Arnon is Arnon Krongrad, M.D. and he’s been treating patients with early stage prostate cancer for 25 years. So he knows his stuff!
Dr. Krongrad is a highly experienced surgeon and researcher with interests in prostate cancer surgery and chronic prostatitis treatment. He practices in Aventura, Florida, and specializes in minimally invasive prostate surgery.
Dr. Krongrad will answer questions when he is able to do so, but he cannot guarantee to answer every question that is posted.
Dr. Krongrad is not your doctor and he cannot give you medical advice unless you become his patient. You should always talk to your doctor about your condition and what you should do.
You may post your question for Dr. Krongrad using the comments/reply box below. Questions and answers are retained on this page for approximately 60-90 days from the time they are originally posted.
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Hello, Doctor,
I am concerned about my PSA level 1 year after cryoablation. Before biopsy, it was 6.2, prompting the April 2010 biopsy that showed 1% cancer in 1 core (Gleason was 3 + 3, stage T1, unifocal). I had the cryosurgery on August 10, 2010. My quarterly post-surgery PSA numbers have been 3.6, 3.4, 4.0, and (3 weeks ago) 4.7.
The urologist who performed the surgery relays to me that this is not necessarily anything to be alarmed about, but my reading in medical literature and in forums such as this one suggests that these numbers should be MUCH lower. I’ll see him in the office at the end of October.
Do you have thoughts or experiences with post-cryo PSA numbers like this?
Thanks.
*****
Dear Steve,
Thanks for writing. I guess there are two issues: (1) What should a PSA be after (whole gland? partial gland?) cryotherapy; and (2) Should it diminish with time or bounce back up with time? On both counts, the values and trends are surprising and, as such, require some thought. Among the questions are these:
1) Is there residual cancer?
2) Is there cause for a repeat biopsy?
3) Is there cause for “salvage” therapy?
These are questions that you could consider directing to your urologist.
Arnon
Dear Dr Arnon,
Really need your advice, as my family are finding it very hard to get straight answers from the urologists, specialists.
My dad is 57 years old, smoker, weighs about 118 kg, put on a lot of kg due to quitting smoking, but started again, and has poor diet, has never had alcohol, and history of prostate [disease] in the family, not necessarily cancer. On Feb 23rd, 2011 my dad had symptoms of urinary problems, the obvious, frequency, urgency, etc. He had a PSA test done which came back 5.6 ng/ml! Urine sample showed no infection but GP started my dad on antibiotics. The course of medication was 1 month. [Afterwards] Dad was still in this condition and a bit worse and GP prescribed same medication for him again, and no, a PSA was not done again.
Dad finished second course of antibiotics and went back to the GP, told him of his situation getting worse. The GP prescribed another course of the same medication. Dad told the GP that the medication was not doing anything for him and asked to be referred to a specialist. He was referred but had to wait 2 months for this appointment. The family, being concerned, advised Dad to go to the hospital and not wait, so he went to the hospital on June 6th, 2011. His PSA was 11.3 ng/ml and his urine sample showed no infection. The next day he was sent, by the hospital, for an ultrasound and got an immediate appointment to see the specialist (also on June 7th). The ultrasound showed:
– NO HYDRONEPHORSIS OR URINARY CALCULI ARE DEMONSTRATED. THE URINARY BLADDER SHOWS A LARGE POST MICTURITION RESIDUAL VOID OF APPROXIMATLEY 260 cc. THE PROSTATE MEASURES 4.1 x 5.8 x 3.5 cm (44 cc). IMPRESSION MINOR PROSTATOMEGALY. SIGNIFICANT POST MICTURITION RESIDUAL VOLUME CONSISTENT WITH BLADDER OUTLET OBSTRUCTION.
On the day of the ultrasound Dad had to drink a litre of water in half an hour. After this my dad could not urinate and was in excruciating pain. He went to see the specialist, was sent to the emergency department to take fluid out and a catheter was put in. He was told to get weekly check-ups to see how he would do without the catheter and had to drink 1 cup of water every hour. By the third cup of water he was back in the hospital with the catheter back. To this day he has a catheter.
A month and a half after hospital admission for 1 night and being sent home the next day, without any biopsy test being done, my dad was seen in the outpatient clinic for the first time not by a specialist but “a major” (don’t know what that is). He said he only knows of two things that could elevate my dad’s PSA level like that: (1) cancer and (2) the catheter. My dad and my sister explained to him the test results were done before the catheter was put in but the doctor said this is not true; it’s not possible. Then he scheduled my dad for a biopsy on August 1st. We got the results of the biopsy on August 19th. They showed that my dad my dad had cancer with a Gleason grade of 9. He was started on anti-hormone tablets (only 50 mg once a day). He was told to take these for 1 month only and then stop it. On August 22nd he was given a CT scan and a whole body bone scan which showed the following:
CT UPPER ABDOMEN AND PELVIS WITH CONTRAST PERFORMED
– Enlarged prostate with surrounding stranding. Bladder callapsed. There is no evidence of metastases seen in the liver, spleen, adrenal glands and kidneys. Cysts are seen within the left kidney.
– There are small para-aortic lymph nodes noted. A retrocrural lymph node measuring 8 mm in the shortest axis. There are bilateral subcentimetre pelvic lymph nodes, measuring up to 7 mm in short axis diameter.
– Numerous focal sclerotic lesions are seen in all lumbar vertebral bodies and the visualized lower thoracic vetebral bodies, in the boney pelvis, more marked to the right. There also a few small sclerocic foci seen within the proximal femur. These are in keeping bony metastasis in this clinical context. Non-specific 1 cm nodule posterior to the left rectus muscle.
BONE SCAN
There are multiple focal abnormalities in the bone scan, best explained by widespread skeletal metastases involving the T7, T9, T10, L1, L2, SACRUM, RIGHT ACETABULUM, LEFT PROXIMAL FEMUR, DISTAL FEMUR BILATERALLY, TIP OF RIGHT SCAPULA, RIGHT CLAVICLE, LEFT T3-T6 RIBS POSTERIORLY, LEFT 3RD AND 4TH RIBS ANTERIORLY AND RIGHT 2ND, 3RD, 4TH RIB ANTERIORLY. It [the bone scan] does not replace a diagnostic CT scan.
Dad was told radiotherapy and chemotherapy were not an option only for pain. The only option is the anti-hormone tablets (50 mg once a day for 1 month only) and [during] that month he will have an injection that lasts for 6 months. The only operation he will be having (on September 27th, 2011) is a TURP operation because he still has the cathettr. (It was supposed to be done last week, but got delayed another 4 weeks. What a waste of my Dad’s time!)
I’m really, really, really sorry to have to resort to writing to you with this but its my father. I only have one Dad, and I feel he has been neglected by everyone, beginning with his GP. Please help. If my dad does not have long to live, I want to know. How long we live for, only God knows, but I’m asking medically, based on patients in this situation, roughly. No one is telling us consistent information. I want to know. There are things we/he might want to do. And if you think he does have a choice of having treatment, please tell me, I can bring them up with the doctors and get their thoughts about it. My dad was not given the option for anything. PLEASE HELP. WE DO NOT TRUST ANY DOCTOR AFTER THE WAY THEY’VE NEGLECTED MY DAD, and the reason I’m asking you is because you’re from another country. Who would have thought the public system in AUSTRALIA would treat people like this?
*****
Dear Najat,
Thank you for writing. I hear your frustration. Yes, it’s been a tortuous road.
Nobody knows how long your father has to live. What we apparently know is that he has a high-grade, metastatic prostate cancer that is only now first being treated. “Virgin” prostate cancers can be exquisitely sensitive to hormone treatments and after initial treatment patients can sometimes live a very long time (many years) and even come out of urinary retention, too, and not need a catheter any more. What’s good is that you now know what you are dealing with and can get him the right treatments and probably real relief.
Arnon
Najat:
Just a quick addition to what Dr. Krongrad has posted above. …
The drugs you refer to in your e-mail appear to be the correct forms of treatment for your Dad. The oral 50 mg per day drug is almost certainly a drug called bicalutimide or Casodex, which is normally given at the beginning of hormone therapy and is important in helping to prevent what is known as a “flare reaction” that can otherwise occur when your Dad gets the first 6-month injection of the LHRH agonist that has been prescribed. LHRH agonists are standard therapy for metastatic, hormone-sensitive prostate cancer. As Dr. Krongrad has told you, your Dad could respond well to this drug for many years. However, it is not a curative type of therapy. At this time we know of no form of curative treatment for men with metastatic prostate cancer.
It may help you to join the associated social network to get information from others like your Dad (including men in Australia) who are also dealing with this type of prostate cancer.
Sitemaster
Dr. Arnon
Is it possible to have metastasizing prostate cancer with a low PSA (0.01 ng/ml) after prostectomy, radiation treatments, and hormone blocker treatments. Before treatments my PSA was 22 ng/ml, Gleason 9, stage T3b.
Thank you, Ken.
*****
It would be unusual, but especially in the setting of hormones, which artificially lower PSA, it’s possible. The PSA alone is not sufficient to exclude the possibility.
Arnon
I am currently in the UCSF prostate cancer program in SF. I am a post-RP patient with a PSA that never nadired. Waited 3 years then started hormone therapy in March 2011. PSA went from 28 to negliable in 2 weeks on Casodex and before first Lupron shot. UCSF program is 1 year before going intermittent. Just wondering how strong the evidence is for 1 yr vs. 6 months? Struggling with severe sweating (although gabapentin is helping) and weight gain and would like to get off. Is there a serious risk here if I do go off after 6 months? I think change to largely organic eating and Eastern approach with herbs, acupuncture, massage, yoga may be helping. Had a Gleason 9 and obviously cancer cells escaped pre-RP.
*****
Hi Jeff,
I am not sure that the additional 6 months is the real issue here. Perhaps the risk:benefit ratio with which you are struggling is a main issue, which you can discuss with your doctor(s). Also at issue is if to consider a different approach altogether, such as re-staging, surveillance, and/or adjuvant radiation. You may want to review all these again.
Arnon
Dr. Arnon:
My husband just had a routine 3-month PSA test today. He is about a year out from robotic surgery to have his prostate removed. Up until today his PSA was 0.05. Today it was 0.20. The doctor suspects that his cancer has returned and he is scheduled for a bone scan and a CT scan to see if the cancer has spread. His Gleason scores were 9s and 10s but his margins were clean as well as his lymph nodes. His tumor was large and his cancer aggressive. The doctor spoke about having radiation therapy and hormone treatments in tandem. Are the chances of a cure still viable or are we looking at therapy for the rest of his life? we are devastated that the cancer has come back.
Sue
*****
Hi Sue,
Yes, a chance of cure is viable. Keep in mind that many times Gleason 9 and 10 prostate cancers are treated with more than just surgery, for the very reason you’re citing: rising PSA. Many times, patients live a very long time after that. Have a look at the story by Pete Gannon, who wrote it 7 years post-op. You can join in and interact with him if you like.
Arnon
Hello Doctor,
I’m 58, and my wife is a surgeon. I learned on June 30 after a biopsy that one of my 12 biopsy cores had 3% Gleason 3 + 3 = 6. Today I’m getting the work-up for a prostatectomy at the end of the month. I’ve put this off once to learn about radiation. I’ve decided that of the two, the surgery is preferable to me. My brother-in-law had the robotic surgery and that is what I’m to have.
I have such a small amount of cancer, I’ve considered other treatments. One in particular is focal ablation. I keep hearing ads on the radio about different methods. My urologist is a friend of my wife’s. They did their residencies together in New York City. He’s well respected and put me in touch with apparently a world renowned surgeon, Dr. Tewari.
My question … Would you recommend, with the amount of cancer I have, radical surgery or as my urologist said he would, given my degree of cancer, recommend it for his family, and we are friends? Would you honestly do this radical surgery for this cancer? My dad died at my age of prostate cancer in 1980; of course that is understandable given the year. I am so conflicted. I’m hopeful by selecting the robotic surgery I’ve made the correct decision. However, I have 15 days to change my mind, again!
Thanks
Joe
*****
Joe,
Take a look at this thread and the link embedded within it. See if these cases help you to think through the uncertainties of your situation. Feel free to join and post your situation and see if anybody comments.
Arnon
I am 57. Had RP 6 months ago. PSA was 7; Gleason was 3 + 4; biopsy showed total left side positive and half right positive; pathology report suggest cancer organ-contained.
Three-month PSA check was 2.5; 6-month PSA was 1.0. Is this normal? Should I wait and see if it continues to drop? My doctor is suggesting radiation. What to do?
*****
Danny,
The word “normal” doesn’t really seem to apply. The PSA levels are relatively high if this was an organ-confined cancer. At the same time, the trend is down and nobody knows yet where it will nadir. You may want to discuss with your surgeon how long you should observe this trend before making a decision on any more treatment.
Arnon
Dr. Arnon:
My husband is 67 and just received a letter from recent blood work stating that his PSA is 77.71. We are trying to schedule an appointment with a urologist but because we go through the VA, it could be a bit [slow]. I am very concerned about that level and have yet to find answers as to why it would be so high. Please advise what such a high PSA level could indicate and what tests we should pursue.
Thank you.
Tiffany
*****
Tiffany,
A PSA of 77 ng/ml can be caused by a variety of things ranging from urinary infection to pelvic trauma to prostate cancer. The absolute first tests he should have are a prostate exam (DRE; digital rectal exam) and urinalysis, preferably with a urologist. The bureaucracy needs to accommodate him.
Arnon
I’m 55 years old and recently received a PSA score of 18; referred to a urologist and tested again; score (after stopping riding stationary bike) dropped to 8 and now 4.5 ng/ml, all within 1 month. Urologist recommends biopsy.
I recently had a urinary infection prior to first test. I feel high scores are from infection. Not sure of next step? Can you shed some light?
*****
Jim,
It’s possibe that your PSAs reflect UTI and its resolution. The easy thing to do is recheck the urinalysis to be sure the UTI is gone and after it is gone to check the PSA again (and maybe staying off the bike until this is clarified?). Certainly a PSA of 4.5 ng/ml — assuming no infection, etc.– merits careful consideration in that it implies a risk of a positive biopsy of 25%.
Arnon
Hi Dr. Arnon:
Would appreciate your opinion on the following. My father, myself, and my brother all developed significant prostate cancer (all aged in our 60s) that required radical surgery and chemo. Because of the strong family history, I am concerned that my son (now in his mid 30s) may also fall victim to this malignancy. Is there any reliable genetic testing available at this time that may help in determining my son’s risk factors?
Many thanks
Neil
*****
Hi Neil,
I am not aware of specific testing that will quantify his risk, other than the family hisory and PSAs/DREs. For what it’s worth, it’s possible that your family cluster is not even genetic, but environmental. Clearly, either way, your son should be under close surveillance and the threshold for biopsy should be set low (but guided by PSA and DRE). I’d point out that I have seen patients as young as 30 with prostate cancer, so if he’s not had a PSA and DRE, he’s clearly not too young for it.
Arnon
Hi.
I’m a 68-year-old man. I had a PSA of 4.5. I had to have the PSA repeated after 3 months. My PSA is now 6.1, and I also have a water [urinary tract?] infection. Should I be worried? I know I’ve got a slightly enlarged prostate.
*****
Hi Patrick,
Assuming the infection has been cleared, the PSAs represent a risk of positive (cancer) biopsy of 25%. This is a fact that your doctor(s) can help you put into the context of your overall health.
Arnon
Dr. Krongrad,
I am 50 years old with a typically enlarged prostate but with a PSA level around 4 and no problems with my digital exam, just enlarged. Ever since I started testosterone injections I now experience daily a weird, dull pain — only between 5 and 8 p.m. It’s only on my left side, coming somewhere around my prostate area. My testicles are not sore and the pain seems to be coming from above the testicular area. Any idea what’s going on?
*****
Lawrence,
No idea. But it may be a mystical force trying to get you to a urologist to evaluate why a 50-year-old has a PSA of 4 ng/ml, which is associated with a 25% risk of prostate cancer. Either way, and regardless of what is causing your symptoms, a visit to the urologist seems in order.
Arnon
Hello,
I am only but 27 years old and I know for a fact that I must have prostate cancer. I started to notice this change in the way things went when I went to the bathroom. It seems the minute I lay down I have to go. When I go it takes forever. My genitals always seem to hurt and I have pain in my thighs.
I want to know is it over for me when having kids? … I have been dealing with this for at least 2 years. I would like to tell my family but my mother just passed this month and I don’t want to burden everyone. …
*****
JJ,
While anything is possible, including prostate cancer in your situation, it is much, much more likely that you have prostatitis, an inflammation that is sometimes due to simple bacteria and that is characterized by the kinds of symptoms you are describing. To get this properly diagnosed and treated will take a visit to a urologist.
Arnon
Hi Dr. Arnon
Thank you for your comments re genetics/prostate cancer. In this instance environmental factors would be very unlikely as my family is scattered world wide. Perhaps genetic testing will materialize eventually. I will ensure that my son regards his situation diligently. Thanks again,
Neil
Dear Dr. Arnon:
My husband is now 65 years old. In 2006 he was diagnosed with prostate cancer and his prostate removed. At the time his PSA level was 6.47 ng/ml.
After the RP, his PSA levels were at 0.04 ng/ml from 2007 to September 2010. They then rose to 0.15 in 2010, to 0.2 in January and April 2011, and now to 0.28 ng/ml.
His doctor’s office told us the doctor would see him again in January. I’m concerned about this and think waiting until January is not prudent. Do these PSA numbers indicate a return of the cancer? What would be your recommendation for our next course of action? I am very concerned about this and don’t want to wait if waiting will put his life in jeopardy. Thank you for your help.
*****
Dear Julie,
There seems to be a clear rising trend line on the PSA. So perhaps the next immediate step in interpretation is a review of the surgical pathology report, most importantly a clear understanding of the Gleason score, a tertiary pattern if there was one, vascular/lymphatic invasion if present, surgical stage including extent of extraprostatic extension if any, and positive margins and their extent if any. This review will help to refine the assessment of what all this PSA means.
