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    Old 04-08-2009, 04:11 AM   #1
    daff
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    Prostate Cancer Treatment Options

    Yesterday's Wall Street Journal (April 7, 2009) had the second of a two-part report on prostate cancer. I'd recommend it to those who have the difficult choice to make as to what to do-- as well as anyone else that wants to get a straightforward treatise on the subject. While nothing can take the place of first-hand discussions with doctors and present/former patients, and reading some of the better book and articles, this is a well-presented and generally unbiased in-depth report including comments/pros and cons of active surveillance, surgery, external-beam radiation, brachytherapy, focal ablation, and drug therapy. (The initial segment, published a week prior, covered advanced biopsy procedures, highlighting 3-D mapping, among others, for example.)
    My take after reading these articles is that they are well worth the price of the paper- would like to hear your opinions on this too (Jim?). If too late to get at the newstand, the public library should be a good place to find this.

     
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    Old 04-09-2009, 02:28 PM   #2
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    Re: Prostate Cancer Treatment Options

    Quote:
    Originally Posted by daff View Post
    Yesterday's Wall Street Journal (April 7, 2009) had the second of a two-part report on prostate cancer. I'd recommend it to those who have the difficult choice to make as to what to do-- as well as anyone else that wants to get a straightforward treatise on the subject... My take after reading these articles is that they are well worth the price of the paper- would like to hear your opinions on this too (Jim?). If too late to get at the newstand, the public library should be a good place to find this.
    What you said - the reporter did a nice job. I too think these articles are worth the price of the paper - in fact of the whole pile of papers, even the whole truckload - or a trip to the library. She appears to be quite savvy , and she does a nice job touching bases with some people who know a lot about our disease.

    As always, however, though reporters may know the territory (I think this reporter did), they usually don't live in it or near it like we and doctors do, so there are almost always some points that are not quite right or are misleading. One point that bothered me a bit was the pros and cons chart for various treatment options. Generally, it was good and useful and should help potential patients.

    However, the table's listing of "cons" for each treatment, while fine for most of the therapies and including needed qualifying and tentative symbols and words like %, "up to", and "can", gave this misleading listing for "Drug Therapies: Hormone medications ...": "Loss of libido and erectile function; osteoporosis; decreased muscle mss; hot flashes; breast enlargement; diminished mental acuity."

    As you can see from those words, there are no qualifying or tentative symbols or words there, and that is highly misleading! The absence of qualifying words implies that these side effects are a virtual certainty for hormonal blockade patients, and that is simply not true! While it is most appropriate and responsible for the reporter to point out these prominent, fairly common side effects - in fact she should have added cardiovascular issues and anemia too, it is wrong to imply that each of us on hormonal blockade will get each side-effect, and it is incorrect that all will get them to a substantially bothersome degree. Would you sign up for such a therapy? I doubt I would if I did not know better, yet I've been on hormonal blockade for more than nine years and am doing quite well, thank you!

    The facts are: that very few of us will experience a full set of major side-effects of hormonal blockade; that for the side-effects we do experience, some will be mild and some stronger - the degree will vary a lot; that younger men tend to have a rougher experience with these side effects; but, that for those of us of any age, countermeasures can be employed that often greatly reduce, avoid, or eliminate the side-effect, and that includes decrease in libido and erectile function; that perhaps the most serious of these side efffects - a tendency to lose significant bone density, is fairly easily and very effectively countered these days with bisphosphonate drugs and associated supplements; and that for those of us who are able to use hormonal blockade intermittently, the side effects are pretty much fully reversible when we go off the heavy-duty drugs, provided we haven't been on them too long, which I believe includes the vast majority of intermittent blockade patients.

