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Old 10-30-2008, 12:55 PM   #1
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Worried about psa reading

In October of 2005, I had a radical prostatectomy. The pathology report said that the cancer was contained within the prostate and all the peripheries were clear. For the last 2 1/2 years, my psa reading was "undetectable" every six months that I had a checkup. Now, at my last checkup this month, my psa reading was 0.1. How can this be? If there were cancer cells lurking in my body after the operation, wouldn't the psa reading have shown this right away?

 
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Old 10-30-2008, 09:28 PM   #2
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Re: Worried about psa reading

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Originally Posted by flyfisher37 View Post
In October of 2005, I had a radical prostatectomy. ... For the last 2 1/2 years, my psa reading was "undetectable" every six months that I had a checkup. Now, at my last checkup this month, my psa reading was 0.1. ...
Hello flyfisher,

The first base to touch is to make sure the test is the same kind that has been used for previous tests. Also, does the test that showed 0.1 have a lower limit that is lower than that? These days it seems most doctors are using tests that at least go as low as "less than 0.1," or "<0.1," and your earlier tests had limits lower than .1, but in the past some tests had a lower limit of .1. Have you ruled out substitution of such a less sensitive test? Perhaps the increase you saw is a testing issue rather than a sign of a recurrence. This is probably a long shot, but worth verifying.

Do you have the previous readings that were defined as "undetectable?"

It is quite possible for cancer that has been left over after prostate cancer surgery to evade detection for a while, especially if a conventional PSA test with a lower limit of <.1 has been used for monitoring rather than an "ultrasensitive PSA test." When those cells have had time to grow enough, the PSA becomes detectable.

There is general agreement that after surgery a recurrence is not considered significant until the PSA reaches .2. Personally, I think that approach is too liberal, especially if ultrasensitive test results show that the PSA is rapidly moving toward .2 and started to move shortly after surgery. However, by that standard, even if your true PSA is .1, most doctors would not yet consider that you have a significant recurrence after surgery.

There is some good news in what you posted: a PSA that has not increased to .2 within three years of surgery! A team led by Dr. Freedland, then of Johns Hopkins' famous Brady Institute of Urology, published some tables a couple of years ago based on their research which found that three main factors were of great value in predicting the seriousness of a recurrence. Some recurrences are, of course, aggressive and serious, while others are quite mild - perhaps requiring no treatment, while others are in between. One factor in their tables was whether or not the PSA had risen to .2 with three years, and yours is clearly on the good side of that factor whether or not there is also a testing issue. A second factor was the time it took for the PSA to double (PSA doubling time, abbreviated PSADT), and it appears your PSADT is probably on the long side, which is good. The other factor was whether the Gleason Score from the surgery pathology report was less than 8 (good) versus 8 to 10, something you may know or certainly can find out.

I am a nearly nine year survivor of a challenging case of prostate cancer and have learned a lot about the disease, but I have had no enrolled medical education, so please regard what this post contains as useful for leads and background but not as authoritative medical advice.

Are you using diet, nutrition/supplement, exercise and stress reduction tactics to minimize the chance of a recurrence? Many of us believe such tactics are helpful.

I wish you luck in resolving your concern.

Take care,

Jim

 
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Old 10-31-2008, 12:42 PM   #3
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Re: Worried about psa reading

Thanks Jim for your reply. You have given me a lot of useful information and hope as well! I do know that my Gleason score was an 8 after my initial biopsy before surgery, although my psa was only 4.1 at that time.

If my psa continues to rise ( I'm getting another test done in a month ), my urologists said I will probably be facing radiation therapy, which doesn't thrill me at all. I elected to have surgery initially because I didn't want to have radiation with its side effects.

I've been trying to research information about having chemotherapy in my particular case, but I haven't found out too much yet. I would like to hear your opinion about having chemo for my situation, assuming that my psa count will continue to rise and I have to chose a course of action.

Thanks again for your input!