In parallel, there is the issue of your anxiety, which, while it does not in itself change your husband’s clinical prognosis, deserves some attention (you also deserve peace of mind). So perhaps in this light, a repeat phone call to try to advance the appointment is something to be considered.
Arnon
Hi,
My 72.5-year-old husband was diagnosed with prostate cancer on 5/3 of this year and a bone scan confirmed the cancer had moved outside the prostate and is throughout his bones from skull to trunk, yet he has no pain. He had 4 + 5 and 5 + 4 on his Gleason scores. His PSA was 600 ng/ml. He was put on Casodex and had a Vantas implant placed in his arm. Yesterday, we saw the urologist and he said that his blood test now shows a PSA of 0.42 ng/ml and a testosterone of 0.09. He said it doesn’t get any better than that! He said he will die from the cancer when it comes back, but for now God has granted him more time — maybe even 2 to 3 years.
My husband is still tired but no pain. Is this normal for this internal radiation, and can we realistically expect to gain years? Is this considered remission? Since the cancer cells obviously have been targeted and destroyed, since it was very aggressive, why can’t it kill all of the cancer? Thank you for your opinion about this. I really would like to know what we can expect now from this point on. I wonder if it will return quickly or will it take a long time?
Thank you for any information you might share from your experience.
Peg
*****
Hi Peg,
You ask lots of good questions, for which answers are only partly available. So there’s gonna be some uncertainty in any answer you get.
I’m not sure what you mean by radiation, since you only mention hormones in the intro paragraph. However, yes, fatigue is very common with hormone treatment. It’s one of the common side effects (as it is for radiation).
While you cite 2-3 years of survival, the fact is that some patients go much longer than that. So as I said, there is some uncertainty here, some of it on the positive side.
Arnon
Hi Doctor Arnon.
My husband had an RP and his Gleasons were 9s and 10s with stage T3 but negative margins and negative nodes. That was a year ago.
At the last appointment his PSA had risen to 0.27 ng/ml. Bone scans and CTs came back negative. He got a shot of Lupron and met with a radiation oncologist. The radiation oncologist feels the best route is to do 26 treatments of higher dose radiation (still trying for a cure) instead of 40 treatments at a lower dose. What are your thoughts? He will also be on hormones for 6 to 8 months in conjunction with radiation. Your thoughts on the shorter duration but stronger radiation.
Thanks.
Sue
*****
Dear Sue,
Radiation dosimetry is a highly refined art practiced by radiation oncologists. I am simply not qualified to comment on the relative merits of fewer doses (hypofractionation). If you want a second opinion, you’re best off directing your very valid question to a second, independent radiation oncologist.
Arnon
November 2010 — PSA dectected at 5.9 ng/ml. In March 2011 — PSA was 7.4 ng/ml; followed up with biopsy.
Nine cores on left side and 4 cores on right side positive out of 18 cores total. In April 2011 had RP. Pathology reports totally contained.
In July 2011 first PSA was 1.49 and at September 2011 second PSA was 1.50 ng/ml. Are these numbers normally this high right after RP, and what should I consider next?
*****
Dear Danny,
PSAs should drop to <0.1 ng/ml after RP, although this may take some time to happen, but not as much as you are reporting. It would seem that two steps could next be under consideration:
(1) Review of the pathology report, with special attention to the grade and any other features, e.g., vascular invasion
(2) A review of the PSAs and their meaning with the surgeon
Arnon
My husband’s PSA level in 2008 was 4.7, then 8.7 in 2011. His urologist suggested a biopsy. His DRE was normal. When his PSA was retested 6 weeks later it was 7.1 and his free PSA was 9.
He refuses to have a biopsy until he can get better confirmation of whether cancer is present because of his fear of over treatment and side effects. I am very nervous. Is there any test you can suggest that would confirm a need or no need for a biopsy and what are your thoughts on these scores. He is 55 years old and otherwise in excellent health.
*****
Michelle,
The urologist is making sense because the scores raise the possibility of a positive biopsy, perhaps in the 25% to 30% range.
The fear of over-treatment is irrational, given that no treatment has even been proposed (because no diagnosis has been established). It actually sounds like both of you are facing fear/anxiety together, each in his own way. So the question is if the two of you can openly discuss your fears and anxieties and help each other as you work through them.
Arnon
Why is perineural invasion in a prostate biopsy specimen not the same as PNI in prostatectomy specimen? I would think they are the same. My post-op pathology had PNI and not my two biopsies … Thinking that the needles are a hit or miss because of their small needle diameter. Thank you.
*****
Tom,
PNI is PNI, regardless of who saw it where. The discrepancy surely indicates the sampling limitations of prostate biosy.
Arnon
Hi Doctor.
My 75-year-old father had a PSA done and it was a level 2.5. Six months later he was retested and his PSA had jumped to 10. He had a biopsy done and it indicated he had prostate cancer. He also has bone pain, back pain, and arm pain and is taking pain pills and the doctor said his nerves are out of place. My dad has lost 20 lb in 6 months and doesnt look good. The doctor did an MRI and said it does not look like the cancer spread to the spine — which we initially thought.
We are meeting with the oncologist and urologist next week and would like to know what questions to ask. At this point, we do not know what stage he is in until the meeting in a couple of weeks. The doctor also said they don’t know the stage yet, which is confusing to me because it has been a week already. Also, my dad is saying he should have his prostate removed, but because of his age, I am not sure this would be the best thing. Any advice you can give me would be greatly appreciated.
Thank you.
*****
Hi Veronica,
There are several issues to sort through, the first being the grade and stage of the cancer. With a PSA of 10 ng/ml, the likelihood of advanced stage is low. However, the PSA level alone is not enough to rule this out. For this reason, the first set of questions should revolve around the question of whether or not this is a cancer that is confined to the prostate. The answer will strongly influence the treatment choices.
Also the age is in itself not a sufficient criterion for treatment choice. If he is a very healthy 75-year-old and has a high grade but low stage cancer, then surgery is not off the table. That’s a lot of “ifs,” so his doctor(s) will have to guide him carefully through them.
Arnon
Dr. Arnon:
My brother-in-law — almost age 55 years — was diagnosed 3.5 years ago with stage 4 prostate cancer. He has had various treatments and appears for now to be holding his own, including being treated with Provenge. My question is this: he recently had a colonoscopy and his PSA level went through the roof and his doctor’s office said it is highly common after a procedure like this and we want to have the the inflammation/swelling go down, so come back in 4 weeks when we expect it will be back in an appropriate range that it was prior to the colonoscopy. Is this true that the PSA level can go dramatically up after a colonoscopy?
Thank you
Andy
*****
Hi Andy,
It’s unusual to check PSA right after colonoscopy, so this is not a situation that I’ve heard of before. That said, it’s not clear to me that even theoretically a colonoscopy would cause a PSA to go “through the roof.” The repeat makes perfect sense to help clarify all this.
Arnon
Dr Arnon,
My husband was just diagnosed with prostate cancer. The doctor went from telling him how awful it could be to how it could be fine with treatment.
My question is in regards to the treatment. They have started him on protease inhibitors. Would this be considered somewhere along the watchful waiting with a little push from a drug?
My husband is freaking out, possibly due to the way the diagnosis was given to him. I don’t see any information out on the web really about the use of protease inhibitors.
Thanks for your website. It has already helped a ton.
Deb
*****
Dear Deb,
I’m afraid I don’t know how protease inhibitors will help your husband. What you may want to consider is going back to learn his grade and stage and then putting those into the context of his overall health as you help him to decide what to do next.
Arnon
Dear Doctor,
My 69-year-old father had a PSA done 5 months ago and the result was 4.5; after 3 months it had gone up to 5.6, and now (after another 2 months) it is 6.5 ng/ml. We’re from Iran. My father takes a terazosin tablet every night, but I don’t know why it is going up so quickly. Six months ago he had a test and there was no sign of cancer, fortunately.
Would you please give us some tips to cure?
Thanks a lot.
*****
Hi Amir,
PSA is not a disease, which means that it does not require a cure. If your father is diagnosed with a disease, such as prostate cancer, possibly after a biopsy that might be done because of his PSA, then a discussion of cure becomes relevant.
Terazosin is an alpha-blocker and has no real effect on PSA. So far the cause of the PSA rising has not been explained, and it may be from reasons other than cancer, such as infection, trauma, and prostate enlargement. You may want to take your father back to the urologist to discuss the wisdom of a repeat biopsy.
Arnon
Dear Dr. Arnon,
I am 53 years old and was recently diagnosed with prostate cancer, 1/12 cores came back positive, Gleason Score 6. My father had beam radiation for prostate cancer at 83 years old; he is still going strong at 94!. My PSA runs 3.8-4.6. Both urologists I have seen recommend RP and I am really wondering if this is the right course of action. I just read Dr. Gary Onik’s book “The male lumpectomy” and am very interested in getting a 3D-PMD done to better understand the extent before jumping into a whole gland removal, I live in Michigan and am looking for a doctor who conducts this biopsy procedure — Any info would be greatly appreciated on recommendations or contacts.
*****
Dear Mr. Malm,
I am not sure what you mean by “biopsy procedure,” in that your cores came from a biopsy procedure that you have already had. You may want to get this and any treatment choices clarified with the urologist who did your biopsy.
Arnon
I am 9 years post radical removal of the prostate. (Pre-surgery: stage T1c, PSA 4.4, Gleason 3 + 3 = 6.)
I have gone these 9 years with PSA scores of zero. My most recent test was a psa of 0.1.
Any way of telling the statistical percentage that I am in the beginning of a re-occurrence?
Thanks
Frank
*****
Frank,
At this stage, given that PSAs are often “wobbly,” the first thing I’d recommend is a review of your original pathology report (positive margins, vascular invasion, pathological stage, pathological grade) and a repeat PSA. Much better than going by the clinical findings from before surgery.
Arnono
I am confused as to the PSAV (velocity) and the recommendation of my PA to get a biopsy.
My PSA has been normal for the last 3 years. It was 1.5 ng/ml in January. A recent test in September showed 9.0 ng/ml. Is it common for PSA to jump this high within 9 months, and if so why? Also, do you think a biopsy is necessary before any further testing? I am not experiencing any discomfort, problems with urinating, or any thing else. I am 51 years old and I feel normal. Any suggestions would be appreciated. (I’m stressing out over this). Thanks.
*****
Dear Terry,
No, it is not common for PSA to jump this dramatically. But it happens. So the question is why it is now 9 ng/ml. Among the reasons are benign enlargement and prostatitis, both of which are generally associated with symptoms, which you do not have. Among the reasons also are prostate cancer, which is generally not associated with symptoms and which would be the only conceivable reason for a biopsy.
Among the suggestions I’d make is to review your situation with your urologist, not a PA, and/or repeat the PSA and then make a decision.
Arnon
Dr. Arnon,
Sorry, I should have explained further — the biopsy I had was the traditional transrectal and I am trying to find the best place that would conduct a 3D mapping biopsy.
*****
Thank you for clarifying. I cannot advise on where this might be done.
Arnon
My husband was diagnosed with prostate cancer 14 years ago and had his prostate removed. His PSA remained 0 until 2 years ago when it started to rise. He had radiation on a lesion they found in C7. PSA went down to 0. Then it began to rise again. He is on Zometa and Zolodex. His PSA was lowered to 8 in July but went up to 55 in September. The oncologist now wants PSA repeated and also a serum testosterone. What is serum testosterone?? Is this a death sentence?
*****
Hi Aggie,
Not knowing your husband as his doctor, I’ll leave the prognostic assessment to his oncologist. I just don’t know.
What you should understand is that testosterone is a hormone (chemical) made by the testicles that cause prostate cancer volume to grow and PSA to go up. Zoladex is designed to suppress the testosterone. It sounds like the oncologist is checking to make sure that the Zoladex is doing its job. You can certainly ask him why he wants to know.
Arnon
My stepfather has high levels of PSA in his prostate and just found out [?] of 12 biopsy cores are cancerous, and he’s been complaining about his legs being weak. Please help me to understand what were up against and the long-term prognosis. They are talking radiation.
Thank You,
Belinda Ansley
*****
Dear Belinda:
On behalf of Dr. Krongrad, he or anyone else would need a lot more detailed information in order to help you get good answers to your questions. We strongly suggest: (a) that some of your questions need to be directed to the doctors who have diagnosed and are suggesting treatment for your stepfather; (b) that if you join our social network we can help you to understand more about the type of information you need to obtain from your stepfather and his doctors in order to help your stepfather make good decisions.
Sitemaster
Hi Dr. Krongrad and everyone else on this site.
Back in May I had posted a question after my husband was diagnosed with prostate cancer. I just want to thank you and the contributors to this site for the advice and support you all gave me at that very distressing time.
On August 17, my husband had a da Vinci robotic prostatectomy, and I am so very happy to say that 6 weeks later he is almost completely back to normal. He has had no issues (almost from day one) with incontinence. He went back to work 2 weeks ago without any problem, and he will be back in the gym this weekend. Yesterday, we received the good news about his latest PSA results — 0.01.The only problem he has now is ED, but with the way he has recovered so rapidly, we are hopeful that he will recover that function too.
My husband had a wonderful surgeon, and we are very grateful to him, but I also want to thank you once again, because you provided support when I needed it most.
My husband is 56 years old. He was diagnosed with clinical stage II, Gleason 7 prostate cancer in August, and is scheduled for da Vinci robot-assisted surgery at the end of October.
He is nervous about a scheduled pelvic MRI due next week and what the findings will be or if the cancer has spread. Can you tell us what does this MRI is intended to show about the location and potential spread of the cancer? If it shows that the cancer has spread outside the prostate, does the Gleason score go up, and will surgery still be an option? How long does it take get the MRI results? The waiting and the unknowns are gut wrenching for all.
Thanks Dr. Arnon. We appreciate your help.
*****
Dear Deanne,
I can certainly appreciate the anxiety of what you’re describing. Take a step back to get some clarity on a key point: grade and stage are independent measures. So the MRI, which is a staging test, has absolutely no bearing on the grade, which is captured by the Gleason score as assigned by the pathologist who read the biopsy.
I would think that yes, the MRI is intended to show location and potential spread. In this, it has some limitations of non-specificity, so even after the MRI there will be some uncertainty about the stage. Not having seen the biopsy report and not having done your husband’s exam, there are some details missing for me. So as to the finer applications of the MRI findings, it makes the most sense to review them with his urologist.
Arnon
I had a TURP a year and half ago in which was found stage T1a adenocarcinoma of the prostate, with a Gleason grade 6. The urologist removed it.
Two months later a blood draw revealed a total PSA of 8.45 mg/dl, with Normality “A”, and last week another revealed a 15.22 mg/dl, also with Normality “A”.
I like my physician, but all of this is still foreign to me. I was informed that, because of extensive exposure to dioxin during Vietnam and because my diabetes is related to Agent Orange, I may be eligible to make a claim based on cancer of the prostate, but before pursuing that angle, I’d like to know what the results of my blood draws above are all about.
*****
Bernie,
The PSA measures risk of prostate cancer. The TURP, which showed you had some prostate cancer, has to some extent disrupted our usual quantitative frames of reference. That said, the PSA would be expected to drop over time, not rise over time. In other words, unless there is an easy explanation for the rise, e.g., a new urinary infection, then among the possibilities is that there is residual cancer. This would be true regardless of the actual PSA level but the rise all the more emphasizes the point that the TURP may have merely uncovered the “tip of the iceberg.” So regardless of your administrative eligibility, it makes sense to review these clinical points with the surgeon who did your TURP and/or your other doctors.
Arnon
I am a 67-year-old male. I was diagnosed with both colorectal (T3N) and prostate cancers (Gleason 6) in 2004. After 2 months of EBRT and chemotherapy I had a LAR with an ileostomy, then 4 months additional chemotherapy (5-FU and Folfox). The ostomy was restored in December 2005.
Brachytherapy was done in February 2006. My PSA dropped from its initial 5.1 to 0.65. At about 24 months post-brachytherapy, the PSA began to slowly and steadily rise. Last year it was 4.1, May this year 5.1. The September 11 PSA was 6.2. Recent bone and CT scans were both negative.
My urologist wants to start hormone therapy, but my oncologist is reluctant because I am asymptomatic. Also, I had a right lung wedge resection of metastatic colon cancer in September 2009, and a partial lobectomy of the upper lobe of the left lung in September 2010. I know that sounds like a lot, but I am physically fit, play competitive racquetball, and my lung capacity is back to full measure. The recent CT scan shows no new activity. My concern is whether to do something about the rising PSA now, or wait until there is clinical evidence that warrants treatment. I have been advised that I am not a candidate for prostate surgery due to the LAR. DRE has been difficult to evaluate due to scar tissue from the LAR.
*****
Dear Charles,
Several issues:
1) The DRE would be hard to interpret in any event because of the brachytherapy. So in itself it is even less of an objective guide of treatment than usual.
2) Salvage prostatectomy is technically possible. It would be associated with a double dose of risk of incontinence and rectal injury because of the double interventions: brachytherapy and lower abdominal resection. Challenging and risky, but possible.
3) The question of any more prostate cancer treatment, be it by salvage prostatectomy or hormones or anything else, must take into acccount not only the risks of those treatments but also the benefits. In other words, they must take into account the competing risk of metastatic colon cancer and what it and/or any other concurrent illnesses (diabetes, etc.) mean for prognosis. In other words, if prognosis is limited by colon cancer, then what is the benefit of treating the prostate cancer? (and what would it mean for the raquetball and such?) This is a difficult, subtle, and important question that I am not in a position to answer for you. Your doctors, on the other hand, would seem to be the right address for this question.
Arnon
Are headaches common for a man who has advanced prostate cancer? Does it more or less mean it’s spread to brain?
*****
Hi Tiffani,
There are many causes for headache, so having headaches does not specifically denote metastatic prostate cancer. Certainly, in addition to the numerous normal causes, the stress of dealing with a cancer diagnosis and the doctors and treatments can be one of the causes of headache in a man with prostate cancer. In addition, in rare cases, prostate cancer treatment with hormones can cause high blood pressure, which can secondarily cause headache (see this story). The patient should seek consultation with his doctor(s) and let them evaluate the situation from the ground up, which should include the prostate cancer specifics but also other possible causes.