    Writing from my own experience with side-efects of hormonal blockade, I know for a certainty that regular strength and aerobic workouts have enabled me to increase strength and muscle mass on this third round of triple hormonal blockade despite a decrease in testosterone to near zero (actually 28 at present), and I'm nearly convinced that other men will have the same success if they are willing to spend a reasonable amount of time working out as well as watching diet and nutrition. I have not had to use the heavy-duty bisphosphonates; Fosamax, and for the past couple of years, Boniva, plus calcium and vitamin D3 supplements in a program of intermittent (rather than continuous) hormonal blockade have enabled me to keep bone density in fairly decent shape (mild osteopenia). Like many of us on blockade who follow advice from leading doctors about romance, I have some romantic capability, though it is well below the normal level that it is when I'm in the vacation period from the heavy-duty blockade drug (for me, Lupron). (My testosterone peaked at over 1,000 during the vacation period from my first round of blockade, for instance; that's pretty darn high, and I enjoyed the associated romantic, strength, bone density, weight control and other benefits associated with normal testosterone.) Hot flashes were more significant during my first cycle, and I still benefitted from fans during the second cycle; during the third cycle, now that I'm 66, the half-dozen or so flashes a day are so short, infrequent, and weak that I rarely feel the need for a fan. (My oncologist offered one of several drugs to eliminate flashes, but I never considered them enough of a problem to warrant the additional drug, even as a potentially just one-time shot.) Breast enlargement has been minor (though it strongly tends to be much more of an issue for antiandrogen drugs (such as Casodex and flutamide) used alone); a short course of preventive radiation will prevent enlargement. I believe I am a little less mentally sharp, especially in remembering names reliably, and some of that may be linked to the hormonal therapy. But again, I don't think it is a big deal. (My wife may differ on that. )

    Daff, thanks for bringing these articles to our attention. I do think the reporter has done a generally exemplary job , and the two articles in this major newspaper will do a lot of good . I don't want to detract from her accomplishment, but I hope not too many readers will be misled by the cons for hormonal therapy in the table for how treatments compare. I suspect the reporter did a good job of touching bases with physicians she considered experts in hormonal blockade, but she just did not reach the true experts. (I've met and read about quite a few urologists who think they know far more about hormonal blockade than they do; I suspect our reporter got her hormonal blockade information from a urologist, perhaps a physician known for outstanding surgical skill, but who just did not know the ins and outs of hormonal therapy, while thinking that he did. On the other hand, some of them are really expert. Generally, medical oncologists seem to know hormonal blockade pretty well.) I'm going to try to get a letter to the Wall Street Journal or post on its blog; some one of us should get some correcting information in the record.

    I have some other comments, and will try to add them as time permits.

    Take care,

    Jim

     
    Old 04-09-2009, 03:08 PM   #3
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    Re: Prostate Cancer Treatment Options

    Jim- Thanks for adding so much clarification. It is difficult for one article to be in-depth for each of the alternatives the same way you or I can focus on what we did, having spent so much time pre, during, and post treatment. I was pleased that she at least included proton as one of the external beam forms of radiation. Obviously there was a lot left out with regards to this, but it's getting difficult to deny it even exists, as some urologists would like people to believe. There certainly are lots of articles where certain topics are skipped completely. Maybe you could condense your writings on this board re: hormonal blockade treatment (from this post) and submit to the WSJ as a letter to the editor. It might be way too complex for them to include in the paper, but if it's just some of the key highlights (like the effects are not irreversible, for example) maybe they would publish it.

     
    Old 04-09-2009, 05:44 PM   #4
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    Re: Prostate Cancer Treatment Options

    what procedure is the best

     
    Old 04-09-2009, 08:04 PM   #5
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    Re: Prostate Cancer Treatment Options

    Quote:
    Originally Posted by ohionutcake View Post
    what procedure is the best
    Sorry there's no pat answer. There are many factors- age, psa trend prior to treatment, biopsy results, physical condition of the patient, among others. There is really no one "best", just a series of choices with a different set of potential side effects and each must decide what fits his circumstances. It takes a serious effort to learn what's out there, and one that looks for someone else to make the decision for him may not be pleased with the outcome. Doctors tend to recommend their specialty and not seriously guide one through all the choices, thus the reason for doing one's own due diligence.

     
    Old 04-10-2009, 08:56 AM   #6
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    Re: Prostate Cancer Treatment Options

    Daff speaks the absolute truth. There is no single best treatment although certain treatments are more likely to produce better outcomes for different cases with different diagnostic and demographic characteristics. There are no pat answers.
    For example, a young healthy man with low grade, early stage, localised prostate cancer would most likely have a better outcome and chance for long term or permanent cure with aggressive local treatment, whereas an older man, say, 75+ with other health problems should probably receive more conservative treatment with different outcome goals depending on the stage and degree of aggressiveness (grade) of his disease.

    Last edited by shs50; 04-10-2009 at 08:57 AM.

