are necessary and mabye they're not, but as I said, it does offer some king of reassurance that the cancer center is doing all that it can to help me, and I really do appreciate that.

Ny the way, the technicians doing the CT and bone scan showed me the pictures afterwards. Of course they could not or would not tell me anything ( that's up to the doctor ) but it was interesting to see them. I had never had a CT scan before and I must say, it sure made a lot more sense to the guys doing the scan, than it did to me.
I've had a bone scan before and had seen the pictures so I had some idea of what to look for but I didn't see anything suspicious. I hope I get the chance to see the results of the MRI also, since I've never had one of those before.

I sure hope that this salvage radiation works and that I don't end up looking like a piece of fried bacon!

Lionel

 
Old 01-22-2009, 05:00 PM   #19
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Re: Diagnostic bone and CT scans: worthwhile?

Quote:
Originally Posted by flyfisher37 View Post
...
I sure hope that this salvage radiation works and that I don't end up looking like a piece of fried bacon!

Lionel
Lionel,

Good luck, and I hope you have a smooth, calm course.

Jim

 
Old 02-23-2009, 09:52 AM   #20
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Re: Diagnostic bone and CT scans: worthwhile?

Do you mind telling me what your symptoms were? I have so much pain sometimes, I can hardly stand it. Don't have medical insurance, so I am trying to decide if I need attention or if this is just part of my arthritis. Had a secondary cancer four years ago, but never found the primary
thanks

 
Old 02-23-2009, 10:51 AM   #21
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Re: Diagnostic bone and CT scans: worthwhile?

Quote:
Originally Posted by psculley View Post
Do you mind telling me what your symptoms were? I have so much pain sometimes, I can hardly stand it. Don't have medical insurance, so I am trying to decide if I need attention or if this is just part of my arthritis. Had a secondary cancer four years ago, but never found the primary
thanks
Hi psculley,

I'm guessing you saw this thread title on the general list for all posts at HealthBoards and did not realize it was posted on a prostate cancer board.

There are not many certainties in prostate cancer, but I can guarantee that you as a woman do not have it because only men have prostates. (If you are the husband of psculley but using her account, well that's a different matter.)

Can you find a free clinic for an exam? Personally, I would not want to have to bear great pain without at least knowing the source, and hopefully something could be done. There are a lot of organizations that help provide medical care for those who lack insurance and can't affort it.

The information on bone and CT scans was only meant to apply to prostate cancer. Each cancer is different.

Jim

Last edited by IADT3since2000; 02-24-2009 at 09:54 AM. Reason: Added additional text within minutes of posting. Spelling.

 
Old 02-23-2009, 11:30 PM   #22
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Re: Diagnostic bone and CT scans: worthwhile?

oops. I thought I was posting under bone cancer.. How funny. I am aware that I do not have a prostate gland,,but thanks anyway. Hope you were able to chuckle about this one. I am!!

 
Old 05-16-2009, 10:51 AM   #23
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Re: Diagnostic bone and CT scans: worthwhile? (April 2009 AUA: nix routine scans!)

The post that started this thread on July 6, 2008 quoted the passage below from the book by Dr. Strum and Donna Pogliano, basically stating that bone and CT scans were a waste of money for low risk cases. The post also lamented that their view seemed not to be taken seriously by the medical community treating prostate cancer, as these scans were virtually routine for all of us. I agreed. I have nothing against scans, they can be of enormous value, but none of us want to go through a costly procedure - involving preparation, time, inconvenience, some discomfort and anxiety as we await results - when the results are extremely likely to be negative.

Well, that has changed - they are in the courageous and visionary minority no longer! There has been a striking new development regarding the usefulness of bone and CT scans: the American Urological Association, the professional group for American urologists and highly influential, has released a new statement (April 2009) of guidelines regarding the use of PSA tests, "Prostate-Specific Antigen Best Practices Statement," and that statement is against doing these scans in most low risk cases!!!