Arnon
Hello Dr. Arnon,
My name is Dan and I am 32 years old.
About 2 weeks ago I started having the urgency to go to the restroom and I was able to go but it was just a lot. After approx. 2 days I felt the urgency all the time and I was not able to go. I had problems starting the flow; it was interrupted; and when it stopped I still felt like going. On top of this, I don’t have normal erections (nocturnal or morning); when I have them they are weak and I don’t feel any sexual drive. (This is very surprising for me because previously it was the exact opposite.)
The urinanalysis came back normal; my PSA was 0.97 ng/ml, and the doctor started me on ciprofloxacin, 500 mg, twice a day for one week. After the treatment I still feel like going most of the time but the urgency is not that strong; the flow is stronger but I still don’t feel any sexual impulse. (I am sorry to repeat myself but this is a very surprising fact for me and it happens for the first time in my adult life.)
I am white, a little overweight, trying to eat and live healthy. I don’t know of any history of prostate cancer through my family; my father, who is 60 years old, has benign prostatic enlargement, but my symptoms were way worse than his.
I am quite concerned about all this, especially that I have the symptoms for the first time (sometimes, after sex or when stressed, I was not able to go but the symptoms were very, very mild compared to the ones experienced now) and I would like to ask you if a score of 0.97 ng/ml is a normal one for my age and what do you think about the whole issue?
Thank you very much for your time, I would really appreciate your input,
Dan.
*****
Dear Dan,
You’re describing an unusual cluster of symptoms that seem to originate in your prostate, bladder, and/or neurological and/or endocrine systems. To dissect out the possibilities, which range from depression to multiple sclerosis to prostatitis to prostate cancer to bladder stone is going to take more than I could possibly suggest in this forum. You are probably best off broadening the discussion beyond the prostate, which can certainly be afflicted by cancer and prostatitis at your age, to consider the full range of possibilities. To this end, you may discuss this broader net with your urologist but also your primary doctor.
Arnon
I have a biopsy coming up and the urologist wants to do a pre-biopsy swab. I understand that this is part of a study. But is it the standard of care for performing a biopsy?
*****
Terry,
Good question. It may be part of his standard. You can ask. And you can ask what the study aims to test.
AK
Hello Doctor,
My husband (64 years old) was recently diagnosed with prostate cancer. `His PSA level was 9.(something — can’t remember exact number — still in shock, and not familiar with terminology). His Gleason score was 8 (4 + 4).
His local doctor referred him to a doctor at Duke, and we’re supposed to have an appointment as soon as possible.
My husband’s doctor kept saying to get the surgery done as soon as possible, after he waits 6 weeks for the biopsy areas to heal.
Can you please explain what all this means in plain English?
Thank you very much.
*****
Rose,
The Gleason score runs from 2-10, where 10 is the most serious. An 8 is fairly high, obviously, but does not in itself suffice to tell us the stage (how big is this thing?) of the tumor. So it’s important to address the new diagnosis in the context of overall health and other things, such as the stage, which the urologist can help you understand, the number of biopsy cores positive, and the like.
AK
Dear Doctor Krongrad:
I had an MRI scan of my pelvis about 2 years ago. Would this have covered my prostate and can I therefore take it that things are OK? I hated going in the MRI and couldn’t face it again so it would be a bonus if it covered that as well. My father had prostate cancer so I believe.
*****
Barry,
It’s possible that the pelvic MRI covered your prostate. This would be of limited diagnostic value, assuming the aim is to diagnose prostate cancer. Not knowing why you had a pelvic MRI, I really can’t advise any further, other than to say that these are the sorts of questions that are best directed to your doctor(s).
Arnon
Dr. Arnon:
My father was diagnosed with ALMOST a stage 2 prostate cancer in Sept. 2011 at the age of 56. :(
It was a shock to all of us and we are hoping for the best!
My question is: He doesn’t want surgery and he has completely changed his diet and is eating the way they say to eat to help the cancer cells lower, but does this help? What is the survival rate for someone who has this cancer but is not getting surgery although he is doing EVERYTHING in his power to make it better? I would honestly be lost without him. :(
*****
Melanie,
Lots of good questions. Lots to talk about. Maybe you’d like to join our Daughters group?
The only thing I can offer is my experience in my situation. In May 2009 (age 46) a routine exam showed my PSA as being 5.0 ng/ml. I had a biopsy that came back 1 out of 14 samples positive (less than 3%); Gleason of 3 + 3 = 6; Stage 1.
I decided to do watchful waiting. I changed my diet drastically: no red meat, no milk, no junk food; only water, fruits and vegtables (lots of dark greens), chicken, and vitamin “D”.
I lost 30 lbs and at my last check-up (in July 2011) my digital rectal exam was normal and my PSA was 0.88 ng/ml. I get another check-up in December and from then on only every year.
Hi Dr. Krongrad,
I am a 30-year-old male that has a left-based variococele and right spermatocele. I did visit a urologist who suggested to me that until I had fathered children the spermatocele was best left alone because of the risks of damage to the epididymis.
However, I recently discovered the article on your website from 2009 about ‘Gat’s Hypothesis’ and this article – http://www.sciencedaily.com/releases/2011/06/110616142726.htm — which suggests that variococele can be a significant problem now, and indeed later in life with an correlated increase in risk for prostate cancer.
I am wondering whether it is better to get the variococele surgically treated now? I am really concerned that any inaction might be exposing me to more problems later in life. My family has no history of any issues.
What are you thoughts regarding variococele, etc.?
*****
Andrew:
Several facets to your story:
(1) Even if it marks a high risk of future prostate cancer, I would be skeptical about the validity of any assertion that varicocele causes prostate cancer. Furthermore, there are no data to show that surgical treatment of varicocele brings a man into a lower risk category. This one is in the curious, but I have no idea how to act on it, category.
(2) The urologist is making a good point. There is risk of infertility any time you do surgery on the sex organs.
(3) One always has the option to bank sperm. Fatherhood is mechanically more complicated when using unfrozen sperm and surely less pleasurable for the would-be mother, but … it’s a fertility safety net that one can consider if surgery is to happen in any event.
(4) Gat is interesting. If you write to him about your situation, please share if he responds.
Arnon
Dear Dr. Arnon:
My father is 69 years old and he received the following results after a TRUS-guided prostate biopsy:
– Prostatic adenocarcinoma, Gleason score 6 (3 + 3).
– Tumor location: left peripheral zone and left apex and a suspect focus in left mid-gland.
– Tumor volume: 4 of 13 cores with tumor involvement, composing about 10% of received tissue (total linear mm of carcinoma/length of cores: 18/167 mm)
– Presence of perineural invasion.
– No extraprostatic tumor extension in this samples.
We are from Iran. I want to know what we should to do, and what these results actually mean. Is this dangerous or not? … Please give us some tips and advice in order to be able deal with this if there is problem.
Thanks a lot.
Amir
*****
Hi Amir,
Prostate cancer must always be seen in the context of overall health: i.e., the other things that may also be a problem. So, for example, you have to look at smoking history, obesity, other illnesses … and then decide if the prostate cancer has a chance to become a problem before the other things become a problem.
Arnon
Thanks Dr. Arnon.
My father does not smoke; he is not fat; just a blood pressure problem.
As the result is: Prostatic adenocarcinoma, Gleason score 6 (3 + 3), does he need surgery? Is it dangerous?
Thanks again
*****
Amir,
Prostate cancer is a progressive and potentially life-threatening illness. Because I cannot be your father’s online doctor — there is way too much I could be missing — I would recommend that you take this question to his doctor(s).
Thank you.
Arnon
Hello Dr. Arnon.
My friend who is 52 years old had RALP done approximately 3 months ago. His Gleason score was 6 (3 + 3); his PSA level was 4.05 ng/ml.
A few days ago he had his first PSA test result after surgery and it read 0.1 ng/ml. Does this means that he is totally cancer free? Or does it means that it can come back. I personally thought that a 0.0 ng/ml would mean totally free. Please help since I was not with him at the doctor’s office.
Thank you,
Mary
******
Hi Mary,
It sounds like you’re reporting his pre-op findings. The long term prognosis is best assessed by the post-op findings. So the first step is to check what the pathologist reported after surgery: Gleason grade, stage, margins, vascular invasion, etc.
Secondly, one can never know with certainty that any patient is “cancer free.” So while we may get a sense that the likelihood of recurrence is very low after checking the post-op findings, we still recommend periodic followups, of which PSA is an element.
Finally, the PSA may have been <0.1 ng/ml (which means “less than” 0.1 ng/ml), as is commonly reported when it's very low. This is different from 0.1 ng/ml. Many times that little “less than” sign is missed by people reading and reporting the result. Best to check it.
Arnon
Dear Dr. Arnon:
I have had BPH for about the last 8 years. I see a urologist every 3 months and my PSA levels have been in the 4 to 5 range but haven’t changed much over the years. My last two readings though were more in the 8 to 9 range. My doctor wants to put me on Cipro to see if he can get the levels down again. He said if they don’t go down, he will need to do a biopsy. Is this a standard practice to use an antibiotic this way? Also, even if the levels go down, it it possible this is just masking a problem?
Thank you.
*****
Art,
You are describing a common practice, yes. Will it do anything? That really depends upon whether or not the PSA is high because of prostatitis due to bacterial infection. This is something that can be partly assessed by reviewing your symptoms, if any. If there is cancer, then ciprofloxacin won’t do anything to it, so it may eliminate bacteria but not the cancer. So in that sense, and contrasted with medications that act directly on PSA production, such as Lupron, it’s not really masking anything.
Arnon
Hi. I had an RP done in June 2006 and have had a PSA level of < 0.01 ng/ml with and ultrasensitive psa test every 3 months since then. … My last test was in July 2011. … I just noticed blood in my urine this morning. … Is that a cause for concern? … I did have a positive margin in the area of the bladder and I had a PSA of 57 before surgery. … After surgery I underwent radiation and chemotherapy plus 2 years of hormone treatment and have been healthy since then except for some bone loss.
*****
Dear Patel,
Blood in the urine is a nonspecific, nondiagnostic finding that may signal anything from urine infection to kidney stone to bladder cancer to recent trauma … and more. It’s best to let a urologist evaluate and sort through all the different possibilities.
Arnon
Dr. Arnon,
I’m a 64-year-old white male. I’ve had prostatitis on and off for about 20 years, with only a couple of bacterial episodes. I’m otherwise in good health. For the past 20 years I’ve had annual PSA tests which have varied between 0.9 and 1.1. Recently, there’s been a rising trend — the last four tests have been 0.8, 1.0, 1.3, 2.0.
My urologist said that my DRE exam was normal. He said he understood my concerns, and suggested a 3-month and 6-month PSA follow-up with a visit and decision as to further investigation, such as trans-rectal ultrasound and biopsy to be made at that time based on the results.
My father died of prostate cancer when he was 85. I suspect he may have had it for quite a while, because he had an emergency TURP about 5 years before his death. This was some time ago, and he was not monitored or checked for prostate cancer as far as I know until it had spread widely and was diagnosed at the hospital.
I’m concerned because of my family history. Should I be relaxed about the time frame for follow-up, or should I be wise to look for more aggressive investigation at this time?
*****
Isidor,
One can have prostatitis, enlargement, and prostate cancer but this does not mean that one causes the other. What is interesting in your case, more than your father’s “trifecta,” is the PSA value and the family history of prostate cancer. Given those features, the likelihood of a positive biopsy is approximately 20-30%. The question back to you is this: If one in four men with these features will have prostate cancer at biopsy, should all four have a biopsy? More to the point: If these are your chances, do you want a biopsy? If so, then you have your answer.
Arnon
Dear Dr. Arnon:
I am a 51-year-old Caucasian who is slightly overweight. I just received the news that I have prostate cancer. This is a result of having a PSA level of 5.5 ng/ml from a blood test a year and a half ago and then having another blood test (done on September 21, 2011) that came in with a PSA of 8.43 ng/ml and a free PSA of 8. My latest blood work, which was done October 26, 2011, came in at 10.4 for PSA and 11.1 for free PSA.
A TRUS biopsy was done a week ago and I initially received the test results over the phone. I am confused on what my Gleason score really is. Here is what I was told: The left apex was 4 + 3; the L mid was 3 + 4 and the L base was 3 + 4 with the left side of the prostate being 50% involved. The right apex was 3 + 3, the mid was 3 + 3 and the base was 3 + 3 with less than 10% involvement. How am I supposed to take all of the six Gleason scores and come up with just one? Would it be a Gleason 7 by taking the highest Gleason that showed up in the left apex of 4 + 3?
I have since received the pathology report. My biopsy was done with 12 cores. I am going to assume that all 12 showed evidence of adenocarcinoma. Here is the pathologist’s diagnosis. R-apex less than 5%, R-mid less than 5%, R-base less than 5%; L-apex 50%, L-mid 30%, L-base 20%. The left apex came in with a Gleason score of 4 + 3 and here is the pathologist’s comments on the specimen. “Three fragments of prostate needle biopsy tissues are present on this slide, one of which is quite small. Adenocarcinoma is present in all three fragments with areas of prominent cribriform formation as well as areas of irregular shape and moderate cytrologic atypia. Perineural invasion is also focally evidenced.”
None of the other samples showed perineural invasion (PNI). But from what I have read about PNI this is not a good sign.
I will be getting a bone scan and also a CT with contrast this Thursday and was wondering if they should be ordering an MRI also. Do you think it is prudent to introduce this much radiation into the body on the same day? Do you think it would be prudent to get both a CT scan and an MRI to determine lymph node involvement?
I am not real confident in the level of expertise of my current urologist. He does perform robotic surgery but has said that he has done around 300 biopsies in his career. That did not seem like very many to me. I have not asked him how many surgeries he has performed. I am currently looking for a second opinion but am overwhelmed by the big “C” bomb being dropped on me today and the thoughts of the possibility of the cancer having spread to either the bone or lymph nodes. Please give me some guidance.
Doug in Utah
*****
Doug,
I’d rather not shoot from the hip on your grade. Too many loose details. It’s best to look at the report and/or let your urologist and/or pathologist explain what the pathologist meant to say.
You ask an interesting question about the radiation, one for which I have no answer. I’m not sure what the risk is to you of the radiation from the CT and bone scan and have no idea if separating them out over a few days makes any difference to that risk. If you ask a radiologist and get a good answer, please share it. Overall, the recommendation to have a CT and bone scan given your findings does seem reasonable and is certainly within the common practice.
Arnon
I have not seen you answer any question in your blog. Or do you give any relief to those who have been diagnosed with prostate cancer!!!
*****
Dear Marcy:
On behalf of Dr. Krongrad. I can assure you that he answers questions posed to Ask Arnon on a regular basis. For example, he responded to two questions earlier today.
You do need to appreciate that — for legal reasons — Dr. Krongrad may not be able to give specific answers to some questions. He may not have been provided with relevant information, and he has not seen the patients. However, I can assure you that Dr. Krongrad, Amy, and Arthur provide answers to every question that is posed to them as quickly as they possibly can (which does not necessarily mean within 24 hours, although that is the goal they strive for).
Sitemaster
My husband’s PSA was 5.5 in August 2011, 3.9 in September, and 5.2 in November 2011.
His biopsy showed no cancer! What causes his PSA to go up and down?
Thank you.
Brenda,
Among the possible factors are infection, inflammation, trauma, sex, and enlargement. Surely there are many more that we have not yet identified. The important part now is to put this into overall context and decide his next move, which can range from a repeat biopsy to just tracking the PSA. This is something his doctor(s) can help with .
Arnon
My husband — at age 68 — was diagnosed with prostate cancer last week after a PSA of 19.5 ng/ml (up from 6.9 two years ago).
The 12-core biopsy revealed:
l. Prostate, left lobe: high grade prostatic intraepithelial neoplasia (PIN III).
2. Prostate, right lobe: “prostatic adenocarcinoma, Gleason’s score 7 (3 + 4) involving 50 per cent of total tissue (6 of 6 cores).
Comment: “panel of immunohistochemical stains performed to clarify nature of this small atypical glandular focus. They are as follows:
Cytokeratin 903 -positive
p63 – Positive
Racemase — Negative
“The above immunohistochemical stain profile fails to identify invasive prostatic adenocarcinoma in Part l (left lobe). Obvious prostatic adenocarcinoma is identified in part 2 (right lobe)”
The urologist suggested removal of the prostate before Christmas. We are still digesting this cancer verdict. We have made another appointment with the prostate center at Duke for tomorrow.
My husband is a healthy, very active 68-year-old with no medications, non-smoker, etc.
What should we do? Should we have a bone scan to see if cancer may have spread? A CT scan?
We are immobilized with fear. I am having to do all the arrangements and am unsure as to how to proceed, the best protocol for determining treatment. We know there are usually various options, and we know that we have to make final decision.
We would greatly appreciate your thoughts about the biopsy results and whether we can afford to wait for Duke opinion, etc.
Thank you.
*****
Dear Rose,
I am sorry you are feeling immobilized. Yes, it’s a lot to consume and there are several decisions to make. Perhaps the most important and immediate task is to identify a doctor who you trust, has expertise, and is available. You can then discuss with him the need for staging tests, such as CT scan and bone scan, taking into account a PSA of 19 ng/ml and the 6/6 positive cores on the right side. Yes, these sound like reasonable next steps, but don’t take that recommendation from me; it should come from your husband’s doctor.
You may want to join our social network at http://prostatecancerinfolink.ning.com.
Arnon
Dear Dr. Arnon,
I am 49 years old. I had a robotic RP 3 weeks 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.
Should I go undergo radiation therapy, and how soon? Are there any advantages in starting radiation as soon as possible or it doesn’t matter. My surgeon wants to see me in a month from now to do the PSA test.
Thank you,
Abbas
*****
Dear Abbas,
There are several reasons why people wait a little. Your surgeon has indicated one: establish a first post-op baseline. This will also give you time to understand that not every “positive margin” is the same. Among the things you want to know are the extent of this “unifocal” margin.