     
    Old 04-11-2009, 12:41 AM   #7
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    Re: Prostate Cancer Treatment Options

    biopsy was #6 but i have been on testostorin injections for 6 months

     
    Old 04-11-2009, 06:56 AM   #8
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    Re: Prostate Cancer Treatment Options

    Quote:
    Originally Posted by ohionutcake View Post
    biopsy was #6 but i have been on testostorin injections for 6 months
    Gleason score of 6 is favorable (not as aggressive as 7 or higher). When you say injections, do you mean hormonal blockade to reduce testosterone? Can you let us know how old you are and what your PSA was at the time you got your biopsy? What do your doctors tell you your choices are?

     
    Old 04-11-2009, 09:37 AM   #9
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    Re: Prostate Cancer Treatment Options

    For those of us board participants and readers who are trying to settle on a treatment option, there is another thread also now active that has a lot of discussion about the merits of radiation and surgery in particular. Among other points, daff, shs50 and I have been discussing these options. Last evening I added a number of key facts from medical research studies as well as references and links to most of the studies on www.pubmed.gov, a site we can use on this board because it is Government sponsored.

    That other thread is CM63's "Husband just diagnosed."

    Jim

     
    Old 04-12-2009, 06:47 AM   #10
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    Cool Re: Prostate Cancer Treatment Options

    Quote:
    Originally Posted by ohionutcake View Post
    biopsy was #6 but i have been on testostorin injections for 6 months
    im a 59 y/o male very sexually active weight 350 lbs diabetic on insulin bid and oral diabetic meds suffer from chronic low back pain worse the last 2 years take epidural steroid injections regurlarly and testostorine icc q2weeks to build muscle instead of fat my gleason was 6 psa2.1 no other psa to evalluate biopsy was daon on the 4-2-09 4-8-09 told of the cancer of prostate incotinent at times withe diabetic and was put on flomax which helps i should have took the tiome to submitted this before out of the the 12 snips 10 were cancerous the doctor is 34 yrs old smart urollogist hin and his partner pionered the robotic surgery here in st peteersburg

     
    Old 04-12-2009, 06:51 AM   #11
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    Re: Prostate Cancer Treatment Options

    Quote:
    Originally Posted by ohionutcake View Post
    im a 59 y/o male very sexually active weight 350 lbs diabetic on insulin bid and oral diabetic meds suffer from chronic low back pain worse the last 2 years take epidural steroid injections regurlarly and testostorine icc q2weeks to build muscle instead of fat my gleason was 6 psa2.1 no other psa to evalluate biopsy was daon on the 4-2-09 4-8-09 told of the cancer of prostate incotinent at times withe diabetic and was put on flomax which helps i should have took the tiome to submitted this before out of the the 12 snips 10 were cancerous the doctor is 34 yrs old smart urollogist hin and his partner pionered the robotic surgery here in st peteersburg
    choices: its agressively going toward the nerve and recomend the prostatectomy robotic surgery in 4-27-09 rush rush rush boy give me the help i need ive got medical background but you never apply it to your self

    Last edited by ohionutcake; 04-12-2009 at 06:53 AM.

     
    Old 04-12-2009, 07:21 AM   #12
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    Re: Prostate Cancer Treatment Options

    Quote:
    Originally Posted by ohionutcake View Post
    choices: its agressively going toward the nerve and recomend the prostatectomy robotic surgery in 4-27-09 rush rush rush boy give me the help i need ive got medical background but you never apply it to your self
    Guess you know you're not the typical Gleason 6 patient. 10 of 12 cores positive for cancer seems high. Lots going on and I won't pretend to say I know enough to recommend anything other than you should keep your appointment for surgery while getting another opinion in the meantime, like right away. I have no knowledge whether you'd be a candidate for proton beam therapy (given your size and the other things going on) but you are so close to Jacksonville's University of Florida Proton Therapy Institute, that maybe you could get an emergency consultation there. One of the things they do is review the biopsy slides, so that would be a way to get a second opinion on those results too. They also have the latest equipment to do photon radiation there too. Please ask if you have other questions. I'm sure you'll hear from others on this board with hopefully additional information for you to consider.

     
    Old 04-12-2009, 04:38 PM   #13
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    Re: Prostate Cancer Treatment Options

    Quote:
    Originally Posted by ohionutcake View Post
    choices: its agressively going toward the nerve and recomend the prostatectomy robotic surgery in 4-27-09 rush rush rush boy give me the help i need ive got medical background but you never apply it to your self
    Hello Ohio,

    I'll also welcome you to the board, though of course all of us wish we never had had to get involved with prostate cancer.

    As daff remarked, your case is unusual. Here is what strikes me. By the way, I'm a layman with no enrolled medical education, but I've had to learn a lot about the disease to deal with my own challenging case.

