I am sorry. I did not make a note of those precise numbers in compiling my notes on this presentation. If I get the chance in what is going to be a very busy week I shall see if I can go back on review the video of Dr. de Bono’s presentation and post those numbers, but please forgive me if I don’t get to this.

You might recall me.

I am 49 years old. I had a robotic RP 6 months ago. Pathology report was as follows: Gleason 3 + 4; cancer volume, 6%; prostate weight, 38 grams; pathological stage, pT2c; no extraprostatic extension; one unifocal positive margin; perineural invasion present.

My pre-op PSA was wobbly between 2.9 and 5.8! And my bone scan and body scan were clear.

My post RP PSA 3 months ago was zero. I am scheduled for another PSA test in 1 month. I feel pretty healthy, with minor side effects.

However, over the past 2 weeks I have developed blood in my urine that at times is quite noticeable. It is accompanied with some major discomforts like urgency, pain, and some sensations. Urinalysis confirmed blood in urine but with no white blood cells or bacteria present.

I am very concerned. Could this be a sign of recurrence of the cancer in my urinary tract? Could this be because of usual side effects of RP and injuries to the urinary tract? How normal or abnormal is this 6 months after RP?

What is the next step (as my surgeon is not communicating well)?

Thank you in advance,

Abbas

***** Answer*****

Hi Abbas,

Not terribly uncommon, though usually associated with urine infection in the first year post-op. Your surgeon will be better able to address, so keep trying to communicate with him.

Arnon

You might recall me.

I am 49 years old. I had a robotic RP 6 months ago. Pathology report was as follows: Gleason 3 + 4; cancer volume, 6%; prostate weight, 38 grams; pathological stage, pT2c; no extraprostatic extension; one unifocal positive margin; perineural invasion present.

My pre-op PSA was wobbly between 2.9 and 5.8! And my bone scan and body scan were clear.

My post RP PSA 3 months ago was zero. I am scheduled for another PSA test in 1 month. I feel pretty healthy with minor side effects.

However, over the past 2 weeks I have developed blood urine in my urine that at times is quite noticeable. It is accompanied with minor discomfort. Urinalysis confirms this, with no white blood cells or bacteria present.

I am very concerned, could this be a sign of recurrence in my urinary tract? Could this be because of usual side effects of RP and injuries to the urinary tract? How normal or abnormal is this 6 months after RP?

What is the next step (as my surgeon is not communicating well)?

Thank you in advance,

Abbas

*****

Arthur responded as follows:

Dear Abbas:

Arthur is not aware of any specific reason why you would have blood in your urine that was free of bacteria and white cells. This is not a common side effect of radical prostatectomy that Arthur is familiar with, and if your surgeon is not communicating well, it may be that he is also puzzled by this condition, which may or may not be associated with your radical prostatectomy.

Arthur is not a doctor, and so it is hard for him to be able to tell you what the appropriate next steps might be, but cystoscopy (a visual examination of the urinary tract and the bladder) might not be a bad idea, to see if there is a specific source of the bleeding. You are right to be concerned about this, and Arthur would suggest that if your surgeon is unable to offer you a sensible strategy to move forward, you might want to seek a second opinion.

Arthur hopes this is helpful, but he is sorry he cannot offer more helpful guidance.

Doctor feels robotic surgery would be best treatment option but chance of cancer returning could be 50% within 5 to 10 years. Do you agree with the doctor and what are my chances of survival?

Thanks for your reply.

Worried

*****Answer*****

Dear worried,

Surgery could well be the best choice, depending upon various factors: height, weight, previous surgery, overall health, and the like. I am not sure I understand what you are asking in regards to survival. If you are asking what are your chances of dying of something other than prostate cancer (assuming you have surgery), then, depending upon your other medical conditions, the chances are good. Again, I’m not sure how to operationalize your question.

Arnon

I would certainly argue that anyone who has any reason to be concerned by their potential risk for prostate cancer would be wise to establish a baseline PSA level when they are healthy and in their 40s (or possibly even slightly younger).

If some 50-year-old presents at the doctor’s office in 2030 with Gleason 9 and several bone metastases and a PSA of 100, will there be a cure for him, or ways to manage such disease much, much longer than today?

May be then, testing at 40 is a reasonable approach, even though it is not blessed by the USPTF either (no age restriction on their recommendation).

The results for progression during what appears to have been fairly short follow-up for each man were 72.7% for African Americans vs. 63.8% for Caucasians, as noted above. These results are in striking contrast to the relatively uniform results under major active surveillance (AS) programs where roughly 60% to 70% are able to stay on AS long term.

Perhaps the difference between the results at Duke and typical results reported by major AS programs is that many of these men may have had case characteristics that would not have qualified them as good AS candidates under the major programs. If that is so, it throws a lot of extra doubt into the calculation of how African Americans would do under AS if they qualified by the main criteria that now seem to be emerging. Unfortunately, the ASCO poster abstract provides no data regarding median PSAs, PSA density, percent of cores positive, etc.

Diet: The thought about diet rings true for me. Possibly the pork, especially ribs, for which North Carolina is famous, is influencing the outcomes for both groups and partly responsible for the unfavorable overall results.

Every one of the very many arguments about PSA screening has landed up by saying, “Yes, we do need a better way of diagnosing which varieties of prostate cancer are potentially dangerous, but PSA is the best we have, so we need to keep on screening.”

I think that attitude more than anything else has been a major stumbling block in moving forward to diminish the over-treatment associated with screening. Hopefully there will be some movement forward now.

But I’m not holding my breath …