Arnon
Dear Arnon,
I have a 58-year-old friend who is 6ft 3in and around 330 lbs. He has been told that he has prostate cancer.
He had a biopsy and bone scan done and he was told that the cancer has moved beyond the prostate into the lymph nodes and into his bones. The only place it did not show up was in his spine and one of his legs. He is very depressed. He told me that they gave him 2 shots in the stomach, and told him to come back in 28 days. The doctors told him that if the shots work, that he could possibly be looking at living for at least another 10 to 12 years as they have seen this happen in other cases similar to his.
My question is this: If the shots don’t work, what kind of time frame would he be looking at?
*****
Hi Lee,
I am sorry to hear about this and appreciate the anxiety it can bring. I’d make two comments. First of all, if the shots don’t work, an individual projection is also very hard to make. Secondly, they generally do work if the patient has not been treated with them before.
Have a look here: http://prostatecancerinfolink.ning.com/group/hormonesuppression.
Arnon
Dear Dr. Arnon:
I had a Gleason score of 6 with cancer in one lobe of the prostate and was treated with IMRT radiation (44 treatments).
I have survived 7 years and I’m concerned about recurrence. I’m 78 years old; I keep thin; I jog and watch my diet (no meat except salmon).
Any statistics on this?
*****
Hi Peter,
Two bits of good news in your report. First of all, Gleason 6 is generally associated with good prognosis, certainly relative to the higher scores. Secondly, the likelihood of recurrence diminishes over time, so your 7 years are a good start. Overall, the answer to your question depends upon more data than presented here, so I don’t want to shoot from the hip and risk misleading you. That said, you’re doing the right things. Keep checking your PSA from time to time and let your doctor(s) guide you.
Arnon
Thanksgiving seems to be the perfect day to spread the thanks around. I would like to thank Dr. Arnon and his staff for all they do year round for all of us out there who have dealt with or are dealing with issues related to prostate cancer.
My prayers and wishes go out to all those whose lives are in anyway impacted by prostate cancer.
I am coming up on 2 years post-op with tests so far all less than 0.1, so I have ample reason to be thankful.
Dr. Krongrad,
In 4/07 I had robotic prostatectomy. I had no serious side effects. In 3/10 my PSA went from 0.01 to 0.02 and has steadily risen to 0.07 in 10/11 (at a PSa Doubling time of 10 months). I have talked to three men who had rising PSAs after surgery who are taking Avodart or Proscar, believing it retards the cancer, and may prevent the need for salvage radiation. My urologist and a second opinion from another oncologic urologist said they do not recommend this treatment — saying that it “muddies the water” or could lead to more aggressive cancer by partially treating the cancer.
(1) Do you have any feedback about using Avodart or Proscar for men in my position?
(2) If you would recommend salvage rediation, at what point? I’ve been told wait until it reaches at least 0.2, in order to avoid side effects of radiation, along with possible short-term hormone therapy.
(3) Is there any other treatment I should consider other than radiation?
A big concern of mine is avoiding the side effects of radiation. I am told that salvage radiation would have very good chance of knocking out remaining cancer. My Gleason was 4 + 3 and my presurgical PSA was 7.2.
Thanks for any feedback you may have.
David
*****
David,
All good questions.
(1) Your doctors are making sense. Unless someone shows a clinical benefit, why medicate?
(2) 0.2 ng/ml seems like a minimal trigger for action. Higher can also be considered.
(3) I would consider checking the urine to be sure that it’s not merely a urine infection, which can also elevate PSA (even after the prostate is gone; has to do with peri-urethral glands).
Arnon
Dear Dr. Arnon:
Does saw palmetto effect the results of a PSA test?
Thanks,
Nasser
*****
Nasser: Not according to this study.
Hi Dr. Krongrad,
My father is 53 and had a 6.9 ng/ml on a scale of 4 for his PSA test. I was wondering if there is much chance of him getting through it because he has already had lymph node cancer in his neck, but that is in remission.
Also, what other organs can get damaged by the prostate cancer?
Please write me back as soon as you can.
*****
Dear Ryan,
Prostate cancer can affect any organ, although it most commonly affects seminal vesicles and bones. That said, be careful to distinguish prostate cancer in lymph nodes and other problems with lymph nodes. His doctor can clarify if the two are related. Furthermore, the PSA has no upper limit and the “4″ is often merely cited as a “normal” value. This, too, needs clarification.
Arnon
Dear Dr. Kongrad,
Thank you very much for offering your knowledge to the public. That’s very kind of you.
I have a dicey situation and I’m not positive where I stand in my recently diagnosed prostate cancer.
I am 50 years old, have a PSA of 65, a Gleason score of 4 + 3 = 7, 80% involvement of cancer in my prostate (10 of 12 cores positive) and signs of seminal vesicle involvement via an MRI. The MRI and a bone scan otherwise didn’t reveal anything; nor did a Prostiscint scan. My prostate is 55 cc.
The current plan is: I am now on hormone therapy (Firmagon) and am scheduled for brachytherapy in a couple months followed by IMRT 2 months after that. I will remain on hormones for 2 years.
I am tending to my diet and exercising when possible. I am 6″11″ and weigh 150 lbs.
My radiologist says there is hope that I can knock the cancer out but I’m skeptical since my numbers are pretty severe. I guess it all boils down to micro-metastasis.
I’d like as clear a picture as possible. If I am longevity compromised, I’d like to craft the rest of life accordingly. Any thoughts?
Also, I’ve been hearing much on triple blockade hormone therapy, including Casdoex and Avodart to supplement the Firmagon. Do you suggest that?
Also … Seeds before radiation or radiation after seeds? I am worried that the placing of seeds could encourage the spread of cancer cells into my blood stream during the procedure. Seeds after radiation would deal with this somewhat in my mind.
Best Regards,
Michael
*****
Dear Michael,
I’ll assume you meant 5’11″ and not 6’11″.
Your situation is not too different from that of this patient with prostate cancer and PSA = 63 ng/ml. As you’ll see in his report, sometimes an individual case is nothing like the average case. So as to your plans for longevity, unfortunately we do not yet have a predictive crystal ball, so you’ll have to craft in the context of substantial uncertainty.
As to the details of the radiation, I’d leave that up to the radiation oncologist. I understand your theory but am not aware of any empirical data upon which to decide.
Arnon
Hello Dr. Krongrad,
What cancer treatment would you recommend to an 82-year-old patient in otherwise good health except for incontinence who has had radiation, cryogenics and Lupron hormone therapy? His PSA has increased from 6.49 to 10.74 in 6 months. No signs of cancer in other organs or bones.
Your thoughts about Provenge and Zytiga?
*****
Dear Rose,
This is a tricky and subtle situation that has to take into account not only age, but also possible side effects from treatment, possible benefits, and his overall medical and psychosocial circumstances. Accordingly, this venue is probably not the best for the answer you’re seeking. I’d advise reviewing all this with him and with his primary doctor(s) and a medical oncologist.
Thank you.
Arnon
Hi Dr. Arnon.
In 2003 I had an RP. The cancer was confined internal to the right side of the prostate gland. At first, the PSA test results were at 0, then after 2 years the readings have slowly climbed each year, including this year’s annual check-up, when the reading was 1.4 ng/ml.
I requested a free PSA test follow-up to PSA test and the reading just came back from the lab at 14%!!! I realize that with a PSA reading less than 2.0, the accuracy of a free PSA test may be inaccurate, but I am nevertheless concerned. I am 73, in excellent health otherwise, and the digital check this month at my annual physical was negative in the prostate cavity. Can prostate cells that remain after surgery cause this rise? And if so, this begs the question, can these cells therefore become cancerous? What is the history of this re-occurrence in a case such as mine, and what do you recommend?
*****
Dear Richard,
Yes, remaining prostate cells can be malignant and they can cause a rise in PSA, which is the most sensitive test for possible recurrence. In such a scenario, it would make sense for the patient to return to his surgeon to review the pathology report, the PSA tests, and options for possible additional action.
Arnon
Does Lupron cause tooth discoloration? How long does Lupron work?
My husband had surgery 6 years ago to remove the prostate. His PSA went up shortly after so he had radiation treatment. He followed up with hormone medication but held off for the Lupron shots because he didn’t want to be shut down. After being on the hormone pills for a year and a half his PSA doubled in 2 months. He had a biopsy on his low back because there is cancer that spread to his back. A very small lesion. He finally started the Lupron shots 2 months ago. How long will they work for and what’s next, chemo?
I want another opinion and need to prepare myself. I guess we are getting closer to the end. He still looks good and has a lot of energy. He is only 54 years old. Heartbreaking. Thank you for answering my questions.
Mrs. Arnold
*****
Dear Marsha,
Thank you for writing. I am sorry to hear about your husband’s situation.
I have not heard that Lupron causes discoloration. As for how long it works, this depends upon the formulation; there are many. And yes, chemo is a possibility in Lupron resistant prostate cancer.
I’d invite you to our social network. Please join us on http://prostatecancerinfolink.ning.com
Arnon
Dear Dr.Arnon.
I’ m writing to you in regards to my father who has advanced prostate cancer with mets to the bone and the dura mater. At present he’s being treated with Taxotere. He’s had 5 infusions and his PSA has been slowly decreasing from 300 to 198 ng/ml.
During our last visit to the oncologist he offered my father if he would be interested in trialing Zytiga. He asked some questions to confirm that everything else like blood pressure, heart, etc. was OK. He also asked if there were any brain issues so I told him that he has mets in the dura mater (I believe this is not the brain but the third layer which surrounds the brain) to which he hesitated and said, “Oh, I’ll have to investigate and I’ll let you know if he qualifies for Zytiga trial”.
My question is, why would mets to the dura mater prevent my father from getting Zytiga? Isn’t the purpose of this drug to battle mets? If my father doesn’t get Zytiga, what other drugs are there to treat patients like my father once Taxotere has no effect?
*****
Dear Jose,
Unfortunately, this is beyond my area of expertise. You are asking great questions and I would suggest you direct them to your father’s oncologist and/or a second opinion.
Arnon
Hello,
Diagnosed with prostate cancer that doctor thought was contained only in the prostate. Did cryotherapy. PSA levels began rising, so doctor said cancer still in body somewhere but all the tests that were taken didn’t show where the cancer is. Now doctor is giving me hormone shots and says that they cannot do anymore until cancer shows up in the bones, when MRIs, etc., are done again. And then they would start chemo.
I don’t understand. Is one’s choice now limited to hormone shots until the cancer spreads to the bones? On third hormone shot in a year. Don’t understand why the cancer can’t be found outside of the prostate, which is supposedly now dead. Should testicles be removed. Can anything else be done?
*****
Dear Erren,
Depending upon the specifics of your situation, then maybe a salvage prostatectomy could be considered. You may want to discuss this.
Arnon
Dear Dr. Arnon,
I went to the ER last Wednesday, diagnosed with acute urinary retention. I had Foley catheter until today, when it was removed. The doctor told me if I can’t uninate I should come back and that he will re-insert the catheter. (He seemed very sure that I would be back.) The doctor also advised me that I will need surgery (a TURP). I am unirating now, but do not have a very strong stream and I am not planning to go back to the doctor — at least today.
My questions are, if you please:
(1) Do I need the surgery. (I start taking Proscar today. I know will take about 6 months before it works.) If the answer to this question is yes, then
(2) How long would I need before I could go back to work after the TURP? (I have no insurance, and no funds, so I can’t stay more than a week out of work.)
(3) I know there other surgery options, so can you please tell me, if you can, what is the second best surgical option after a TURP?
Thank you soo much for taking the time to read my request and sorry for my English. (I did the best I could.)
Nasser
*****
Hi Nasser,
I can only tell you a little based upon your report. The first thing: You need to urinate. So if you cannot urinate, then you need help, be it by medication or surgery. Maybe Proscar will work, and then you don’t need surgery.
Arnon
Dr. Krongrad:
I am 63 years old and have been on active surveillance for 5.5 years. Durring this time my PSA has been stable, ranging between 4.3 (5 years ago) to 5.3 with a recent 4.65. I have had an annual biopsy. Most recent biopsy had 2 cores positive, one with 20% and the other 5%. Gleason every year has been 3 + 3. One year no detection.
I would like to know if I should continue with annual biopsies or if they can be spread out to 18 months. The driving force behind the question is financial but I do not want to put myself at unnecessary risk.
Also I would like to know your thoughts on taking Advodart to slow progression of prostate cancer. The FDA has “black labeled” the product as possibly causing more aggressive cancer. One view is that the Advodart reduces the size of the prostate which increases the chance of detecting high-grade cancers that were previously present but not detected. I recently started taking the Advodart but I am in a quandry whether I should continue.
Thanks so much for your response.
****** Answer *****
Dear Rich,
Let’s distinguish primary prevention from treatment. To the best of my knowledge (and please share if this is incomplete), Avodart was only tested in the former application. So it’s not clear to me that it has a role in “slowing” progression.
You have a cancer. Yet one year your biopsy didn’t find it. Thus, biopsy is deficient: It can miss cancer. Thus, biopsy is an insufficient measure of disease burden. Thus, any assumption that it’s “safe” to watch carries the risk that it’s wrong. When is this risk “necessary,” as you ask? That seems to be a personal decision. As is the decision to not treat a cancer, which has to also account for the many other relevant factors: overall health, social environment, finances …
Arnon
***** Sitemaster’s addendum *****
Dear Rich and Dr. Krongrad:
Actually, there are data from the REDEEM trial suggesting that dutasteride can, in fact, slow the progression of prostate cancer in men with early stage disease. Preliminary data from this trial were presented earlier this year. The full report from this study is apparently due to be published in the not too distant future.
A patient aged 76 years old with metastatic prostatic cancer to the bones. Hormonal therapy has been instituted but bone pain continues to be severe. Orchiectomy has been advised. Your opinion please.
****** Answer *****
Orchiectomy would make sense if the patient has drug resistance. This is rare but has been described. In other words, hormone therapy fails idiosyncratically, but orchiectomy works. The key to determination if this is possible is to check the serum testosterone. If it’s not at low (anorchic levels), then orchiectomy could be useful.
Dear Dr. Arnon,
This is a follow up to a prior question. A week ago I wrote:
“I am 49 years old. I had a robotic RP 3 weeks 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.
“Should I go undergo radiation therapy, and how soon? Are there any advantages in starting radiation as soon as possible or it doesn’t matter. My surgeon wants to see me in a month from now to do the PSA test.”
Now I have got my first PSA test results at 0.04. And my surgeon says that the positive margin was very small, no actual measurement was given. He thinks radiation is absolutely unnecessary.
My questions are: (1) if all cancer cells have been removed, why do I still have a detectable PSA and (2) should I consider radiation at all and if not how often do I need to have a PSA test?
Thank you in advance,
Abbas
****** Answer *****
No test is absolutely specific. At very low levels, you get more non-specificity and what we call “background noise.” Your urologist is making sense. You may want to follow his directions.
Dear Dr. Arnon.
I hope I don’t lose you in my question; we communicated earlier in 2011 and things have changed for the better.
After having a complete physical with my GP in July 2011, my PSA was 2.8 ng/ml (pretty much normal for the last 10+ years). While doing a rectal he told me that my prostate felt out of shape and he felt a nodule; upon further examination by a urologist he said he felt nothing out of the ordinary but did a PCA3 test. My test score was 42 as compared to 35 ( which supposeldly the upper level of normal). At that time he wanted to do a biopsy and I chose to be re-tested within a very short time of [7-10] days of my earlier test; the result of that test showed my PSA had riosen to 4 ng/ml. With that I sought out another uroligist and upon further exam (prostate still felt perfectly normal) he had said I should wait 6 months and then get re-tested. That is what I did, and my PSA result was 2.4.
Now here’s is where it gets complicated. … My testosterone level came in low and I want to be treated for it, but I know that if there is any type of cancer low T treatment will be fuel on the fire. What type of treatment would you recommend for low T? I am truly experiencing all of the effects of low T.
Thank you.
Guy
******
To the best of knowledge, testosterone is the only treatment for low testosterone. You should check with your endocinologist.
Dear Dr. Krongrad:
Sadly, my husband is one who has resisted any kind of medical care until last month. He now is being treated for extremely high blood pressure, adult onset diabetes, and CURRENTLY has a PSA score of 246. After tests, his Gleason score was 8+. He’s had a CT scan and a bone scan is scheduled for Tuesday. My husband will be 75 in February, and after reading a great deal I am wondering how far we should go with the treatments which have been proposed. He did choose to start the hormone blocker treatment. The physician says that the ultrasound shows an indistinct gland and his thighs are swollen which could indicate lymph node involvement. Are we buying much time with any of the options out there and which would be best in his case?
Dear Lenore,
It sounds like you have your hands full with a somewhat complicated situation. It’s impossible for me to say based upon these details what your husband’s prognosis is and how the 3 diagnoses affect that. A few things do seem clear:
1) Hormone blockade can affect interpretation of bone and CT scans, so depending upon the timing, this may be an issue or not.
2) If his thighs are swollen because of prostate cancer, then hormone blockade, totally apart from “buying time,” may provide important relief and functional improvement. This is a basis for considering it.
You can certainly review these and other questions with his doctor(s).
Arnon
What are the percentages, at the time of initial diagnosis, by Gleason score, of the the results of the biopsy that verify a man has prostate cancer? In other words, what percentages of men are are diagnosed as Gleason 6, Gleason 7, and Gleason 8-10?
Do these percentages vary significantly depending on the environment in which the biopsies are performed?
*****
Robert,
I can’t give you exact breakdowns, other than to say that Gleason 6 is probably the most common grade found at biopsy no matter where this is done.
Arnon
My yearly PSA for 5 years was an average of 2.2 with very little difference year to year. Then it went to 2.7 to 2.9 to 3.3 to 3.7 and recently back down to 2.2 (Bostwick Laboratories). These last five readings were about 4 months apart and the laboratories (Quest, Lab Corp, Bostwick) used different assay methods. DREs were all normal with estimated prostate size 25-30 cc.