 
Old 10-31-2008, 01:47 PM   #4
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Re: Worried about psa reading

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....
I elected to have surgery initially because I didn't want to have radiation with its side effects....
I don't have any specific information on the chemo question (although my feeling is that should you need further treatment, this wouldn't be enough in isolation-- but you can check that out with your doctors). However, as a relatively recent radiation patient (proton beam radiation), I can say that I chose that form of treatment because I believed there would be fewer side effects than surgery. So it doesn't ever seem to be an easy call, as there are pros and cons of each treatment type, but if you do need to go down the radiation path now, there are some pretty advanced forms. Hopefully, you'll find out that the increase in psa was just a testing aberation. Good luck!

 
Old 11-01-2008, 08:42 AM   #5
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Re: Worried about psa reading

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Originally Posted by flyfisher37 View Post
Thanks Jim for your reply. You have given me a lot of useful information and hope as well! I do know that my Gleason score was an 8 after my initial biopsy before surgery, although my psa was only 4.1 at that time.

If my psa continues to rise ( I'm getting another test done in a month ), my urologists said I will probably be facing radiation therapy, which doesn't thrill me at all....
Hi flyfisher,

You're welcome - glad to help! We are all here for each other!

I'm sorry that you had that Gleason 8 cancer , but as you may have learned, your prospects, if the cancer is recurring, include a basis for hope and optimism, along with strong motivation to have some kind of follow-up therapy . That's the other main value of the Freedland tables as I see it: when they don't reassure, they motivate, giving us a clearer picture whether follow-up therapy is needed.

As daff said, there are good options, and I can add a few. I'll do that in a separate post later today I hope, as this post is mostly about the Freedland tables for your case and I don't want it to be too long.

Here's what the Freedland tables say for Gleason 8 prostate cancer that has recurred 3 years or more after surgery at Johns Hopkins, for different PSA doubling times (PSADT) when the recurrence develops:

PSADT..........% Surviving (Prostate Cancer Specific Survival (Average percent, then ....................95% confidence range)
---------------...--------------------------------------------------
...........................5 Years..........10 Years..........15 Years

>15 months*.......99% (98-99)..96% (93-98)...87 (79-92)

9 - 14.9 months...98% (75-100).90 (58-98).....72% (35-92)

3- 8.9 months......94% (74-99)...68 (37-89)....30% (10-63)

<3 months**.......83% (52-96)...30 (10-63)....02% (<1-38)

* ">" means "greater than"

** "<" means "less than"

You can see that PSADT is very important; in fact it's the most important of the three factors. You can also see that, with decent doubling time, survival was quite good even for Gleason 8-10 patients.

You will get a better handle on your PSADT after the next PSA test. Since it is such a key indicator, be sure it's done with the same brand of PSA test at the same lab. I hope you see no change, or even a lower figure. (It can happen!)

It's important to keep in mind that these survival figures were developed from a group of men who were treated a number of years in the past. That means those with the more challenging cases were not able to enjoy treatments and approaches that became available later, such as use of bisphosphonate drugs, particularly Zometa for well-advanced cases. The advances are making large, not small, differences in our prospects! Also, a peculiarity of surgical treatment of prostate cancer at Johns Hopkins is that hormonal therapy was typically reserved until the patient showed symptoms from recurrence . While not yet completely proven, there is accumulating evidence that early hormonal therapy is superior to later therapy.

The confidence range, following the average percent: the average projected is sometimes based on many cases, and sometimes on fewer. Obviously, the projection is more reliable if it is based on many cases and if the variation in results is smaller, in contrast to projections based on few cases, especially where the results vary a lot. The 95% confidence range is a statistical tool; it is a sound, highly reliable (95% confidence, 5% possibility that chance is behind the results) estimate that the true result (if all possible cases were studied) would fall in the range. For example, if the result is "99% (98-99)," as it is for Gleason of 8-10, recurrence at three years or more, and PSADT greater than 15 months, we have 95% confidence that the true result is 98% or 99%. This contrasts with the result for Gleason of 8 or higher, recurrence at 3 years or more, but PSADT of less than 3 months. While survival of 83% is projected, the true value is between 52% and 96%. It is clear that not that many cases fell in this category, and they probably had a wide variation in outcomes.