    Right off, I'm puzzled by the combination of your PSA (quite low at 2.1), Gleason of 6 based on 12 cores (normally Gleason 6 cancers "leak" a normal amount of PSA for cancer, not the deceptively reduced amount that is fairly common for Gleason 8 to 10 cancers), and yet so many cores positive (10 of 12). The puzzle is that you would expect that so many positive cores with Gleason 6 cancer would generate a higher PSA. The doctor probably would not have thought you were ready yet to absorb that kind of detail, but it is something for your medical team to think about, and it's worth asking him about that.

    Has the biopsy been reviewed by an expert pathologist who specializes in prostate cancer? Frequently general pathologists will undergrade the prostate biopsy, and it can make quite a difference in making decisions and managing your case. Second opinions for biopsies are fairly common for prostate cancer. If your doctor does not have a good explanation for the question I raised, if I were you, I would want to get that second, expert pathologist opinion. There are a number of such experts around the country.

    I'm also puzzled why you say the cancer is "aggressively going toward the nerve." That could be a reason to move fairly quickly toward treatment, but what is the basis for that statement? There probably is a good and ready answer for that one - the locations of one or more positive cores near usual nerve locations.

    What "stage" is your cancer? That's usually based mainly on the Digital Rectal Exam (DRE). Normally, surgery is not done if the cancer is stage 3, which means it is already beyond the prostate. Based on your biopsy, it seems that the cancer is already substantially on both sides of the prostate, which would class it as stage 2c.

    Did the doctor talk to you about those testosterone injections, and have you stopped them? Testosterone seems an unlikely cause of prostate cancer, but it sure as heck fuels it. In fact the central goal of my own therapy is to reduce testosterone to a very low level - 20 or lower. That and associated medications and tactics have enabled me to lower my PSA from its original 113.6 to <0.01 in two previous cycles of intermittent hormonal blockade, and I'm now on my third. I understand why testosterone might be given to help you convert fat to muscle, but now that you have a diagnosis of prostate cancer, that strikes me as highly counterproductive for your overall health. What did the doctor say about that, if anything? But see a thought below on how you might be able to keep at least your normal testosterone.

    Did the doctor order a bone scan? Normally bone and CT scans are almost worthless for patients with low PSAs like yours combined with a low Gleason Score of 6. However, because prostate cancer likes to metastasize to bone, and since lower back pain like that you described is one symptom that can be due to that metastasis, in my layman's opinion, a bone scan seems appropriate to rule out such spread. CT scans are also almost useless for low risk cases, but you do show an unusually high number of biopsy cores positive (all mine were positive, so don't feel lonely), and that might also warrant a CT scan.

    I'm thinking you might benefit by checking further on possible spread of the cancer before going ahead with the surgery. It is always good to avoid therapies with prostate cancer that are unlikely to accomplish the objective, and there is an extra large benefit in your case because of the burden of substantial diabetes. Surgery is likely to add some burden and risk to your overall health as a diabetic weighing 350 pounds (such as risk of blood clots), and if the cancer has spread beyond the prostate capsule, surgery is not going to cure the cancer.

    Several options are available for checking for spread, in addition to the bone and CT scans. If those are positive, then you probably don't need to pursue these other options, and surgery would probably not be a good choice of therapy. One is an endo-rectal MRI, preferably with spectroscopy. Among other virtues, that scan is good at determining whether the cancer has spread beyond the prostate capsule. There is a scan currently available only in the Netherlands known as Combidex that is excellent at determining whether there is spread to any of the many lymph nodes. Dr. Michael Dattoli, a world-class radiation doctor practicing in Sarasota, has patients get a Combidex scan fairly frequently, and you might want to schedule a consultation with his office.

    That would bring you the benefit of a second opinion and a wealth of experience, no doubt including experience with diabetic patients. However, the fact that you already have continence problems, decreases the desirability of radiation as an option (but does not rule it out either - just added weight on the negative side of the scale). That's because radiation typically makes existing continence problems ("lower urinary tract symptoms," known as LUTS) worse. Also, there are some technical problems in effectively delivering radiation to patients carrying a lot of weight as you are. That's about as much as I know about it, but the Dattoli office, or another expert radiation doctor such as in the proton clinic that daff mentioned, could probably assess the viability of radiation as an option, and also comment on the benefits and pitfalls of surgery as viewed by a radiation doctor - a useful "devil's advocate" view.