I have good health, no family history, am aged 60, and no night time problems. I was concerned about the rising PSA levels until the last test, which showed a drop from 3.7 to 2.2 in just a few months. I take no medications. Should I be concerned or simply wait another year for a retest of my PSA.
Joseph,
Your risk of a positive biopsy is at 20-25%. If you are the one in 4-5 men with prostate cancer, do you want to know?
Arnon
Dear Dr. Krongrad,
I have spoken to three urologists with daVinci RP or open RP surgery experience and one radiation oncologist who recommends a combination of brachytherapy and IMRT. I am not thrilled with either therapy choice right now so I am trying to find other curative therapies for my prostate cancer.
Below are my criteria for the “best PC therapy choice for me”. I would greatly appreciate any response with a therapy or therapies that satisfy all six criteria or at least the first five:
(1) Success rate at least as good as any other therapy currently available.
(2) Minimal side effects — especially in the areas of ED and incontinence.
(3) Treats my prostate cancer but does not remove my prostate.
(4) Does not leave any active radiation in my body after treatment.
(5) Allows a wide variety of follow-on prostate cancer therapy options if it is necessary to combat a recurrence.
(6) Initial treatment has the ability to treat my prostate cancer within the prostate and outside the prostate if cancer is found outside the prostate.
I am looking into proton therapy to see how many of the criteria it meets. Perhaps it is wishful thinking but I believe discoveries and improvements in prostate cancer treatments will provide better options for patients in the near future (someone with more knowledge may want to be more specific than “near future”). For example, in 2010 the FDA approved the first immunotherapy for advanced prostate cancer, Provenge. Provenge’s approval provided “proof of concept” for using the body’s immune system to fight prostate cancer. I would love to find a treatment option similar to Provenge that involves collecting some of my blood, treating the blood with cancer fighting agents and infusing the treated blood back into my body to attack my cancer. Provenge’s side effects are generally compared to having the flu for a brief period of time (I could handle that). More immunotherapy options for prostate cancer patients are now in clinical trials and hopefully help is on the way.
A new method of delivering proton therapy called “pencil beam therapy” is currently in use for treating prostate cancer. Google the all the words “pencil beam therapy” on YouTube to see the videos (I looked at the mdandersonorg created video). The Mayo Clinic is currently building two proton therapy facilities in the U.S.. Both facilities will employ only pencil beam therapy.
If I can find a therapy that meets the six criteria and cures my prostate cancer, I will be much more than totally thrilled. At a minimum I am hopeful the therapy of my choice at least provides enough time and a body healthy enough to take advantage of any improvements in treating prostate cancer.
Thank you, Terry
*****Answer****
Terry,
A French company is currently building two water bottling facilities in the U.S. Both facilities will employ water as a main ingredient. This water won’t hydrate any better than the water from the faucet, but it will market much better because of clever branding: more profit without more value.
You write about new treatments that will be available in the near future. Depending upon your definition of “near future,” this may not be realistic because new treatments will take 15-20 years to prove themselves, assuming the right trials are even done; they often are not.
If you want conformal radiation, why not brachytherapy, the most conformal technique of all? And, unless you want to father children, why keep your prostate?
Your presentation is good. The ambitions are clear. Find a good doctor, one you trust, and let him work with you to a solution.
Arnon
Terry:
If you have low-risk prostate cancer (Gleason score 3 + 3 = 6; PSA < 10 ng/ml; only one or two biopsy cores positive; only a small amount of cancer in any positive core), then you may be an excellent candidate for active surveillance — simple monitoring of your cancer over time, because it may be a relatively indolent form of cancer that can be monitored for years without active treatment but could still be treated effectively later if necessary. This would meet five of your six criteria … but not no. (3).
If you have a higher-risk form of prostate cancer, the ability to treat your condition effectively depends on a whole variety of things you didn't tell Dr. Krongrad, but no one could tell you with certainty whether any currently available form of treatment could meet all of your criteria. We just don't have the available data.
Don't believe everything you read on the Internet!
Sitemaster
Terry:
At age 62, I had a PSA of 6.1 and the %Free PSA test came in at 15%, the biopsy came in at 7, the cancer was confined internally to the prostate. Being otherwise very healthy, I opted for RP. I no longer have to worry about “will it get me later in life.” I am now 73 and very healthy. My neighbor elected to play the wait and see game, then later he had radiation. It lasted 5 years then he was past 75 and the cancer came back, so now they cannot operate because he had radiation. He is worse now because of all the hormone side effects, etc, etc. Don’t screw around Terry, if you are otherwise healthy and a good candidate for surgery, get the prostate removed and have peace of mind!!! I was out of the hospital a day later.
*****Editorial Addendum*****
All readers should please note that the individual experiences of specific patients and their opinions based on those experiences are not necessarily a good guide for what may be appropriate management for another patient, whose individual clinical situation and priorities may differ considerably from those expressing the type of opinion above.
Dear Dr. Krongrad,
This may not be appropriate for discussion on this particular board but I may find myself among the members here at some point in my life.
I’ve had three PSA tests and two DREs. My PSA has moved from 2.9 to 4.4 in 2 years’ time (ages 57 and 59 years). I now have a urologist (second DRE; second and third PSA) who also has outpatient facilities for ultrasound-guided needle biopsies.
After a 3-week Cipro regimen to rule out infection, the third PSA came back essentially the same (2 months later, and a bit lower at 4.4). DRE’s are normal.
Of course an ultrasound-guided biopsy is his next suggestion — more than a suggestion, as putting it off by 6 months was objectionable to him. Immediately this bothered me — worry at first, but irritated me after I thought about it.
I’m fairly informed and this seemed a bit aggressive as I feel that I should have more time to consider all options.
In particular: I feel that 6 or 12 or 20 or 40 needle punctures through the rectum is not an insignificant, risk-free procedure. (He actually didn’t fully explain how many samples he would take.) Infection, of course, is one risk, but not enough studies have been done on the effects of the biopsy on the prostate and/or any cancer contained in the prostate.
With so little to go on I feel that other tests should be considered before a biopsy is called for. I say that because even if a biopsy were to come back “mildly positive” I likely wouldn’t act on it in any significant way.
Are all urologists this “trigger-happy,” or is this simply insurance industry cost-effectiveness?
***** Answer*****
Chris,
Like all patients, you have the right to decline a medical suggestion. But while you may decline this suggestion, it’s not clear to me that this suggestion is a basis for a broad generalization about all urologists or for a judgment that he was “trigger happy.” Actually, his suggestion has solid, well-established merit relating to what we know of the positive predictive value of a PSA in the range of 4 ng/ml.
Sure, there are risks associated with biopsy. If you don’t think you understand them, that is a reason to ask questions about them of the doctor who is suggesting you have a biopsy. And as for how many samples he would take, he may not know until he “sees” your prostate with the ultrasound.
And as for “so little to go on,” I don’t understand what that means. You have PSAs and DREs. You want “other tests.” Which other tests? Bone scan? That feels like the “cart” before the “horse.” It’s not known if you have prostate cancer, let alone which grade and stage of prostate cancer, if it’s there. Again, you can be your own doctor if that’s your preference and you can take more time if you want, but based on what you’ve reported, your doctor is making sense. You can ask him again if he hasn’t made his logic clear to you.
Arnon
I am a 64-year-old male in generally good health, except that I take Diovan 160 mg/HCT 12.5 mg for high blood pressure. I exercise three of four times per week. I have over a 20-year history of PSA scores of 0.5 to 0.7 and one score of 1.0. In 1999 and 2008, my PSA score rose to 1.6 and 1.5, respectively, from the 0.5 to 0.7 baseline, but on subsequent testing returned to the 0.5 to 0.7 baseline. I very recently I had an annual physical and my PSA score had risen from the 0.6 (within the baseline) to 1.5 ng/ml. A urologist told me in 1999 that the temporary increase may have been due to exercising too vigorously close to the PSA test and I thought that this could also be the reason for the 2008 increase. This fall I exercised about 36 hours prior to my most recent PSA test. My internist recommended that I retest in about 6 months. My thinking is that I should retest in about 3 months. Any thoughts about the timing of the retest or related comments?
Thanks, Larry
*****Answer*****
Larry,
I’m not sure I see any connection between exercise and PSA. If there is any doubt, just don’t exercise and re-measure the PSA. And overall, unless there is some odd circumstance, e.g., a hard prostate nodule, then I am not sure that with a PSA at approximately 1.0 ng/ml, there is any meaningful difference between 3 and 6 months.
Arnon
Dear Dr. Krongrad,
I am 30 years old. I have had a bacterial infection which led to chronic prostatitis for the last 5 years. I have had different antibiotics and they did not help to cure it. My biggest problem is frequent urination during the day and also during the night. I have also unbearable pain. Is laparoscopic prostate removal an option for me? I am ready to take the risks of this operation to have a pain-free life again. I also have a partner who is showing symptoms of an infection such as smelly discharges and frequent urination. Is putting her on antibiotics helpful if I remove the prostate?
*****Answer*****
Dear Iman,
Antibiotics are the most commonly prescribed treatment for prostatitis. They are often ineffective and are not uncommonly associated with all sorts of ill effects. Please realize that there are many other treatments for prostatitis, ranging from prostate injections to trigger point release to tai chi to quercetin to alpha blockers and on and on. It’s important that you make informed decisions about your situation. In this light, we’ve posted relevant material on this web site that you might find of interest. Have a look at the Treatment tab, which provides some structure and lots of data from the published medical literature. Likewise, the table in this prostatitis article will provide some perspective. If you like, fill out the Consultation form, which will provide more of the specifics that might guide a treatment decision. I’ll be pleased to discuss it with you.
Arnon
Dr. Krongrad,
I am 45 years old, good health until this year. In August 2010, my PSA was 0.9. It has been that or below since I started testing at 35. No history of prostate cancer in family. In May 2011, PSA jumped to 3.88. I was having pain only after urinating, discomfort in the prostate area, pain on ejaculation, and leakage after urinating. I can’t seem to push out the last of it when I am finished, which continues today. Urologist thought it was an infection. After a round of antibiotics, my PSA was 2.55 in July. The doctor did a biopsy (12 cores), which showed absolutely no sign of cancer in the late summer. Prostate was a little enlarged, but has always felt normal on DR exam and during biopsy. Now in December, PSA is back up to 3.55. We will retest in June 2012, and doctor listed it as “stable” on the test result.
Additionally, In January 2011, I suddenly started having terrible pain in both upper triceps, shoulders, and mainly elbows, accompanied by muscle twitches all over and some leg fatigue. Muscle twitches can be anywhere, like popcorn pops. Some shakiness in arms and fingers, but it comes and goes. Neurologist did MRIs with contrast of cervical spine and brain looking for MS, but there was no sign. EMG was fine as well. He has been watching me for a year, but no visible weakness. He does not think Parkinson’s either — it is too symmetrical, and affects both sides fairly equally. All symptoms are still there after a year, but not as bad, especially the shakes. He thinks I have had a “post viral syndrome” that is affecting my nerves — could have been recent or years ago, and the virus has laid dormant or hidden. I have been on Cymbalta for the neuropathic pain for 10 months, and it works great. If I forget to take it, the pain comes back by the next day — horrible pain like banging your funny bone or tendonitis — makes me nauseous. My prostate issues started at the exact same time as my nerve issues in late December 2010/early January 2011. Blood work then all came back OK accept for Epstein Barr virus, which was four times what it should be. Infectious disease doctor that the neurologist then referred me to said he did not think EB was the problem, and that it was neurological.
All this to say, the two issues, prostate PSA and urination issues, and nerve pain in upper torso and arms, have to be related in my mind. The neurologist first thought MS, and that it was affecting my urinary muscles and nerves, but now he is pretty certain that is not the case. The urologist thought “whatever I am dealing with nerve-wise is causing urine to not fully leave (it does empty bladder, however) and it is backing up in prostate area causing irritation.” Neither can say what it is. I don’t think they talk to each other either.
QUESTIONS: I am at a loss as to what to do next after a year of bouncing around. Is there a virus (or viruses) that could be causing both? I was tested for many strange viruses, and my liver function test looked fine. I was concerned that my liver might be affected, causing my PSA to rise. What other things could I be dealing with here? Could this still be cancer? I have never heard of cancer affecting other areas like this unless it is at a later stage and in the bones. My prostate is clear and feels normal. Is there another disease or illness (liver for example) that might be causing these issues?
Sorry for the long post — there are two issues and I needed to explain background.
Thank you for your response Dr.!
*****Answer*****
Dear RC,
You are describing an unusual constellation of symptoms and asking all the right questions. No simple e-mail exchange like this will do your questions justice. So … some very simple reactions:
(1) Sure, a virus could explain some of your symptoms. Proving it is another matter.
(2) While anything is possible, PSA rise is almost surely not from the liver. It’s probably related to the prostate, prostate inflammation, etc.
(3) Other things could be reactive arthritis, formerly known as Reiter’s Syndrome, for which the best specialist is a rheumatologist.
(4) Prostatitis can present with many of the complaints you’re listing, but some don’t seem to fit. So either this is very atypical prostatitis, it’s two conditions coexisting, or it’s not prostatitis at all. If you find interest, you can find more on prostatitis on the Prostatitis Surgery web site and on the Prostatitis Forum and Social Network.
I’d be interested in any follow-ups from you. You can post here or just e-mail to ak @ laprp dot com.
Arnon
Dear RC:
I had prostate cancer 18 months ago and had a RP and am doing good now. Fifteen years ago, at age 43, I had symptoms very similar to what you are describing as far as being muscular and neurological. I had these symptoms for at least 6 months and was tested for many of the same things you have been tested for, but you did not mention lyme dissease. Have you been tested for this? When I had these symptoms, the test for lyme disease was very inconclusive, but doctors said this was still a possibility. I finally went to see a rheumatologist at the University of California in San Francisco and he thought it was a virus and that he had no name for it but that I would get better with time, and I did. I know your frustration but try to keep your head up because the depression can take you down also.
Good luck,
Dave
Dave expands the differential to include non-viral infectious causes, including bacteria that cause Lyme disease. One can also add parasites, such as Strongyloides stercoralis. So obviously travel to the right locations where these agents are common, e.g., Connecticut and South Africa, respectively, increases suspicion. All of which points again to the possible value of a rheumatology consultation to rule out reactive arthritis. During such a visit, one can ask about the possible value of a tropical medicine or infectious disease consultation. Keep us posted.
Doctor:
At my last blood test, my PSA was 3; about a month later I went for a follow-up visit to my urologist and, after the DRE, he ordered a PCA3 test and the result was abnormal (68).
Is possible to have a low PSA and such a high PCA3? Do you think that the test should be repeated?
Thank you very much,
Omar
If there is any doubt, then yes, the test can always be repeated.
Doctor:
I have been diagnosed with a PSA of 18 and Gleason 6 prostate cancer. … I will soon be undergoing HDR brachytherapy treatment. … Since I was diagnosed I have been suffering from hair loss and extreme dandruff that I cannot get rid of with topical applications of five different well-known dandruff shampoos. … Is there some connection to my cancer? … Any suggestions? … Could it just be the stress, or is there some other reason?
Thanks,
Wayne
*****Answer*****
Dear Wayne,
This is an interesting situation. Whether it’s driven by emotional turmoil or dermatological illness is not known to me. You may want to get an opinion from a dermatologist and/or your other doctors.
Thank you.
Arnon
Hello Doctor,
I’ve just finished a round of 39 radiology treatments after being diagnosed with prostate cancer (2.3 to 12 PSA and 3 + 4 Gleason score). According to current information, is there any average of recurrence in patients after the radiation treatments and two Lupron injections that I’ll have had. (Please note that I’m a 58-year-old man, whose late father had a TURP at age 76.)
*****Answer*****
A bit hard to quantify without more detail, but the treatment you have described (Lupron and radiation) is generally pretty effective at dealing with Gleason 7 prostate cancer with a PSA = 12 ng/ml.
Arnon
Dear Arnon,
My boyfriend had a medical test and he was diagnosed with 6.5 PSA level. He is just 26. What are his chances of having prostate cancer?
Natalie,
Assuming no family history, no nodule, no signs of infection or prostatitis, no recent trauma … in other words, lots of assumptions, then the risk is approximately 30%. This is a very simple assessment, which should be refined by a urologist.
Arnon
Dear Dr Arnon,
I’m struggling to understand a statement made by Dr Howard Scher in an interview (anybody wishing to read the full interview may have to register, but registration is free). The discussion point related to the importance of not labelling tumours as hormone refractory once they progress after hormone therapy.
Dr Scher stated that “… once a physician has given chemotherapy to a patient with castration-resistant prostate cancer, hormonal therapies are no longer a viable therapeutic option.”
Why is this? Why would further hormonal intervention be precluded by prior chemotherpay?
Many thanks.
Regards
Jonathan
*****Answer*****
Jonathan,
I think the operative term here is “castration-resistant.” In other words, this seems on its own merit a mere teleological assertion: If hormones don’t work (the tumor is castration resistant), they hormone therapies are no longer a viable therapeutic option. Not sure there is a deeper hidden meaning in this seemingly casual remark.
Arnon
The most recent data on MDV 3100 look very good, but it is unclear when it wiil be available. Do you have any insight?
*****Answer (by Sitemaster on behalf of Dr. Krongrad)*****
Assuming that the developer of MDV3100 (Medivation, Inc.) can submit the new drug application (NDA) to the U.S. Food & Drug Administration (FDA) early in the New Year, and that the application is “clean” (i.e., there are no significant regulatory issues with the data in the submission and other related factors), The “New” Prostate Cancer InfoLink feels confident that MDV3100 will be approved before the end of 2012 for the treatment of men with castration-resistant prostate cancer who have received at least once cycle of docetaxel-based chemotherapy.
Trying to be any more precise than that is almost impossible. As yet, Medivation has made no formal statement about when the company expects to submit the NDA or about side effects to MDV3100 reported in the AFFIRM trial. Both these factors could significantly impact the probability and the timing of an approval.