It is also clear that some men were able to do quite well even when they were in an unfavorable survival category, as is indicated by the upper limit of each confidence range in those categories. I am keenly aware of this kind of thinking, as two doctors well respected in prostate cancer circles (one at Johns Hopkins, the other at the City of Hope, Duarte, CA), gave me a prognosis of five years back in late 1999/January 2000. Obviously, I'm doing a lot better than they thought I would do! I'm thoroughly convinced we can do a lot to affect our prospects.

Do you know how much your PSA rose in the year before diagnosis when it was at 4.1? That's another important clue.

To be continued,

Jim

 
Old 11-01-2008, 10:14 AM   #6
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Re: Worried about psa reading

"Do you know how much your PSA rose in the year before diagnosis when it was at 4.1? That's another important clue"

My psa in the year before it reached 4.1 was 2.3, quite a jump for one year. Obviously my cancer was quite aggressive, hence the 8 on the Gleason scale.

I certainly appreciate your input: you've have given me a lot of useful information and have encouraged me a great deal. I know very little about this whole business of prostate cancer and sometimes it is very difficult to get a definitive answer from my urologist, who it seems to me is so busy, that he just doesn't have a lot of time to sit down with his patients and explain things at their level.

As you can imagine, while waiting for a little over a month before my next psa check, I will be understandably quite anxious to see what's going to happen.

Thanks again......Flyfisher

 
Old 11-01-2008, 05:14 PM   #7
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Re: Worried about psa reading

Quote:
Originally Posted by flyfisher37 View Post
"Do you know how much your PSA rose in the year before diagnosis when it was at 4.1? That's another important clue"

My psa in the year before it reached 4.1 was 2.3, quite a jump for one year. Obviously my cancer was quite aggressive, hence the 8 on the Gleason scale.

...
Hi again flyfisher,

The difference between 4.1 and 2.3 is 1.8, and the significance is that that is 2.0 or less; 2.0 or less for an increase in PSA in the year prior to diagnosis is an important, fairly new risk factor per research per renowned prostate cancer doctor/researcher Anthony D'Amico and his team. It could make a difference if the tests were significantly shorter than a year apart, and I forgot to ask you for the dates. Do you have them?

2.0 or less of an increase is on the good side of what the team found. My impression is that leading physicians are now using the D'Amico finding as an independent additional risk factor that is more or less on a level with PSA, stage, and Gleason Score.

Take care,

Jim

Jim

 
Old 11-02-2008, 09:22 AM   #8
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Re: Worried about psa reading

"It could make a difference if the tests were significantly shorter than a year apart, and I forgot to ask you for the dates. Do you have them?"

Hi Jim, actually the time frame was more than 1 year. I don 't recall the exact dates but I do know that when my psa was 2.3, that was in the early part of 2004, say April or May. In 2005, I didn't go for my annual physical until about June or July. I almost didn't go at all that year ( 2005 ), because I was busy and involved in several other things and I was telling myself that I could wait for the following year for my physical, since my general health was good.

I did decide finally that I should have my annual physical done ( the more I think about it, I'm almost certain it was in June of 2005 ) and I'm glad now that I did. If had waited another year, with a Gleason 8 cancer, it might have been too late.

Actually, when my urologist did my biopsy and discovered that I had a Gleason 8 cancer, the first thing he did was send me for a bone scan to see if the cancer had spread to my bones. Fortunately it had not.

I hope you have more encouraging things to tell me. I have felt a lot better and more relaxed since I started posting on this board!

Have a great day......Flyfisher

 
Old 11-03-2008, 12:08 PM   #9
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Cool Re: Worried about psa reading

Quote:
Originally Posted by flyfisher37 View Post
"It could make a difference if the tests were significantly shorter than a year apart, and I forgot to ask you for the dates. Do you have them?"