First, here is the key part of the first post on this thread:

Quote:
Originally Posted by IADT3since2000 View Post
...
Here's what is said about the CT scan in the book "A Primer on Prostate Cancer - The Empowered Patient's Guide," Strum and Pogliano, 2005, p. 62: "Unfortunately, a CT scan of the pelvis and of the abdomen is routinely ordered in virtually all newly diagnosed men with PC. However, it is our contention, based on published literature, that this is a serious waste of healthcare dollars while exposing the patient to unnecessary radiation and inconvenience.... For at least 90% of men undergoing baseline staging procedures, a CT scan of the pelvis is not indicated. In 99.9% of all newly diagnosed patients with PC, a CT of the abdomen is definitely not needed...." The Primer, published in 2005, also advised against routine bone scanning if the PSA were over 10, but pointed out that even for newly diagnosed patients with a PSA not exceeding 10, there is an abnormal bone scan in only half a percent of patients. (pp. 60, 61) [May 2009 addition: Note that the AUA not only has come to agree with that view of overtesting but has taken an even more conservative view on bone scans, as described below.]

It's obvious that the authors of the Primer are in the minority, but what they have written makes sense to me. It's at least worth a little discussion with the doctor. He may be prescribing the scans just because it's defensive medicine protecting him against an ill-founded lawsuit.
...
Now here are some of the key details from the 82 page document that was just published about a month ago in April:

From a table on page 33, the section entitled: "Additional tests, based on preliminary staging, include:
Radiologic staging: CT or MRI. Generally unnecessary if the PSA is < [meaning less than] 25.0 ng/mL.

Surgical staging [meaning sampling lymph nodes]: Generally unnecessary in low risk patients as defined by PSA [less than or equal to] 10 ngmL and [stage T1c/T2a] disease and no pattern [meaning Gleason Grade here - not the full score but one of the two components of the score that are added to get the score] 4 or 5 disease.

Bone scan: Generally unnecessary with clinically localized prostate cancer when the PSA is < [less than] 20.0 ng/mL.
On page 34 the AUA statement expands on its bone scan guideline with a section entitled "2. Routine use of a bone scan is not required for staging asymptomatic men with clinically localized prostate cancer when their PSA level is equal to or less than 20.0 ng/mL."

The AUA described results from a study which reviewed 23 other studies, concluding that bone scans found mets in only 2.3% of men with PSA levels less than 10, and in fact in only 5.3% of men with PSAs between 10.1 and 19.9 ng/mL (the usual unit of measure). For men with PSAs higher than 20, bone mets were found in only 16.2%.

Here's what the AUA also said:
"The authors concluded that low-risk patients are unlikely to have disease identified by bone scan. Accordingly, bone scans are generally not necessary in patients with newly diagnosed prostate cancer who have a PSA <20.0 ng/mL unless the history or clinical examination suggests bony involvement. As metastatic disease is significantly more common in advanced local disease or in high-grade disease, and as some high-grade prostate cancers have lower PSA values, it is reasonable to consider bone scans at the time of diagnosis when the patient has Gleason 8 or greater disease, or stage ≥T3 prostate cancer, even if the PSA is <10.0 ng/mL (Abuzallouf 2004, Murphy, 2000)."

From a personal viewpoint, I'm still glad I got the CT and bone scans, both of which would still have been recommended under this AUA updated best practices guideline since I was a high risk patient. Even so, with a baseline PSA of 113.6, all biopsy cores positive, most of the cores 100% cancer, with perineural invasion, and with a "rock hard" prostate, both my CT and bone scan were negative. That's consistent with the AUA view that distant mets are quite unusual in men in the United States in the current era when most of us get timely screening.

For newly diagnosed, low-risk patients whose doctors want to order (or have ordered) bone and CT scans, a phone call might help that mentions that the patient has heard that the AUA has just revised its "best practices" guidelines against routine scanning for low risk patients. It would not be unreasonable for the patient to ask if the scans could be cancelled, or whether there is a reason to do them in his particular case. If the doctor still wants to do them but appears to be doing them but with no good reason and just because he has always done them, it might be time to get gently more assertive as an empowered patient, or possibly to look for a different doctor. Hopefully, insurance companies will lean on doctors not to do these scans in circumstances when their costs and bother are extremely likely to outweigh any benefit.