I have supposedly low-grade, organ-confined prostate cancer. I am 60, PSA 3.3, Gleason 3 + 3 = 6. My doctor did not give me a certain “T” stage. All the guys here go to Birmingham, AL, to Dr. Scott Tulley. He is apparently a wonderful surgeon, and has done around 5,000 robot-assisted procedures, according to their website. We are lucky to have him here. Even so, I talked to some friends who had the surgery. Seems like about half do well, and half struggle with the side effects.
All my friends say I should have the surgery. But I’m pretty well set on proton beam radiation therapy (PBRT) after reading till I’m cross-eyed! Very few here know anything about PBRT, including apparently the doctors. I talked to a local radiation oncologist, and he says PBRT is pure smoke, and that photons are just as good, and more exact. To his credit, however, he recommended surgery, not radiation as you might think. He said that if the surgery fails, I would have a “lifeboat” with radiation. So, to his credit, he did not recommend his own treatment as so many do.
Any advice on treatment choice of PBRT vs. robotic surgery? Is PBRT really better than photon? My urologist says my PSA has bounced up and down a lot, from 2.8 to 4.6 at the highest, so he’s not confident in AS. Plus it doesn’t seem like AS makes sense at 60 years of age, does it? Thanks!
PS: I had stage 3 colon cancer 11 years ago, and have been cancer free ever since. The colon surgeon says he thinks Tulley could probably do robotic even with the scar tissue, but Tulley might not even know until he gets in there if I have surgery.
*****Answer*****
Lots of questions. Not sure I can get them all straight in one answer, but it does seem to me you’ll find value in this video: http://vimeo.com/6675210 As for scar tissue, that’s generally an issue that a surgeon can evaluate before surgery. Having done laparoscopic prostatectomy for men who’ve had their colons, aortas, pancreases, and other things resected, I’ll say there’s rarely so much scar tissue I can’t get to the prostate. Well, actually never. Again, this is an assessment the surgeon has to make.
Dr. Krongrad,
My 51-year-old husband was recently diagnosed with prostate cancer. His cancer is a 3 + 3, presented with a 3.2 PSA, and had cancer in 1% of one of the 12 cores. He is thinking about active surveillance. I have two questions: (1) Where does the PSADT begin? With the 3.2 or the 1.8 a year and a half ago. (2) How do we find a urologist in metro Phoenix who doesn’t just want to do surgery?
Thanks so much for the help,
Christie
*****
Christie,
Doubling time takes several measurements, so the more the merrier. As for a urologist who fits your preference, I have absolutely no idea how you would find him other than going for second opinions.
Arnon
Dear Sir …
At 53 years old I had the da Vinci robotic surgery for positive-prostate cancer … the surgery outcome was positive — post-surgical PSA was 0.0 , with no need to do any radiation treatments, I was told. …
Three years later my PSA rose from it’s nadir of 0.2/0.3 to 0.5 ng/ml, and 2 weeks later to a 1.2 ng/ml … I then received three months of docetaxel chemotherapy with Sutent pills and steroid [prednisone] pills … The PSA remained at 1.2 after chemotherapy — never rose during the 3 months of treatment.
A month after chemotherapy, the next step was 36 treatments of radiation. After this treatment (6 to 8 months) my PSA went down to a nadire level of 0.2/0.3 ng/ml for a year.
I am now 57 years old. My PSA is 0.4 ng/ml (0.5 ng/ml on a recent confirmatory re-test — as of 12/11). …My worry is “what does this all mean?” I have no prostate — hence there should not be any antigens, should there? Do I have to be concerned regarding the slow rise? Any recommendations? I want to hear 0.0 regarding my PSA – is that ever going to be possible?
Jim
*****Answer*****
Jim,
All good questions. First of all, if your prostate is removed, then the sources of PSA are either non-prostatic sources or prostate cancer cells. To get a sense of the likelihood, it makes sense to go back and review the original pathology report: Stage, grade, vascular invasion, margins … Secondly, to get a sense of the chance of bringing the PSA to 0.0 one really has to look at the hormone levels. In other words, if you’re off hormone treatment and the serum testosterone is not very low, then sure, it’s possible that the PSA could drop further.
Overall, I am missing too many details about your situation and would recommend you redirect these questions to your doctor(s).
Arnon
Dr. Arnon,
My husband had a radical prostatectomy in 2009 (age 64) and his PSA level was 10.4 after surgery (Gleason score 8). Recommended therapy included radiation plus hormone therapy (Zoladex). His most recent PSA result was 0.36, which shocked us both given that he doesn’t have a prostate. He has one more injection to go and we wonder if he should really have it? What’s next, more therapy? He’s tired of the side effects (sweating, mood swings, weight gain, libodo loss, etc). (Other scans, x-rays did not show any signs of cancer in 2009 and no new scans done since then.)
*****Answer*****
Dear Mrs. Jones,
Please understand that the PSA is not being used to measure his prostate, but any prostate cancer cells that may have remained after surgery. I’d put the hormone question into the context of the radiation. If he’s planning to have the radiation, then the hormone shots could make sense in that this appears to potentiate the effect of radiation. You’re best off asking the radiation oncologist who’s seeing him if the hormone shot is necessary, being sure to point out the side effects.
Arnon
Dr. Arnon,
My husband, age 48, African American (with no access to family history of the disease), was just given his biopsy result of 3 + 3 = 6 Gleason score. His first PSA reading was 4.0 ng/ml back in August 2009. From November 2010 through October 2011, he had four more PSA tests, with results indicating a rapid velocity (11/2010: 5.9 ng/ml; 4/2011: 8.1 ng/ml; 6/2011: 8.0 ng/ml; and 10/2011: 35.0 ng/ml). The doctor indicated his belief that the 35 PSA must have been an error due to how much of an increase in short span of time. However, no other PSA test has been done since the October test.
In May 2011, he had a transrectal ultrasound with findings of: an enlarged prostate (volume 73.8 ml), no focal prostate lesion identified, and “seminal vesicles are normal.” In late December 2011, he had a biopsy of the prostate with 12 core samples taken, and last week the doctor gave him the news over the phone (2 of the core samples had a positive indication of cancer, grade T1c and Gleason score 6).
Based on my husband’s summary of his phone conversation with the doctor, it seems that surgery is what was suggested. However, the doctor asked that we read a book called “Surviving Prostate Cancer …” and then meet with him to discuss our options. We immediately got the book and have been reading it over the past 4 nights. I am concerned about the risks of side effects from surgery and would hate for him to undergo surgery, recovery, and side effects and then still have to get radiation or some other serious treatment anyway. Based on the research I’ve done so far, his rapid increase in PSA level and the fact that African Americans have had history of more aggressive prostate cancer (not exactly sure what is meant by this statistic — is it detected at a later time and therefore is often at a more advanced stage or does the cancer tend to advance more quickly in general?) makes me wonder if we should do more before having surgery.
I would like them to conduct tests of his lymph nodes (and maybe also his bones) to see if there is evidence that the cancer has already spread. Is this is reasonable thing that I want? Should I be at ease due to the fact that the ultrasound showed his seminal vesicles being normal? Also, I just came across information about proton treatment but have not seen much mention of it on many websites regarding treatment (nor in the “Surviving Prostate Cancer” book that we are reading). Do you have any suggestions that might help guide us in our research and ultimately in our decision on what treatment to elect?
Sincerely,
TRG
*****Answer*****
Dear Tiffany,
All good questions but way more than a simple online thread can answer. There are many facets to each of your questions and each requires a deeper understanding of the circumstances. I will say that, based upon your report, there is a chance that your young husband can get rid of this cancer surgically. Adding that the likelihood of side effects has to be assessed in context of him, not a book about other patients, looking at illness, obesity, and the like; and in the context of “who is the surgeon” too. One final point: there is risk associated with active surveillance, too.
Arnon
Dear Dr. Krongrad,
My husband, 59, had a PSA of 7.4 and a nodule on the prostate. His initial biopsy showed high grade PIN cells in the right lateral apex (the location of the nodule). An insurance exam a month later showed a PSA of 8.31 and the %Free PSA at 10. (The urologist did not do %Free PSA.). A second biopsy 3 months after the first came back completely normal with no PIN cells. How can the PIN cells return to normal? My research shows that would be unusual. We don’t know what to think — of course we are very happy with the second result, but is it to be trusted?
Any information would be appreciated.
Thank you.
*****Answer*****
Jamey,
Biopsies are like sticking needles in Swiss cheese. Sometimes you hit the hole, sometimes not. So it’s more likely PIN was merely not sampled the second time, not that it has devolved to normal.
Arnon
Doctor:
I am a 61-year-old male that had seeds implanted in my prostate in April of 2010. My PSA level in May of 2011 was 0.9 ng/ml. My most recent PSA was 3.8 ng/mla week ago; on a retest it was 2.9 ng/ml. Should this be of great concern to me?
Thank you.
*****Answer*****
PSAs should drop to very low levels after seed implantation. So while yours “bounced” up to 3.8 ng/ml and may be dropping, you want to follow closely to be sure it keeps dropping, also keeping in mind the original pathology (stage, grade) and its implications for success and also while asking your doctor(s) to review this pattern with you.
Arnon
I’m a 35-year-old male who has had two episodes of prostatitis.
With the first episode I was given Levaquin; my doctor gave me a DRE, and he also did a PSA (which was 1.6 ng/ml). He said my prostate was enlarged. After I finished the medicine my symptoms went away and everything was “back to normal.”
Almost 3 years later I have had a second episode. I was again given an antibiotic and have been on it for 13 days. I went to see my primary care physician for my yearly check up and asked him to do a PSA test since I had been diagnosed with prostatitis; my PSA level was 20 ng/ml.
I don’t know what to think. I have no history of prostate cancer in my family. What do you think might have caused this? I am really worried.
*****Answer*****
Rudy,
If by “this” you mean high PSA, then the answer is lots of things can cause it, including prostatitis. If by “this” you mean prostatitis, I’d suggest you join the prostatitis forum, where this is the topic of discussion.
Arnon
What is your thought on orchiectomy vs. hormone therapy?
My father is 70, and had a prostectomy 7 years ago. His PSA remained very low all this time and then it went up to 8.4 ng/ml. The bone scan and the CT were clean, so they want to start him on Lupron. From what I have read, the hormone therapy would give the same results as the orchiectomy (minus the psychological effects of the orchiectomy). It seems to me that orchiectomy would be a better choice, but I’m just not sure.
Thanks for your thoughts!
Keli
*****Answer*****
Hi Keli,
To be clear, surgical orchiectomy is a hormone therapy. So in that sense, it’s as effective, if not more effective, at reducing serum testosterone as pharmacological hormone therapy. Orchiectomy is permanent and only requires one treatment. Remember that both approaches are associated with a range of possible side effects: bone loss, hot flashes, mood changes … So in the end, both are effective and he will probably wind up making a choice (which may include further observation) based partly, if not largely, upon the relative inconvenience and, as you suggest, the psychology of it.
Arnon
Hello Dr. Arnon,
My father, a 63-year-old in great health, was diagnosed with prostate cancer. His test that they collect the multiple samples showed that one piece came back cancerous. He has multiple choices to choose from to get rid of the cancer. Surgery, radiation seeds, etc. My question for you is, what is the safest most reasonable choice to go with if there is one. I’m going with him to his appointment in a couple of weeks when his doctor told him to bring questions with him. Could you let me know what questions I could be helping him with and/or provide us with some resources to help with the questions. Thank you for your advice and help
Sincerely,
Paul I.
*****Answer*****
Hi Paul,
It’s great that you’re getting ready and that you are going. That will really help him.
There is no one right answer for everyone. Each treatment is associated with risks, and you should ask his doctor to explain these to you. In addition, the decision to treat should be placed in the context of his overall health. So for a very healthy, thin, non-smoking 63 y old who has lots of support the recommendation might be different from that of a diabetic, obese, smoker who lives alone.
Arnon
***** Added comment from Sitemaster *****
Paul:
It might help you to look at the list of questions suggested by the National Comprehensive Cancer Center on page 93 of the NCCN patient guidelines about prostate cancer and its management.
Doctor:
I had radiation therapy 6 years ago and my PSA went from a 7.4 to an 0.8 after therapy. Now it is up to a 2.2. The 2.2 has been the same for a year. My doctor is recommending cryotherapy but I am not convinced that I need anything else at this time. Isn’t the fact that the PSA stayed at a 2.2 for a year a good sign for me?
Is the doubling time the time from first being diagnosed or from the lowest PSA? I would love to hear your opinion.
*****Answer*****
Leland,
Cryo is only one option. And sure, it is absolutely an option to keep on observing. However, the decision to move forward depends on many things including your tolerance of the risks of any proposed treatments and the wisdom of treating in the context of your overall health. These are subtle considerations and best handled in concert with the doctor who best understands your circumstances.
Arnon
*****Additional comment from Sitemaster*****
Leland:
Your PSA doubling time is measured from the time (and value) of your lowest (nadir) PSA level after radiation therapy to the present time. Ideally, all PSA values used in the calculation should have been generated by the same PSA testing service (to ensure that one is comparing apples to apples). There is an automated PSA doubling time calulator on the Memorial Sloan-Kettering Cancer Center web site that will help you to calulate your personal PSA doubling time with accuracy.
Dr Arnon,
My husband, aged 55, underwent LRP 2 weeks ago. Catheter removed at day 7 postop. Had reasonable stream, some dribbling, stress incontinence upon rising, etc., …
This morning, 3 days after catheter was removed, he experienced severe pain, 11/10, bladder spasms that took him to his knees, urgency and “dribbling.” We went back to our hospital and a urologist (fellow) carried out a bladder scan, found he was retaining urine and replaced the catheter. He immediately drained about 300 cc of clear, yellow urine.
My husband is devastated. … What does this mean? Will he struggle with incontinence? This is a man who is very active.
Thank you
*****Answer*****
Dear p,
Urinary retention happens in maybe 1% of cases. Probably from a clot or some swelling at the anastomosis. The treatment is a catheter. And … there are no apparent long-term implications for anything. This is typically a very limited event.
Arnon
Doc,
Just got results; age 50; active physically and sexually; non-smoker; no symptoms; PSA 2.4; Gleason 3 + 3 = 6.
What do you advise? Cyberknife, seeds, or Da Vinci?
*****Answer*****
On behalf of Dr. Krongrad, I can tell you that there is no good answer to this question because it depends on your opinions and who you select to treat you. If you join our social network, then you can benefit from the experiences of other men who have needed to make similar decisions over the past few years.
Sitemaster
I HAVE VERY SCARY PSA VELOCITY NUMBERS AND URGENTLY SEEK ADVICE.
My PSA has risen from 4.7 in June 2011 to 8.2 in November 2011 to 10.9 in December 2011! A prostate biopsy, performed 01/13/2012, has shown that I am positive for prostate cancer in three (3) of the twelve (12) areas biopsied; all positive areas in the same half of the prostate.
My own research leads me to believe these “high-risk” PSA velocity numbers are indicative of extremely aggressive prostate cancer growth, yet my urologist recommends “watchful waiting.”
Added pertinent information is as follows:
(1) I am a 55-year-old white male and have lived all my life in Chicago. (2) My father had prostate cancer, but he died of a heart attack at age 73. (3) Results from my prostate biopsy include a Gleason score of seven (7)… 3 + 3; clinical stage has been determined to be IIA or T1cNXMX; prostate size 43 cc.
How concerned should I be about having an overly aggressive cancer that may kill me within seven (7) years?
I am scared and need other opinions.
What course of action would be recommended for an individual presenting these results?
Thank you for any thoughts you may be able to provide concerning my situation!
Respectfully,
Frank
*****Answer*****
Frank,
There are major internal inconsistencies in your report. First of all, 3+3 does not equal 7. So the first thing to do is to get clarification on your Gleason score. Secondly, I’d get clarification of the stage, too. And then, while your age is useful, I’d ask to put all this into the context of your overall health: diabetes, smoking, obesity, anxiety, social situation …. lots to pull into the discussion. And if this is not enough, then a second opinion is in order.
Arnon
I am a 52-year-old male. In 2009 I had a PSA level of 5.8 ng/ml … and my doctor did a biopsy which he reported was negative. Now its 2012 and my last PSA reading was 6.9 ng/ml. Could that biopsy have been wrong?? Should I be getting another biopsy? … If its not cancer, why is my PSA level so high?
My last exam confirmed my prostate was slightly enlarged … Given my age, I’m not suprised. Im more concerned by the extremely high PSA level and the possibility that the biopsy was incorrect.
Should I get another biopsy?
Appreciate any thoughts …
Steve
*****Answer*****
Dear Steve,
In theory, sure, anything is possible. So it’s possible that a biopsy was wrong. Overall, yes, there is a chance of a second biopsy being positive when the first was negative. So this is something you can discuss with your doctor.
There are many explanations for high PSA. Cancer is just one of them.
Arnon
Get a %free PSA test and see what that yields for results. Everyone that I know that had this test and had a %free PSA reading less than 25% had cancer. You want the number to be high, the closer to 100% the better.
Dr. Arnon,
I just got my most recent PSA result, which went down from 6.2 to 1.9 ng/ml. I’m elated, but concerned that the test was inaccurate. I had a biopsy in the fall of 2011 that indicated a 1% positive biopsy core in one of 16 samples, Gleason score of 3 + 4 = 7. I have been on Avodart since then. Could the medication have so drastically reduced my PSA number?
*****Answer*****
Jack,
Yes, along with other things, e.g. resolution of unrecognized prostatitis, dutasteride can lower PSA.
Arnon
Hi Doctor,
I am 61 and had an RP in 2003, followed by radiation and hormone therapy later that year when I had an immediate recurrence. My PSA before surgery was 14 and my Gleason score was 9.
My PSA has stayed at 0 since the radiation/hormone treatment, but I still struggle with anemia. It was extreme back then — a 3 red count. Not so bad now, but below normal. Any thoughts?
Also, does small cell carcinoma with no elevated PSA ever occur in patients who once had higher numbers.
My concerns, obviously, have to do with wondering when/if the other shoe will drop, given my high Gleason score.
Thanks so much.