Hi Jim, actually the time frame was more than 1 year. I don 't recall the exact dates but I do know that when my psa was 2.3, that was in the early part of 2004, say April or May. In 2005, I didn't go for my annual physical until about June or July. ... I hope you have more encouraging things to tell me. I have felt a lot better and more relaxed since I started posting on this board!

Have a great day......Flyfisher
Hi again Flyfisher,

Yes, the fact that the period between the two PSAs was more than a year adds a lot of confidence that your cancer will not behave as cancers do for men who have an increase that can be calculated as greater than 2.0 in the year prior to diagnosis. (For those on the bad side, we now have better treatments available than were available for the key studies, and thanks to these studies, we have the knowledge that we need to get right on the job of improving our odds of avoiding recurrence and surviving.)

In essence, for you the bottom line is that, while a pre-op Gleason 8 is not a good sign, the fact that your PSA velocity in the year before diagnosis did not exceed 2.0 per year takes much of the sting away.

The two landmark studies of PSA velocity in the year prior to diagnosis were by the teams led by Dr. Anthony D'Amico, as I mentioned. One study was for radiation with similar findings, so I won't go into it. The other was published in the prestigious New England Journal of Medicine (NEJM), vol. 351, no. 2, on July 8, 2004, entitled "Preoperative PSA Velocity and the Risk of Death from Prostate Cancer after Radical Prostatectomy. There were four authors, with the lead and last authors listed traditionally getting the lion's share of the credit; Dr. D'Amico was the lead author, and Dr. William J. Catalona, another world renowned prostate cancer researcher and widely regarded as one of the best prostate cancer surgeons, was the final author.

Here's the key idea for someone like you with a pre-op Gleason 8 but a pre-diagnosis PSA velocity (PSAV) that did not exceed 2.0: since Gleason 8-10 patients with a PSAV of greater than 2.0 (>2.0) did much worse than other Gleason 8-10 patients whose PSAVs did not exceed 2.0, when you pull their results out of the total pool of Gleason 8-10 patients, the results for those remaining average out to much better than they looked before. (Unfortunately, the reverse is also true ; but again, follow-up treatments have improved a lot! )

Now for specifics: there were 46 men in the study with biopsy Gleasons of 8-10 who recurred (of 1,063 RP patients in all including those who did not recur), and based on the authors in the paper and other information, it appears they were all Dr. Catalona's patients, and they were treated between January 1, 1989 and June 1, 2002. (There were 366 recurrences for patients regardless of Gleason, and there were also 84 deaths, including 27 from prostate cancer, altogether.)

The paper's Table 2 shows that at the 2.4 average ("median") follow-up point, 25 of the 46 Gleason 8-10 patients had recurred (as defined in this study, reached a PSA of .2 on two consecutive tests after the RP). Even if you have recurred, you can see that your recurred a bit later than the average patient - past that meaningful three year point, and you can also see that you have a lot of recurrence company as a pre-op Gleason 8 patient with more than half recurring fairly quickly, even in the hands of an extraordinary surgeon.

Table 2 also shows that at the 4.8 year median follow-up point there were 9 deaths in this Gleason 8 group of 46 recurring patients, with 7 of those from prostate cancer. From Figure 2 C, page 133, we can see that about 58% (9 men, some statistical rounding here) of the 15 men with both Gleason 8 and a PSAV of >2 have died by about the seven year median follow-up point, a percentage that is stable through the ten year point, and they all died from prostate cancer. In a backhanded way, that's a bit of positive news, as 42% of recurring patients with these two adverse risks characteristics were still alive at the ten year point after their RPs. (By the way, the figure shows that there was a 30% jump in mortality for this group during the 6th and 7th year follow-up periods, with mortality increasing from about 28% to about 58% during this period; mentioning this warrants repeating the caution that considerably better follow-up treatment is now available and outcomes should also be better.) And, because only 9 GS 8 men total died from prostate cancer, it appears that no GS 8 men with a PSAV of 2.0 or lower died from prostate cancer as of the tenth year of the study's actuarial projection.