For those very few cases where apparently low risk cases would turn out to have mets detectable by these CT and bone scans, my hunch as a layman (no enrolled medical education, mainly educated in the School of Hard Knocks) is that (1) the mets would have been picked up in a timely manner in the course of regular care , and (2) that some would be found in patients in that extremely rare group of extremely highly aggressive cases where even finding them early would not help much.

In addition to helping most of new prostate cancer patients avoid the bother and worry of scanning , these new guidelines will help the nation hold done health care expense.

Jim

 
Old 06-28-2009, 03:18 PM   #24
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Re: Diagnostic bone and CT scans: worthwhile? (April 2009 AUA: nix routine scans!)

Jim, you are all over the place. Really appreciate your involvement. You seem very well informed and up-to-date with the info. Reading something of a "thread" yesterday in the ongoing dilemma many of us are facing, surgery or no surgery, someone wrote that if you have the surgery and the cancer comes back, then you can have "salvation" radiation, but if you have the radiation and it fails, there is nothing surgery can do at that time. Thoughts? BWhitney

 
Old 06-28-2009, 07:16 PM   #25
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Re: Diagnostic bone and CT scans: worthwhile?

bwhitney, I think I can help with a practical explanation. Think of it this way as two scenarios...

(1) Surgery first option scenario — Surgery is generally considered for the low-risk cases where there is a strong belief (with as much supporting clinical evidence as is practical) that the cancer is fully contained within the prostate (organ confined). The surgeon fully removes the prostate during the operation, and the expectation that removing the prostate also removes the cancer. Visualize the surgeon's scalpel removing the prostate gland, and nothing else.

After surgery, the patient undergoes a series of PSA tests (for example, 6-weeks after surgery, 3-months after surgery, 6-month, 1-year...). If the cancer was indeed fully removed, the PSA result will be essentially zero. If it remains essentially zero, there is no further action required by the patient.

On the other hand, if there is a positive post-surgery PSA reading, then some of the PC has likely (unexpectedly) escaped the capsule of the prostate and was "left behind" after surgery...your words were "the cancer comes back." It doesn't "come back" per se, but it might be just a little bit left behind, perhaps immeasurable at first, but then over time the cells double, and double again, then eventually (either right away, or some time later) become measurable in PSA blood tests.

When this occurs, the typical next step is a radiation treatment to the prostate bed area to attack the remaining PC. Keeping in mind that this patient was originally low-risk and thought to have had the PC fully contained, the spread is probably slight and the follow-up radiation it typically very highly successful in suppressing the PC and driving the PSA down to an acceptably low level. However, even though the dose is lower than if radiation were selected as the primary treatment, the absence of the prostate results in the bladder and/or rectum being a part of the targeted field, possibly leading to problems...in other words, this solution doesn't exist without risks. The follow-up radiation treatment is known as "salvage therapy", also known as "Plan B." Of course, there are lots of variations to this "typical" case which can lead down other paths.

(2) Radiation first option scenario — Radiation used to be the "second choice" of treatments, mostly used for those too old or unhealthy to undergo surgery, or for patients with advanced PC cases for whom surgical removal of the prostate would not completely solve their situation. This is no longer the case, and with advances in radiation doses, targeting and other delivery advances, radiation therapy is also considered by many as a "first choice" alterative option for low-risk cases.

There are, or course, a very wide range of PC cases for which it is difficult to generalize, but I believe the 2nd part of your question seeks to address similar low-risk cases who have chosen radiation first over surgery, but have found that the radiation treatment (RT) does not succeed in fully suppressing the cancer. The RT measurement goal is to drive down the PSA to an acceptably low value, and have it stay there for a very long time or for the rest of the patient's life.