*****Answer*****
Dear John,
I understand your anxiety but have no crystal ball. At this point, regardless of any theoretical construct, e.g. small cell carcinoma possiblity or not, there will continue to be an element of uncertainty.
Anemia is a nonspecific finding and can be caused by lots and lots of things. If it persists and/or is problematic, then the best way to sort those out is to consult a hematologist.
Arnon
Dr. Arnon,
I am 73 and had an RP in 2003, at biopsy my Gleason score was 3 + 4 and I had 16 core samples (right side sample clean, left side had cancer cells). [After the RP], the surgeon felt that everything looked very good because the cancer was contained within the gland.
After 1 year the PSA reading was 0.1 and from that time forward to November annual PSA, where the PSA read 1.4 ng/ml, the rise seems to be 0.2 per year since 2008. I am concerned about a constantly rising PSA. As I understand it, PSA can be produced by either or normal prostate cells or cancer cells remaining from the RP in 2003, slowly multiplying in the cavity, or around the urethra or bottom of the bladder.
My primary care doctor scheduled a consultation for me with a specialist who flatly said I had cancer again. How can he determine whether or not these remaining cells are cancerous, seeing that the cancer was totally within the prostate prior to the RP, without any tests?
He did order a bone scan, which I have just received, and a CT scan which will be performed this Tuesday, as a “base-line.” I also have a consultation with a radiologist this coming Friday — presumably to discuss what and if radiation is recommended at this time with a PSA at 1.4 and apparently low risk.
I was also told that with low-risk cancer/slow growth, as in my case, after an RP and 10 years later a PSA at only 1.4, they would not start aggressive treatment until the PSA reached 20 ng/ml.
What does the historical data show in cases such as mine, for the PSA increasing more rapidly at some point, as more cells multiply, healthy or cancerous or both?
Do you recommend radiation therapy for me at this time, or wait until the PSA rises to a trigger level? I know that radiation can have unsought consequences of it’s own.
Thank you in advance, Dr. Arnon.
*****Answer*****
Dear Richard,
The bone scan is a good idea. It will probably be negative, but a baseline is useful in the future. And it is possible that the bone scan will be positive, even if low likelihood and in which case you definitely do want to know because it will potentially alter management.
Yes, with time, if this is cancer, there is a chance that the PSA rise will accelerate. But so far it’s risen slowly, so all bets are off. Only time will tell.
Yes, radiation has risk, as you noted. So any decision to have it has to take that into account (and only after the bone scan results are available).
Arnon
Hello Doctor,
My father is 71 years old; no history of prostate cancer. His PSA 11.6 in November and 17.0 ng/ml in December. The urologist suggested a biopsy for him. He had a heart bypass 8 years ago and he has diabetes and high blood pressure. My question is, are there any side effects of biopsy?
*****Answer*****
Hi Sangita,
Yes, like all invasive procedures, prostate biopsy is associated with a range of risks, including bleeding and infection, which can include sepsis (bacteria getting into the blood stream). Your father can review these risks with his doctor(s) so he can make an informed decision and consent.
Arnon
My husband still feels bad 4 weeks after LRP. Is this normal?
His results were fabulous, all organ contained; cancer was very small and found through PSA. Surgeon said he was able to save nerve bundles. He is continent except for a few “stress incontinence events.” He has moderate abdominal bloating and some back/flank type pain which bothers him and I know worries him. His bowel pattern has changed.
He has gone back to work (desk work) but sits a great deal of time at home, complaining of discomfort and swelling. Cialis 5 mg/day but nothing in the erection department. I am very frustrated and not sure if this is to be expected, depression, or being “whiney”. This is our first health crisis. Surgeon follow-up vist in 4 weeks.
My husband has talked with office nurse, but is told all is moving as expected. Thanks for your help!
*****Answer*****
Hi P,
Unless your husband is 30 years old, then the lack of erections at 4 weeks post-op, especially since he has other physical discomforts, is not at all surprising. It also has no particular prognostic significance and you may not want to work into anxiety with it.
Back pain is not uncommon in the first few days if the patient has been lying in bed a lot. This is especially true in men who have chronic back pain, which can be exacerbated by bed rest. On the other hand, flank pain is less common, although it can represent muscle spasm and ache. However, at a month post-op, and especially if flank pain is stationery (doesn’t move about as you would expect if it was from intestinal gas; which raises the question of if he’s constipated) and/or is associated with nausea/vomitimg/loss of appetite and/or is getting worse, then it unusual and would warrant serious attention and, at the absolute least, informing his surgeon.
Arnon
P,
I’m not sure of your husband’s age or general health, but 4 weeks post-op is certainly not long enough to be concerned about an erection.
I had DaVinci prostate removal 2 years ago (nerve sparing and localized cancer contained in the capsule) by an excellent surgeon. It took 2 months for total continence to return, and about the same for some rectal pain to subside. To this day an erection without some sort of mechanical intervention is not possible. Shots will do it with no problem, but I do not tolerate those well. I personally prefer a vacuum pump, which does well. I am now — after 2 years — capable of achieving a slightly firm appendage on my own, but it is not sufficient for intercourse. I am 54 years old and in great health and fit. The point is that everyone is different and the recovery period for each will be different. Be patient and support your husband as much as possible through his recovery. There are many ways of achieving closeness and intimacy without the actual act. If you both are anxious, then ask about the injections, because they do work, but don’t let your husband get discouraged because his recovery doesn’t happen as quickly as you or he think it should.
Greg
I have been diagnosed with prostate cancer (3 + 3 = 6/10) and (3 + 3 = 6/10) so I am considering treatment options. I also have an atonic neurogenic bladder and so I have to catheterize myself in order to urinate. Should this condition affect my choice of cancer remedy? Thank you.
*****Answer*****
Thomas,
Have a look at this discussion thread on the social network.
Arnon
Dear Dr. Krongrad,
I was diagnosed with prostate cancer in October, 2005. My minimally invasive surgery 2 months later was very successful. My PSA since then has remained less than 0.1.
My question, however, is not about me. It’s in regard to a friend of mine who was diagnosed with early stage prostate cancer about 2.5 years ago. I don’t know what his PSA was at the time, nor do I recall his Gleason score or exactly what stage his cancer was, but during his “watch and wait,” period, he has had a few biopsies and several PSAs. The PSA levels have steadily decreased. Because his most recent PSA was down to less than 1.0, his primary care physician told him that he’s now probably cancer-free. Is this possible? Could a biopsy, or repeated biopsies, somehow remove the cancer? Does cancer ever disappear without treatment?
Tom
*****Answer*****
Tom,
Not too likely, even as his overall risk is low (as implied by a low PSA).
Arnon
Hi Doctor.
My husband was called in 10 months ago as his PSA count was 4.08. He was sent to a urologist who did the DRE test and felt a small hard nodule. He was advised to have a prostate biopsy, which he had, and they took at least 12 cores; he was advised that they all came back as negative for cancer.
Six months later his PSA has gone up to 4.40. … The urologist wants him to either get his PSA checked every 2 months for the next 6 months to see what happens or get another biopsy. My husband has decided to do the PSA tests as his prostate size is small with no cancer and there was no change in the DRE test. Is there anything else we should be doing?
He has no problems with urination but has always had very little semen and was unable to have kids with a nil to low sperm count. His health is otherwise good except he always has achy legs. … Do you have any suggestions?
Thanks, J.
*****Answer*****
Dear J,
With little semen, a small prostate, and infertility, one wonders if the testosterone is low. If so, this would artificially lower the PSA. Which means that perhaps with a normal testosterone (assuming it’s really low), his PSA would be even higher. All this is to shape the assessment of the PSA level, which is to say that it might shape the assessment of prostate cancer risk.
He may want to put all this together and ask his doctor(s) to also check the testosterone the next time, so as to put this into proper context.
Arnon
My husband had a negative prostate biopsy in 2008 for an elevated PSA. He has been on medication to lower the PSA for a couple of years. He decided to stop taking the meds and now his PSA has increased to 6 ng/ml. Should he have another biopsy?
*****Answer*****
Hi Maggie,
PSA is not an illness, so it’s not altogether clear why one would want to lower it. Before making decisions, it might be sensible to ask his doctor(s) for a clarification of what has been done so far and what might be the objective going forward.
Arnon
Dr. Arnon,
I am a white male, 54 years old. My father had prostate cancer — never treated — which had spread everywhere, but he lived to 86. My grandfather on my mother’s side also had prostate cancer — also never treated — which also had spread but he lived to 83. Two uncles on my mother’s side (out of three) have prostate cancer and were diagnosed in their 60s. Both have been undergoing different treatments, but it has spread and may not have been diagnosed early enough.
I had an elevated PSA level of 5.4 in December 2011 and 5.8 in January 2012. My biopsy came back with 5 of 12 cores positive, but only one more than 50%. I had an MRI and I was told the cancer is contained within the prostate; I am T1c and Gleason score of 3 + 3 = 6. I have seen four specialists so far — radiotherapist , urologist, surgeons, and will be seeing two more, including a top HIFU practitioner. All, so far, have recommended surgery, but I do not want the poor quality of life likely after a radical robotic prostatectomy. As for waiting, they all said I am just deferring the inevitable, and the best course of action is to have the prostate removed now before the cancer spreads. Currently, I have health insurance, and I may not have it in the future, or coverage for this. But I am very concerned about impotence and incontinence and the impact of related side effects on my quality of life.
*****Answer*****
Peter,
There is a lot missing from this report that would be useful in making assessments of risk related to the side effects you fear: current function, smoking history, illnesses (diabetes), obesity, mood, fatigue, who the surgeon is …. To put the concerns into some sort of realistic framework will require a thorough review of your clinical and social circumstances. Surely one of your doctors can take you through that. Surely you would find that useful.
Arnon
Dear Doctor,
My dad was just diagnosed with prostate cancer. He will soon be having a CT scan and bone scan to find out if the cancer has spread beyond the prostate. He told me his PSA level was 22 in December 2011 and, after a month of antibiotics, his PSA went up to 27 in January 2012. Isn’t this too much too soon? Do his PSA levels mean that the cancer is spreading? My dad is 57 and very worried.
*****Answer*****
Hi Erika,
The PSAs can bounce around for many reasons. So no, not necessarily.
Arnon
I have metastatic prostate cancer that is currently in my lungs, where I have about 10-15 growing tumors that are about 1.5 cm. in diameter, based on very recent scans. My PSA is 72.
Removal of my prostate was not “indicated” because of the metastasis, and subsequently my prostate seems to have returned to normal. I am reluctant to use docetaxel or other chemotherapies for the lung tumors because they will compromise my excellent quality of life. I have been able to control the cancer in other parts of my body using radiofrequency ablation and radiation.
Question: Is my distaste for chemotherapy a realistic concern, and can you think of any better options for a person in my condition?
*****Answer*****
Dear Julian,
Your distaste for chemo is understandable. However, what is not clear is if you have a realistic understanding of its actual benefits and risks in your case. Accordingly, it would make sense to have a conversation with your doctor(s) to make sure that your expectations and insights are realistic, and then you can apply your personal preferences to those expectations and insights.
Arnon
Dear Arnon,
I’m 65 and healthy. My PSA went from 3.6 to 4.3 ng/ml in 1 year. Should I start to worry?
*****Answer*****
Vladimir,
You should consider going to see a urologist for an evaluation of what may be something important or nothing at all. The number itself is not enough to know.
Arnon
Question for Dr. Arnon:
I’m 79 and in excellent health. Play ball, look like 60 and feel like 40.
Eat healthy, take walks every day. Am on no medications. Great blood work results,just done recently.
Had a prostate biopsy two years ago. Negative.
DRE shows a “rough” spot, which has been there for a couple of years.
In July 2010, II had a 4.2 PSA but a FREE PSA of 31%.
I asked my urologist, How is this possible? To have an elevated PSA, but yet a very good number on the FREE PSA?
He couldn’t answer this.
In Dec 2010, I had PSA of 3.8. Ditto on July 14, 2011.
Yet two weeks ago I had a PSA of 5.6, but yet a FREE PSA of 31.8%, which was even better than last time.
My urologist recommended a PCA3 urine test which came back positive, a score of 102.
Again I asked my urologist about what he calls a “worrisome” score on the urine test and how this jibes with the high FREE PSA. He said there is a “disconnect” but could not say any more.
Today Feb 20, I had an MRI of prostate. No results yet.
Would you care to comment on this apparent contradiction?
Thanks,
Jay Festa
*****Answer*****
Hi Jay,
I am not sure where the contradiction is. If the various tests all correlated perfectly, there would not be additionally informative value in them individually. Because they are not all correlated perfectly, their aggregation tells us a nuanced story and it is our task to interpret what they are saying. In this case, they may be saying conflicting things, but each is limited and fallible. So … with a PSA of 5.6 and a FREE PSA of 31.8%, there is a real finite risk of a positive biopsy. And there is a chance that this positive biopsy will show high-grade cancer. And in a very active and healthy 79-year old man, a high-grade cancer could be a real problem. One question: Would this man want to know if he has prostate cancer? What if it was high-grade cancer? If so, why not discuss a prostate biopsy, which can actually make a diagnosis, in place of many more suggestive but inconclusive blood and urine tests?
Arnon
Dear Dr. Krongrad,
My dad (81) had cryoablation in March 2008. His PSA had been 6.9 and his Gleason score was 2 + 3. I am not sure what stage it was, but it was in both sides but was not palpable. His PSA a few weeks post-surgery was 0.
Starting with his 6-month follow-up test, his PSA has been gradually rising. I believe that his PSA at his 2-year test was about 0.4. The last two tests (at 2.5 and 3 years post-cryo) returned PSAs of 1.01 and 2.13 respectively. He is starting to worry. His MD said that he’s not worried, but he does want him to come in in 3 months instead of 6 months for his next blood test.
I have a few questions that I’m hoping that you can help me with:
Gwynn, please see below.
(1) Is there ever a “PSA bounce” after cryoablation? Answer: I am not sure that I have ever heard of “bounce” after cryoablation, only after radiation.
(2) If so, would it have occurred within the first 2 years after surgery? Answer: See above.
(3) Is it normal for a PSA to rise like this following cryoablation (i.e., can it happen at this rate if there is NOT a recurrence of cancer)? Answer: The word “normal” would not seem to apply to any aspect of this situation.
(4) Is a rise to 2.13 ng/ml following a nadir of 0 considered biochemical recurrence? Answer: Aside from what we might consider this to be or how we label it, the question is this: What are the clinical implications? The answer depends upon much more than the test result and your father’s age. It must inherently also depend upon his overall health, function, smoking, social circumstances … which can be put into view by his doctor(s).
(5) What is the likelihood (%) that he would have a positive biopsy at this point? Answer: It’s possible, but should the question outline in (4) not be answered before any procedure is done?
(6) At what PSA level should we start to be really concerned (as I already am concerned)? Answer: There would only be cause for concern if the answer to (4) is that any of this has any potential clinical meaning. This Q&A simply does not provide enough detail for us to get to that point. I would recommend that your father step back from the “tree” of the PSA, talk with his doctor(s) about the elements listed in (4), and see if he can come to a broader view of the “forest” before any more worry and/or action appear. I hope this helped.
Thank you so much for your help!
Take care,
Gwynn
That helped a lot. His overall health and function is currently excellent (many people think he’s 60 when they meet him). Your response provided a great framework for his next discussion with his MD re: the “forest”. I appreciate that analogy. Thank you again.
I am 64 and was recently diagnosed with prostate cancer and I am having difficulty in deciding which treatment to pursue. I am torn between focal cryotherapy and robotic-assisted prostatectomy.
My PSA jumped from 2.1 to 3.1 in a year and then to 3.64 in 2 months. I had a 16-core biopsy with three cores cancerous; Gleason score 3 + 4 = 7;
prostate normal on DRE; small prosate and no other symptoms at all.
Most doctors except one are suggesting removal. They all seem opposed to cryotherapy since not enough time has elapsed to study results. I think it may be the answer for many men in the future when the long-term results are in.
Any thoughts?
*****Answer*****
Ray,
Lots of things “may” be the answer for many men in the future. But many things that seemed like they “may” be the answer turned out actually to be either no better or more toxic. Such is the case, for example, for proton beam radiation. And so it is with pomegranates, HIFU, and grandma’s chicken soup.
You’ll have to decide for yourself if you want to go something that “may” be the answer.
Arnon
Ray
Dr. Krongrad,
Can you imagine any circumstance in which orchiectomy might be a reasonable first option for non-metasticized, medium-risk (say T1a, Gleason 3 + 3, PSA 15) prostate cancer? I know it’s not a cure, but in a 64-year-old, otherwise healthy patient, wouldn’t the lack of testosterone slow cancer progression significantly? Is osteoporosis the greatest risk, and can’t it be treated successfully?
Rob
*****Answer*****
Rob,
T1a suggests that the cancer was diagnosed on a TURP done for BPH and is of a very minimal amount. So one question: Should any treatment be instituted at all?
Arnon
Dear Dr. Arnon Krongrad:
Just a short note to commend you on a fresh and vibrant website!
Your info and commentary are cutting edge. Mike Scott was wonderful, in his speedy and factual replies to my experiences.
Just finished up 39 IMRT salvage treatments after failed HIFU procedure, preceded by a 6-month shot of Eligard. PSA 6 weeks post-treatment 0.04. As Mike has pointed out, its necessary to wait for the hormone effects to disappear to get a true picture of the situation.
As you may have gathered, I am not a poster boy or, in retrospect, a fan of HIFU. I am glad to see that there is more evidence mounting, that it is not the miracle cure it has been touted to be.
Cheers
Gerry Macdonald
*****Answer*****
Hi Gerry,
Yes, Mike certainly has lots to share. And yes, it’s important to bring out the data as a source for informed and objective decision making.
Thank you very much for the feedback.
Be well.
Arnon
Dear Doctor Arnon:
I am scheduled for a biopsy in 2 days due to a rise in my PSA. I have heard conflicting information concerning the benefits of a 12-core biopsy versus a 20-core biopsy. Could you offer some feedback from your perspective as a doctor?