Figure 1 C shows the overall importance of a PSAV of <=2 versus >2, regardless of Gleason: for those with a pre-diagnosis PSAV greater than 2.0 (>2), death rates start to climb significantly at about the 3 year point and keep climbing fairly steadily, though with some leveling off in this study after 8 years, at around 15 % death/85% survival. In contrast, death rates for PSAVs of <= 0.5, of 0.51 to 1.0, and 1.01 to 2 are all within the 1 to 2 % range and not increasing beyond the fourth year through the tenth year, regardless of Gleason Score. That's not a good basis for going to sleep on monitoring, but it is a reason to be optimistic.

You can get a brief abstract of this study by going to [url]www.pubmed.gov[/url], a website we are authorized to mention on this board because it is sponsored by the Government. If you enter " d'amico a [au] AND 2004 [dp] AND PSA velocity " into the search block, the citation for the study will pop up, and you can view the abstract by clicking on the blue hypertext list of authors. However, you get a lot more information if you look at the full paper itself. Because it is older than the NEJM's threshold period for limiting electronic access, you can activate the button in the upper right corner of the search result from [url]www.pubmed.gov[/url] and view the paper for free. Alternately, you could find a medical library that gives free access to patients. My community hospital does that, and I have taken advantage of their free patient access. Your doctors may also be able to provide a copy of the article as the New England Journal of Medicine is one of the most respected journals in the world.

This should be a strong dose of encouraging news! You could ask your doctor about it. By the way, the paper states that no patient received supportive hormonal therapy - something that is frequently done with marked effectiveness today, and apparently patients receiving follow-up radiation were excluded from the study. These days, my impression is that, despite the encouraging information in this study, most doctors would want their pre-op Gleason 8 patients to have some kind of follow-up treatment for recurrences.

As I've written often, I've had no enrolled medical education. Though I have done my best to interpret the D'Amico paper, and though I think I've related everything accurately, I would welcome comments from anyone who spots a flaw. Interpreting the paper is a bit tricky particularly because different median follow-up figures are used throughout depending on the group of patients whose results are being discussed.

Take care,

Jim

 
Old 11-04-2008, 10:08 AM   #10
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Re: Worried about psa reading

Hi Jim,
Thanks so much for all that information. I'm really impressed with the amount of research you've done on this subject of prostate cancer. I fully intend to read the D'Amico paper as soon as I have enough time to do so leisurely.

I can only hope that my case will turn out okay, and that I will have several years left ahead of me. I'm 71 now, so if I could get 15 years ( that's being optomistic ), that would be about all I could ask for. It would make my wife happy!

I just wish I could go for my next psa test now, rather than waiting a month or so. I've braced myself for the reality of an increase in psa and subsequent treatment. There is an cancer center called " The Juravinski cancer center" near Hamilton ON that I would like to go to for treatment. They are using a lot of the newer cancer drugs and that might interest me.

Thanks once again Jim. You don't know how helpful you've been!!

Take care ........... Lionel ( aka Flyfisher )

 
Old 11-05-2008, 01:40 PM   #11
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Re: Worried about psa reading

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Originally Posted by flyfisher37 View Post
Hi Jim, ...

I can only hope that my case will turn out okay, and that I will have several years left ahead of me. I'm 71 now, so if I could get 15 years ( that's being optomistic ), that would be about all I could ask for. It would make my wife happy!

I just wish I could go for my next psa test now, rather than waiting a month or so. I've braced myself for the reality of an increase in psa and subsequent treatment. There is an cancer center called " The Juravinski cancer center" near Hamilton ON that I would like to go to for treatment. They are using a lot of the newer cancer drugs and that might interest me.

Thanks once again Jim. You don't know how helpful you've been!!