Keeping in mind the visualization that radiation impacts the "targeted" tumor, plus some (small) "margin" area around it, as opposed to the surgeon's scalpel. A salvage surgery is possible after RT, but it is reportedly done infrequently because it is more technically challenging (after radiation, the tissues become stiff), and because of a higher incidence of severe complications. A more specialized surgeon is needed/desired. A surgeon would probably only operate if, even after failing RT as the primary treatment, he still somehow thought the cancer was organ-confined. If the patient would have been an excellent candidate for surgery before undertaking radiation as the "first option", then the likelihood of successful salvage surgery is higher.

After radiation as the "first option", the more typical "Plan B" is probably hormone therapy, or cryotherapy (although the salvage results are generally not as good), or other solutions or combinations, largely because the PC is not likely, at this point, organ confined. Lots of possible variants.

Each case is unique, and depends on the personal circumstances which define the diagnosis...both the initial circumstances, and the subsequent "Plan B" circumstances. My reply is a combination of first-hand and learned knowledge. It got a little long-winded as I tried to be careful with words. Does this description help answer your question?

Last edited by kcon; 06-30-2009 at 07:42 AM. Reason: clarification

 
Old 06-30-2009, 04:14 PM   #26
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Re: Diagnostic bone and CT scans: worthwhile?

KCON, thank you very much for the explanation. Very helpful.

 
Old 07-01-2009, 05:19 PM   #27
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Re: Diagnostic bone and CT scans: worthwhile? (April 2009 AUA: nix routine scans!)

Quote:
Originally Posted by bwhitney View Post
... someone wrote that if you have the surgery and the cancer comes back, then you can have "salvation" radiation, but if you have the radiation and it fails, there is nothing surgery can do at that time. Thoughts? BWhitney
Hi and you are welcome.

First, kcon gave a superb response. Here are a few more thoughts, not quite in the direction of your question, but in the direction of your thinking whether surgery or radiation is better.

My bottom line is that both are fine options for low risk men, but you are in territory where radiation begins to get the edge over strictly local therapies, including cryo. It's not that surgery is ruled out, in fact, depending on your exact circumstances it might be curative, but the odds of success begin to suffer.

If you have a Gleason 8 cancer (and especially where a majority of cores positive), the odds that the cancer is confined decrease pretty quickly if the cancer can be felt, in the best case from 66% confined (PSA not exceeding 2.5, can't be felt) to 47% (stage T2a) - not as good as an even chance), 37% (stage T2b) and 34% (stage T2c) - all still in the row for PSAs not exceeding 2.5. (This is from the 2001 version of the Partin Tables. There has been at least one update, but I don't think these numbers have changed significantly.) If the cancer is not confined, then local therapy is not going to do the job. It may do a lot of good in "debulking" the cancer, but it will not be curative.

Kcon covered the fundamental advantage of radiation in reaching beyond the prostate. When I was considering radiation, based on my high-risk case characteristics, radiation would have covered the whole pelvic area, including areas at least several inches away from the prostate. Radiation can do that, and it can be the best approach, especially if more than minimal spread beyond the prostate is suspected.

When surgery and radiation statistics are compared, there are some typical flaws in the way we compare results:

- we forget that surgery success rates are based on added radiation when initial surgery fails to do the job; salvage radiation is often effective, and salvage surgery is much less frequently attempted than salvage radiation after surgery, in addition to being less effective as a salvage tool, as I recall it.

- when we try to compare similar cases, with similar Gleason Scores and stages, we often forget that the Gleason and stage for surgery are fairly often adjusted, more often than not upward, based on post-surgery pathology, while no such adjustment is possible for radiation. That means that more accurately staged surgery cases are compared with radiation cases that are typically somewhat under staged: in reality that cannot be fully known, God's view, the radiation cases are on average somewhat higher in Gleason Score and stage than can be known and recorded in research statistics. Do you see what I'm driving at?