    Hormonal blockade therapy is an option, I think, especially because of your overall health situation potentially being compromised by surgery or radiation. Such therapy would almost surely knock the cancer back on its heels, and it would be very unlikely to aggravate your continence problems. However, hormonal blockade with the typical LHRH-agonist drugs (such as Lupron, Zoladex, or Trelstar) sometimes aggravates cardiovascular and diabetic concerns.

    One established alternative with a lot less or no such risk is to use a hormonal blockade drug in the antiandrogen class, typically Casodex or flutamide, without the LHRH-agonist drug. That is not quite as effective as also using the LHRH-agonist, but it avoids some of the side effects that would be of key concern to you. It does not reduce testosterone, but rather blocks most of it from linking up with the cancer cells and fueling them.

    Another drug you could use with the antiandrogen is in the 5-alpha reductase inhibitor (5-ARI) class, either finasteride or Avodart. The main function of those drugs is to virtually eliminate conversion of testosterone in to DHT, which is far more potent at fueling prostate cancer. In the vast majority of men, there are minimal or no side effects, though libido is decreased in about 10% to 20% (which reverses if the drug is stopped). I've heard one expert say that this antiandrogen approach, especially when boosted with the 5-ARI drug, gives you 80% of the benefit of the LHRH-agonists in controlling the cancer at the cost of only 20% of the side effect burden.

    Another hormonal therapy drug that might fit your case nicely has just been approved by the FDA. It is known as degarelix. I believe that it too, like the antiandrogens, would not reduce testosterone, which could be of value to you.

    I feel like I'm giving you too much to absorb, but here's another important point. Decreased bone density is epidemic among prostate cancer patients. Especially with your health profile, getting a bone mineral density assessment looks important to me. Many of us without arthritis and with unlikely calcification of blood vessels can be scanned with a DEXA scan, but in your case a Quantitative QC scan might be a better choice. If you do have decreased bone density, a bisphosphonate drug, coupled with calcium and vitamin D3 supplementation, can help a lot. My impression is that urologist are often not very aware of this potential problem area for prostate cancer patients. Mine weren't.

    Here's another therapy option - cryosurgery. I think it does not involve some of the health risks that surgery would involve for you. One of the world's premier cryo surgeons is in Florida, in Celebration. His name is Dr. Gary Onik, MD. He and Dr. Centeno have co-authored a book on prostate cancer, and there is an excellent chapter or two on cryo surgery.

    Speaking of books, I highly recommend you get two: "A Primer on Prostate Cancer - The Empowered Patient's Guide," by Dr. Stephen B. Strum, MD, and Donna Pogliano, and "Beating Prostate Cancer: Hormonal Therapy & Diet," by Dr. Charles "Snuffy" Myers, MD. Both are highly informative, and I consider them vital reading for patients with unusual cases like yours.

    I have a sense that your doctor is rushing you toward surgery. I can see why he thinks you need some kind of treatment fairly soon, but there is a gamble in rushing: you may be making a choice of therapy that will not do the job, and, in view of your overall health, that could be a heavy burden. Usually it is better with prostate cancer to do it like the carpenter's old saying: measure twice so you need to cut just once. Prostate cancer is normally a fairly slow growing cancer, and your quite low PSA and normal Gleason of 6 are consistent with that (though the high number of positive cores is not). All in all, I'm thinking you would do well to take more careful aim. You may end up with robotic surgery from the same doctor, but there is at least a fair chance that one of the other options will emerge as being far more attractive.

    Please keep in touch and let us know what you are thinking and any questions.

    Keep up your spirits, and good luck with this.

    Take care,

    Jim

     
    Old 04-13-2009, 07:53 AM   #14
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    Re: Prostate Cancer Treatment Options

    Quote:
    Originally Posted by ohionutcake View Post
    choices: its agressively going toward the nerve and recomend the prostatectomy robotic surgery in 4-27-09 rush rush rush boy give me the help i need ive got medical background but you never apply it to your self
    there sending me to a onocoligist this wensday and a pet scan when i was 20 i was told and i had prostittitis and a prostate gland of an 80 year old man my current doctor is good on digital exam he said the prostate gland was very hard and large you all have been very informative and i really thank you keepit coming one other thing i have been on strong pain meds for years any one else so when i have surgery what i can use im a whimp no pain is what i like and this will make me more active with my size i cant afford to lay side pneu ect

     
    Old 04-13-2009, 09:45 AM   #15
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    Re: Prostate Cancer Treatment Options

    are you guys tired all the time

     
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