Take care ........... Lionel ( aka Flyfisher )
Hi Lionel,

You're most welcome for the information. Sharing what we have learned helps all of us, and I'm glad I've been able to give you some useful information and ease your worries a bit.

By the way, Lionel is not a very common name in the US, but it is the name of a character in one of my favorite TV series, "As Time Goes By," featuring Judi Dench and Geoffrey Palmer ("Lionel Hardcastle") in the starring roles. Are you familiar with the series?

It may still be hard for you to accept, especially after starting out with a Gleason 8 and now recurring, but you have a good shot at surviving prostate cancer and even avoiding a major additional impact on your life! It was very difficult for me to absorb a similar optimistic view back in early 2000, a few months after I had been diagnosed. My urologist, an excellent doctor I believe, told me that he thought researchers would find a cure for prostate cancer in my lifetime. Well, he obviously knew my case was challenging, and I thought he meant that he expected a cure in what would have been my lifetime if I had not had the disease. It wasn't until many months later that I realized he meant that I had a shot at surviving the disease!

While your biopsy showed a Gleason 8, even if you are recurring (which is not certain yet), there's a real possibility that the surgeon was able to remove all of the really aggressive cancer - the Gleason Score 8 to 10 cancer, or all the Gleason 7 cancer too if any, and that, if any cancer at all had spread beyond the reach of his scalpel, that it was less aggressive cancer that would have had a Gleason Score of 6 or lower if anyone had been able to find it and do a biopsy.

There is no test or scan that will reveal that, but your PSA doubling time is an important clue, as is the fact that it will be at least three years before your PSA hits 0.2, if it ever does. (A surgeon could remove lymph nodes and check, but the benefit of that would most likely not be worth the cost, particularly when finding a lymph node with cancer for a surgeon out of many lymph nodes is a chancy proposition. Sometimes a few are sampled before or at the time of surgery, as you probably know, but cancer could be in one that isn't sampled. There's also a new kind of scan that is cheaper than a ProstaScint or Fusion ProstaScint scan and that appears to be excellent for determining whether or not cancer is in lymph nodes. It is known by various names, such as USPIO, Combidex, and Sinerem. However, no North American facilities exist yet. There is a center apparently doing high quality work in Belgium.)

Dr. Mark Scholz, an expert medical oncologist specializing in prostate cancer in the LA area, gave a talk in 2006 in which he emphasized his new view of risk for men with recurring disease, from the point of view of men on hormonal therapy. He said he believed that the two main clues for the seriousness of a recurrence were the PSA doubling time and how well a man responded to triple hormonal blockade, specifically whether he could get his PSA to drop to less than 0.05. He said he thought these two responses were much more important than positive margins and lymph node status. Of course you are not on hormonal blockade, let alone triple blockade, but you will be able to determine your PSA doubling time.

As I mentioned briefly before, a lot of us now appear to benefit a great deal from nutritional and lifestyle tactics to counter the cancer.

Some of us are not going to have favorable outcomes, and prostate cancer recurrence if far from a cake walk, but for most of us there is a solid basis for optimism.

By the way, there are quite a few Canadian doctors and researchers doing fine work on prostate cancer, including some not that far from you. I don't know about the center in Hamilton that you mentioned, but I do know that Toronto has some leading facilities such as Princess Margaret Hospital and the U. of Toronto, Sunnybrooke, facility.

Hope this also helps.

Take care,

Jim

 
Old 11-07-2008, 06:30 AM   #12
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Re: Worried about psa reading

Hi Jim,

Actually, there are a couple of places in the Hamilton area that are leading cancer institutes. The one I mentioned ( Juravinski Cancer Center ) and also McMaster University hospital in Hamiltion. I've heard a lot of good things about the Juravinski center and know of several people that have been there for treatment. My wife and I took a drive there several days ago just to see where it was and I see that they are adding on. They are building a new hospital and cancer center. It looks like a huge undertaking, covering several city blocks! One good thing about the cancer center, is that they have a Tim Hortons inside! In my book, that's a real plus. As far as Toronto is concerned, I try to avoid that place as much as possible. The city is crime ridden and the traffic is unbelievably congested! Not a nice place.