- One other flaw is that in earlier years radiation doses were being given that were too low to achieve very high confidence in wiping out cancer in the prostate itself. Those doses were lower because (1) it was not realized that higher doses would have a substantial benefit in cancer control, and (2) because technology then would not permit the higher doses without increasing the likelihood of substantial side effects. That means the statistics for lower-dose radiation from a decade ago or so do not reflect the kind of cancer control (or cure) and side effect minimization that is achievable today. Now, there is a firm grasp of the doses needed to eliminate cancer from the prostate, and that can be done with high reliability.

Take care,

Jim

 
Old 07-02-2009, 04:49 PM   #28
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Re: Diagnostic bone and CT scans: worthwhile? (April 2009 AUA: nix routine scans!)

Jim, thanks for that. Both you and kcon have given me a very good insight to the differences making the decision much easier. The thing that reall has me "freaked out" is the hormonal therapy. I posted a thread that nobody has responded to. Hormonal Therapy or No HT? I realize I have a Gleason 8 and understand the purpose and significance of the HT. What am I looking at in long-term or permanent side effects? The Dattoli Clinic, where I am fairly certain I'll be going, to is talking 12-18 months. I have been in contact with the Radiation Centers of Georgia and they say they don' t use it generally speaking. I realize hearing what I want to hear or would like to hear is not the best basis for making such a serious decision as this. Can you give me some input .

Bwhitney

 
Old 07-02-2009, 05:26 PM   #29
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Re: Diagnostic bone and CT scans: worthwhile?

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--------------------------------------------------------------------------------

Jim, thanks for that. Both you and kcon have given me a very good insight to the differences making the decision much easier. The thing that reall has me "freaked out" is the hormonal therapy. I posted a thread that nobody has responded to. Hormonal Therapy or No HT? I realize I have a Gleason 8 and understand the purpose and significance of the HT. What am I looking at in long-term or permanent side effects? The Dattoli Clinic, where I am fairly certain I'll be going, to is talking 12-18 months. I have been in contact with the Radiation Centers of Georgia and they say they don' t use it generally speaking. I realize hearing what I want to hear or would like to hear is not the best basis for making such a serious decision as this. Can you give me some input .

Bwhitney

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Old 07-04-2009, 04:28 PM   #30
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Re: Diagnostic bone and CT scans: worthwhile?

Hi again,

This response is to your post #29 on this thread. You're welcome for the information. I'm glad it has made things easier.


Quote:
Originally Posted by bwhitney View Post
.... The thing that reall has me "freaked out" is the hormonal therapy. I posted a thread that nobody has responded to. Hormonal Therapy or No HT?

I just put a long response there that covers most of the issues, including the permanency of side effects, and comments on the Charleston approach, the RCOG approach and the Dattoli approach.

I realize I have a Gleason 8 and understand the purpose and significance of the HT. What am I looking at in long-term or permanent side effects? The Dattoli Clinic, where I am fairly certain I'll be going, to is talking 12-18 months.

I was thinking they had anticipated a shorter period of around 3 to 6 months, based on your other post, but 12-18 months is more in line with recent research as I understand it (as a savvy layman, but with no enrolled medical education). However, I would have high confidence in whatever period the Dattoli folks suggest. They are really on the top of their game!

...

Bwhitney

I am convinced that men who are on hormonal blockade for any period longer than just several months need to use countermeasures to ease their time on hormonal blockade. Many doctors prescribing blockade still seem to be unaware of the role these countermeasures can play. The Prostate Cancer Research Institute (PCRI), a non-profit organication, has published an article on countermeasures fairly recently in its free newsletter. It's by Brad Guess, and I believe it was published somewhere around December of 2007. Dr. Mark Scholz and Richard Lam have also published excellent information along this line. Of course their primary concern is their own patients, but they are pleased to share this published information from their practice, "Prostate Oncology", with the rest of us. In my view Dr. Scholz is one of the leading experts in dealing with the side effects of hormonal blockade. I have put to use all of his suggestions that apply to my own case, and they have made a substantial difference. I'm a huge fan!

I've mentioned some of these countermeasures frequently on this site, and if you search for that word, you may find some of this overview information here.

Take care and happy Fourth,

Jim

 
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