Because you had radiation, that must mean that you will have a psa count. Do you have to be checked every 6 months and are you taking any kind of medication to keep things under control? You also mentioned triple hormone blockade. How effective is this for fighting prostate cancer and how severe are the side effects? My uro did mention to me when I first met him, that hormone treatment was one option open to me, but since I was determined to be rid of the cancer once and for all, I elected to have the surgery. And it seemed to be working until just recently. My uro was quite surprised to see the cancer possibly returning after a 3 year period.

I don't know the character you mentioned, but in this neck of the woods, my name is not all that uncommon. In the French sector, "Lionel" is a very common name. I guess my parents, who were of Scottish and German ancestory, must have liked it. Personally, I was never too crazy about it!

Take care..........Lionel

 
Old 11-07-2008, 02:48 PM   #13
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Re: Worried about psa reading

Quote:
Originally Posted by flyfisher37 View Post
Hi Jim,

... Because you had radiation, that must mean that you will have a psa count. Do you have to be checked every 6 months and are you taking any kind of medication to keep things under control? You also mentioned triple hormone blockade. How effective is this for fighting prostate cancer and how severe are the side effects? My uro did mention to me when I first met him, that hormone treatment was one option open to me, but since I was determined to be rid of the cancer once and for all, I elected to have the surgery....Take care..........Lionel
Hi again Lionel,

Actually, I never got to radiation and have had only intermittent hormonal blockade therapy. After I was rejected for surgery, a ProstaScint scan in early 2000 had a surprisingly good result - no detectable prostate cancer with just one doubtful area in an unlikely place, opening the door to radiation. I was headed in that direction, with several planning consultations up to the verge of the final planning consultation. However, I was learning more and more about combined hormonal blockade, and my PSA was responding well . With the encouragement of my urologist team, in May of 2000 I decided to rely on hormonal blockade. Part of the thinking by all of us was that there was a strong chance I had some micro metastases that were just too small to be picked up yet. That likelihood made cure by radiation for my particular case a long shot as the cancer probably was beyond the range of the radiation. If I had had a better shot at a cure, I believe I would have gone for it like you did, rather than shooting for long-term control instead.

As you may know, the idea and practice of combining hormonal blockade drugs was fathered by a Canadian, Dr. Fernand Labrie of Laval University in Quebec. The concept was that men would do much better if a drug like Lupron or Zoladex had an "antiandrogen" class of drug like Casodex or flutamide in support. Other Canadians, particularly Dr. Nicholas Bruchovsky in Vancouver have pioneered intermittent blockade along with some American doctors. Intermittent triple hormonal blockade emerged out of this with the addition of a "five alpha reductase inhibitor" drug, Proscar (now generically available as finasteride), or recently, Avodart. The role played by each drug in triple blockade, encouraging results, and information about side effects are presented in two books, "A Primer on Prostate Cancer - The Empowered Patient's Guide," Strum and Pogliano, and "Beating Prostate Cancer: Hormonal Therapy & Diet," Myers.

Accumulating evidence indicates intermittent triple blockade is highly effective in controlling cancer for the vast majority of us. However, there is only one key paper about it in a major prestigious journal, which details impressive experience at the Strum/Scholz - now Scholz/Lam practice, though several other practices have less formally documented their success with it. While I'm convinced that triple blockade is best for most of us, some approaches using single drug blockade (such as just an "LHRH agonist" (Leutenizing Hormone Releasing Hormone agonist) like Lupron, Zoladex, Viadur, Eligard or a different class of drug - an antiandrogen like Casodex) or two drug blockade (the LHRH agonist plus an antiandrogen, or an antiandrogen plus finasteride or Avodart) appear to work very well for some of us and are probably better known and accepted in the medical community treating prostate cancer.

Also, there are a couple of very widespread negative myths about hormonal blockade. One is that it does not work for very long. The myth is supported by studies from the 90s that correctly indicate hormonal blockade did not control prostate cancer for very long for men who were already at a late stage of the disease, such as widespread and painful metastases, when the therapy was started. Men at such late stages do somewhat better today based on advances since the 90s, but the really striking successes with intermittent triple blockade come with men who use it as primary therapy for early stage disease or for recurrences that have not yet turned detectably metastatic - that's most of us! Dr. Mark Scholz, one of the leading doctors with this approach, said that typically men achieve excellent for about ten or eleven years, or indefinitely, with the latter more likely if it has controlled prostate cancer for three to five years, as it often does.

Another myth is that hormonal blockade patients suffer from all kinds of terrible side effects. What is true is that there is a risk of a number of side effects: hot flashes, decrease in bone density, bone and joint pain, weight gain, loss of muscle mass - especially in the upper body, weakness, loss of libido, loss of potency, increase in cholesterol - etc., "hypercholesterolemia, mental/emotional changes, and anemia.

What is also true is that most of us will only experience some of these, and that those we do experience can be quite tolerable, especially if we use countermeasures if needed. Perhaps the most serious potential side effect is a decrease in bone density. Fortunately, my impression is that can be virtually eliminated by using a bisphosphonate drug. Such drugs range from the mild ones, like Fosamax, Boniva and Actonel, to the powerful Zometa. I've virtually reversed the loss in bone density I experienced, before starting the drugs, with Fosamax, and more recently Boniva. Dr. Scholz, his colleague Dr. Lam, and the Prostate Cancer Research Institute have written some excellent papers on using countermeasures. The Primer has a good table on the likelihood and severity of the main side effects. For reasons not yet fully understood, younger men seem to have a generally rougher time with side effects. I'm on my third cycle of triple blockade, and each cycle has been less of a burden than the previous cycle, though for me it was always tolerable. Also, a key point, when we intermittent patients go "off therapy" - meaning off the heavy duty drugs like Lupron and Casodex, the side effects disappear after a few months for most of us (as they do for me).

Advancing knowledge is indicating that about a year to a year and a half achieves most of the benefit from one round of hormonal blockade, with long-term continuous use adding little except side effects. (However, up to at least a couple of years ago, Dr. Labrie would debate that, arguing instead for up to around nine years of blockade before going off therapy.) These much shorter cycles of use have cut down substantially on the impact of side effects.

Also, the most annoying side effect for some - intense, frequent, prolonged hot flashes, can be virtually eliminated through use of one of several medications, such as Megace, from what I've read. My flashes have never been enough of a burden for me to choose additional medication.

While on full therapy, I'm monitored with PSA and other tests, as well as an exam by my oncologist, every two to four months, typically closer to two months except when my PSA is very low.

I hope this helps,

Jim

 
Old 11-08-2008, 08:42 AM   #14
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Re: Worried about psa reading

Thanks again Jim,

Once again, you have demonstrated your impressive knowledge and research done on this subject of prostate cancer. Not only have you given me much to consider, but I feel I will be in a better position when I next see my urololgist. Hopefully he will lean in this direction ( hormone therapy ) rather than radiation ( which I really don't want ). For some reason, I feel that radiation treatment would be insufficient to kill off all the cancer cells that could be in my body. Especially with a Gleason 8 cancer, there could be a good chance that the cells have not remained in the prostate area.

My thinking could be entirely off base in this matter though, since I am still reeling from finding out that my cancer could be recurring ( only a week this past Wednesday ). That's why I appreciate someone like yourself who has given me much information and encouragement.

Once again, thanks..........Lionel

 
Old 11-09-2008, 03:38 PM   #15
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Re: Worried about psa reading

Lionel,

You're welcome.

Now let's hope all this extra knowledge is unnecessary and that you do not have a recurrence after all! Either way, it helps to be prepared.

Take care,

Jim

 
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