William
*****Answer*****
Hi William,
In principle, the more you sample, the more you know; that’s the upside of the additional cores. In principle, the more you sample, the more discomfort you can cause and the more risk there might be of an adverse event. So it’s always a balance. With a small prostate, one can get a pretty good sampling with 12; not infallible, but pretty good. So one question is this: How big is the prostate? This can be assessed at the time of biopsy, by ultrasound.
Arnon
Dr Krongrad,
I am a 72-year-old male with an elevated PSA of 17. It has been as high as 31 and as low as 7. I have avoided biopsies out of fear. I have many symptoms of prostate cancer. I am being treated for prostatitis. There is now talk of putting me on a drug that destroys all testosterone. I am sexually active. With the loss of the testosterone. will I be impotent?
*****Answer*****
RB,
Low testosterone can be associated with erectile dysfunction.
Your report does beg another question: Is your PSA high because of prostatitis? It’s a question worth asking your doctor(s). If yes, then perhaps a treatment with antibiotics will reduce the symptoms, as well as reducing the PSA, theoretically even to a level at which the risk of cancer is judged to be low. Also worth asking your doctors.
Arnon
Dr Krongrad:
I am 56-year-old white male who had prostate cancer back in 2006, with a PSA of 5.6 and a Gleason score of 4 + 3 = 7; clinical stage T2a.
I had 42 IMRT treatments and was put on Lupron for 2 years. At the end of the 2 years, in 2008, my psa was undetectable. In 2009 my PSA was 0.05; in 2010 it was 0.12; in 2011 it was 1.80; and now in 2012 it has jumped to 8.01 on February 2nd, with all tests done at the same lab. I had it rechecked at my urologist’s lab last week and his reading was 12.5 just 4 weeks later.
I am scheduled for a biopsy next week, and I am getting a lot of anxiety. My uroligist — even before the biopsy — is letting on that my cancer has to be back and the outlook not good … 2 years at best. I’m not happy with his demeanor!
I have no new symptoms. I actually feel good physically. I’ve always had frequent urination and am up three times a night; nothing has changed in that regard.
What do you think the odds are that it is reacurrent cancer? What are the odds it has spread (with the PSA of 12.5 and now going up so quickly)?
What other salvage therapy would you suggest I consider if it’s back?
Will Lupron be able to be used a second time if needed, and would it work as long, since we used it before?
Sincerely,
Randy D.
***** Answer*****
Hi Randy
I can certainly appreciate that this situation is causing lots of anxiety. Try to separate your emotional reactions to his demeanor from the objective information he is trying to collect with which you will be better able to make informed decisions. Obviously, if he is so remote that he won’t communicate clinical data, that’s a whole other story.
In the meantime, you’re asking good clinically oriented questions for which I simply don’t have enough detail to render a precise assessment … all of which means that there is a dominant element of uncertainty, which is to some extent transient. As the data come in, including from the biopsy and possibly some other tests, e.g. bone scan, the uncertainty will to some extent dissipate and you will better understand where you are.
There are several possible approaches to this situation, which depend on the answers to the clinical investigations. Among them are hormone deprivation, salvage surgery …
Hang in there. You need more data and soon you will have it. Stay focused on that. It’s important.
Arnon
March 4, 2012
Dear Dr Arnon,
This is Jay Festa writing to you again. (I wrote before, on February 20, and thanks for your reply.)
I had mentioned that I was getting an MRI of the prostate which, thank God, despite my worries about the high score on the PC3 urine test, came back OK. The radiologist determines I have benign prostatic hypertrophy
I had also mentioned that I had a PSA of 5.6, while half a year ago and 9 months ago I had 3.8.
But 3 days before my lab work for the PSA I had had a colonoscopy. Could it be that the insertion of that examining tube skewed the results of the PSA?
I remember hearing that one should not have an internal prostate exam and then have blood drawn for a PSA because such an internal exam can distort the results.
I appreciate your good work in answering so many questions.
Jay
***** Answer*****
Hi Jay,
It would probably have to be one heck of a colonscopy to cause a big bump in PSA. If you were sedated, you might ask your gastroenterologist just how vigorous that scoping was. I doubt that is the reason. Either way, you can settle its hypothesized effect by simply repeating the PSA (without first getting a colonoscopy).
Arnon
Dr. Krongrad:
Thanks for your quick response.
One more question. … If my cancer is back and I start hormone therapy right away, before I get a second opinion, would that alone influence the second opinion on whether I could have a salvage crysurgery or any kind salvage therapy if I had started hormone thearpy already?
Thanks,
Randy D.
*****Answer*****
Randy,
It might affect which staging tests your second consultant might want, which might affect which treatment is recommended.
Arnon
Dr. Arnon,
I am 32 years old, female. I have mild pain on left side of my ear, and get pain when I turn my head or rotate it; it feels tight.
I got ultrasound of the lymph nodes and a thyroid test done. The reuslts are:
(1) Right lobe 4.8 x 2 x 2 cm (small hyperochoic region which measures 6 x 4 x 4)
(2) Left lobe 3.5 x 1.4 x 1.4 cm (hyperochoic region measures 4 x 5 x 5, possibly parathyroid adenoma)
(3) Left neck, enlarged lymph node without a definite fatty hilum which measures 1.8 x 1 x 1.4 cm; other adjacent nodes are identified as well.
Is this something serious? Please help me.
*****Answer*****
Dear Kavs:
We regret that Dr. Krongrad is a prostate cancer specialist. He cannot attempt to answer questions on clinical matters about which he has no specialized training.
Sitemaster
Dear Dr Arnon,
My profile:
– Age: 57
– PSA history during 5 month period before RP: 5.5, 6.5, 8.2 (sent for biopsy), 9.7 (on day of RP)
– Pre-RP biopsy result: Gleason 4+3 in one of 24 samples
– RP method: da Vinci, “highly successful”, “textbook surgery”
Histology report after RP:
– Prostate weight: 57 grams
– CA stage: pT2c (i.e. in both lobes), CA in 10% of total prostate, “well away” from exterior wall
– Final Gleason score: 3 + 4
Astounding result:
– 12 weeks after RP, three PSA measuments were: 9.7, 9.6, 9.2 (tested in two different labs over 3 days)
Quotes from my da Vinci surgeon: “Makes no sense according to the histology report”, “During RP everything looked clean around the prostate”.
Action done so far (now 4 months after RP):
– Bone scan: No sign of CA in the bones, mild arthritis showing at the knees
– CT scan: No sign of tumors, a slight swelling of some lymph glands in abdomen
My questions to you:
(1) Could this persistent PSA be a false positive, for example, due to certain antibodies present in the blood? (I have not yet tested if such antibodies are present.) Paul, it’s a positive, but the question is if it represents PSA manufactured in cancer cells. Maybe. Maybe not.
(2) What alternative PSA testing methods are available which do not yield false-positive results? None that I know of.
(3) Is it possible the slightly swelled lymph glands are a result of the severe blood infection I suffered after the biopsy? In theory, yes, but lymph node infection would not explain high PSA.
(4) Should I immediately embark on hormone therapy and radiation therapy “just in case”, as my apparently panic-stricken da Vinci surgeon suggested? That’s not clear. Have a look at this: http://laprp.com/files/pdf/2007_Krongrad_The_Majors_PSA.pdf
Regards,
Paul
I am 63 years old and I have been getting annual physicals for about 20 years. Early on my PSA’s were below 1. Then the psa crept up to between 1-2. The past 4-5 years it was in the 2′s. Last two scores were 2.8 then 2.3. I just received my latest report for March 1st psa and it was 3.4. Should I be concerned. I am going back in 2 months for another psa. My primary care Dr. Is an internist. I just received my blood work today and he wrote on it “everything looks good!”
Joe,
A PSA in that range is associated with a risk of positive biopsy of 25%. This is worth discussing in the context of your overall health.
Arnon
Dr. Krongrad:
I am 68 years old, have a heart stent (4 years ago), have CLL and prostate cancer; feel fine; general health good; weight 216 lbs.
My PSA is 7.05. Recent biopsies show 5 areas out of 12 with 3 + 3 = 6 and 1 with 3 + 4 = 7.
I am considering HIFU.
(1) Would you recommend this? Probably not.
(2) Which variety: Sonablate by a prostate cancer specialist in Peoria, Illinois who goes with you to Cancun, Mexico or Ablatherm at the Cleveland Clinic, Canada? See above.
(3) Other treatment? Possibly, but I’d have to know a lot more detail.
FYI, see: http://prostatecancerinfolink.net/2012/02/10/korean-study-says-that-hifu-does-not-provide-effective-oncologic-outcomes/
Thanks for taking the time to answer questions!
I started with T1c prostate cancer and had HIFU in November 2009; the procedure was done in Canada. It was a complete failure with nasty complications, i.e., urinary retention which required surgical intervention. I am not a poster boy for HIFU.
I subsequently needed salvage radiation, with Eligard prior to radiation treatment (39 treatments @ 200 cGy each). I have since had a declining PSA with levels down to 0.05 and 0.04 ng/ml.
All the best
Gerry
Dear Jerry Gilbert,
PLEASE … Hope you do NOT do HIFU!!! You sound to be perhaps in the same situation as my husband was, except he does not have CLL. He started with da Vinci surgery but had a positive right surgical margin; after 18 months his PSA started to climb, and although it was low, the doubling time was pretty fast. Being very proactive, we decided on further workup at Dattoli Center in Florida, where he had radiation treatments to the area, plus androgen deprivation, etc. Very happy with results!! It is nearly 2 years post-radiation now and his PSA negligible. Yearly scans and ultrasounds look clear.
Best wishes,
Judy Yoakum, R.N.
Hi. My husband is 52 years old. His doctor ran a PSA test last year and it was elevated. He was told to re-test in 3 months, which he did. It was even higher. They tested again and still high.
They ordered a biopsy, which he had done and they found nothing yet his last PSA test was 6 ng/ml.
We don’t know what to do. What could cause his PSA levels to be so elevated with no evidence of cancer?
*****Answer*****
Hi Cindy,
Please understand that PSA is a non-specific test, for which reason one moves to a biopsy to establish a diagnosis. At 6 ng/ml, the PSA indicates a risk of approximately 25% of a positive biopsy, with a laundry list of other things possibly explaining the negative 75%. The only question now is if to repeat a biopsy, which reflects index of suspicion that depends upon such things as family history, prostate size, findings of atypia on the first biopsy, and the like. This is a question best addressed by your husband’s urologist.
Arnon
Dear Doctor,
Thank you for this site.
I had a radical prostatectomy on 15 November 2005 (at age 56 years and 9 months). The PSA was 3.5 in May 2005. By August 2005, it was 4.5, and by November it was 6.0. (A biopsy had revealed cancer by then.)
I have always been very healthy — before and after the RP. The pathology report summary after the RP stated, “Moderate and poorly differentiated adenocarcinoma. Gleason 3 + 4, predominantly involving the right anterior lower zone, the right and left apex, and the right posterior lower zone with lymphovascular invasion; positive surgical margins at the right anterior lower zone and the left and right apex; seminal vesicles not involved; and associated high grade prostatic intraepithelial neoplasia and adenomatous hyperplasia.
Not good. However, my PSA stayed down until 2007 and rose to 0.2 by April 2007 and was 0.4 by August. Between October and November of 2007 I underwent 7 weeks of radiotherapy. This reduced the PSA to < 0.01 at one point, and it has slowly started to climb again:
25/01/08, 0.04; 11/07/08, 0.01; 8/07/09, < 0.01; 6/01/10, 0.10; 14/01/2010, 0.10; 5/02/10, 0.10; 9/04/10, 0.10, 5/07/2010, 0.16; 20/08/10, 0.13; 19/11/10, 0.17; 21/01/11, 0.15; 19/03/11, 0.23; 30/07/11, 0.27; 25/02/12, 0.30 ng/ml.
My oncologist says, given that I am now 63, it could be 10 years before a real problem presents, and only in later stages do any real treatments take place, given that I am not prepared to undergo hormone therapy (nor castration ever). I think that quality of life is lost sight of as I am still active and “healthy”.
My question is that all the reading I do deals with patients who are, let’s say, at a very advanced stage. Why are treatments like sipuleucel-T not trialed on patients like me in the early stages. Why wait for the train wreck, when you may be able to prevent it?
*****Answer*****
Dear John,
I don’t know how the makers of Provenge set the specific criteria for their trials. However, to speculate, it may be that they avoided trying it in early stages because there are other commonly accepted treatments in early stages. So one problem would be that patients would not agree to be randomized to some of these other treatments and Provenge, which would interfere with trial organization. But you’d have to ask them to really try to get at their actual reasons.
Arnon
Dr. Arnon:
This is Randy D. again, I first left you a question on March 3rd and again the next day.
I just received my biopsy results, they were negative: no cancer found out of the 12 samples from the prostate. The urologist commented when doing it that the prostate was still very small from the radiation 6 years ago and he did not see anything suspicious with the ultrasound.
He still thinks I should go on hormone therapy anyway, to be safe. I know my insurance won’t pay for it if we can’t prove there is cancer.
What would you suggest? Could prostatitis cause my PSA to jump from 1.8 to 12.5 in a year? Should I try antibiotics first and see what the PSA does?
I have no symptoms other than my prostate has felt inflammed after riding a motorcycle.
Thanks,
Randy D.
*****Answer*****
Hi Randy,
Sure, prostatitis can increase PSA, although one would expect it to also be accompanied by symptoms, e.g. discomfort. You can certainly ask your urologist what he thinks of this idea.
Arnon
Dear Dr. Kongrad…
I’m 55 and was diagnosed last week with prostate cancer. My PSA was above 5 at my last routine blood test so the doctor suggested a round on antibiotics and a retest. When my PSA hadn’t changed he referred me to a urologist who performed a DRE and recommended a biopsy. I had the biopsy early last week and received the results later in the week.
My PSA was 5.65 and they found cancer in one core (10%) on the right side and two cores (5%) on the left side. Gleason on both sides was 3 + 3. The clinical stage is T1c and the Partin projection for organ-contained disease is 80%.
The urologist also does open surgery and he recommended against that approach because of my physical size (I am 6’2 and 350 lbs). I have also looked at research online showing that robotic surgery is not as successful in obese patients, so I am concerned about going that route. He did refer me to a radiation oncologist to talk about the radiation therapy options and I meet with him on Monday.
My question for you is really about the urgency. The urologist is telling me that I should get treatment in the next 4-6 weeks. As indicated above, my options seem to be limited by my overall health. Am I better off getting the prostate cancer treated and working on my overall health in parallel, or do I have time to get a good start on improving my overall health before starting treatment?
*****Answer*****
Dear Ron,
Not having full knowledge of your overall health, my first question is this: If you don’t drop weight, what are the implications for your survival? Meaning, if you don’t drop weight, what is the relevance of any other new diagnosis, including prostate cancer? Does it even matter?
Secondly, if you believe that not losing weight is not a viable health option for you, then by which method: exercise, diet, surgery? And how rapidly? And at what effort and risk? And what are the implications for your overall health if you succeed? And how does that weigh against any threat from the newly diagnosed prostate cancer?
I am in no position to tell you how long you can or cannot wait before the prostate cancer becomes autonomous of any steps you may be contemplating, such as radiation and surgery. Hopefully, the questions are ones that resonate in your circumstances and with which your doctors can help you.
Arnon
Thank you in advance for your time and advice! I am 70 and I have been “watching and waiting” since my initial prostate biopsy indicated I had early stage cancer just over 2 years ago. A follow-up biopsy 1 year ago indicated no change and my periodic PSA results run between 5.7 and 6.5 ng/ml. Now my doctor wants to schedule another biopsy. Is there any other way to know how my disease is progressing, or should I just have a biopsy once a year?
*****Answer*****
Gerry,
No method, including periodic biopsy, can deliver a precise measure of stage progression. They are all at best crude estimates and, accordingly, associated with a risk of missing the threshold beyond which effective action is no longer is possible. Is there a better, more precise method than what you are describing? Not that I can think of.
Arnon
Dear Dr. Arnon:
Four biopsies taken over 5 years (12 needles) show one needle with insignificant cancer. My PSA is 28 and Gleason 6. They now want to do a saturation biopsy of 33 needles. However, I read from many sources that the procedure is controversial. I think I would rather wait until some obvious indication of cancer before I do anything else.
Please advise your opinion.
I am 72, in very good health, take no drugs, and do not have ED or urinary problems.
Thank you for your response.
Bill P.
*****Answer*****
Dear Bill,
Saturation biopsy is not any more controversial than PSA testing and prostate biopsy. That said, it is associated with risk, as is any invasive procedure. You may want to review the risks with your urologist and ask him to help you understand them so you can decide what is more risky: having the biopsy or not having the biopsy.
AK
Hi. I was diagnosed with a PSA of 17.6 and an aggressive (Gleason 5 + 3), stage T3 prostate cancer with meso-rectal fascia involvement in May of 2010 and started hormone treatment immediately, taking 50 mg bicalutamide tablets daily for 28 days, before switching to goserelin/Zoladex 10.8 mg implants every 3 months.
By February 2011 the hormones had done their work and my cancer was deemed sufficiently reduced to allow 37 treatments of tomotherapy (2 Gy per day, Monday to Friday). Since the conclusion of the tomotherapy in May 2011, my PSA — taken at 3-monthly intervals — has remained at 0.03. My oncologist has suggested that I stay on a regimen of regular 3-monthly Zoladex implants for a total period of 3 years, counting my first injection in May 2010 as the starting point. In other words, it is suggested that I continue Zoladex implants for a total period of 3 years until May 2013.
Why not go intermittent? I wondered, as, just as regular use of an antibiotic will diminish the antibiotic’s potency, regular use of goserelin will render the cancer immune to its restraining influence and cause it to make a bid to return to the road of metastasis. By spreading out Zoladex implants, by definition one extends one’s life, as statistical evidence suggests that goserelin/Zoladex works for about 2 to 2.5 years if taken regularly. Take it intermittently, however, and you extend its effects and your lifespan significantly.
Also consider the following:
A fellow patient who had tomotherapy at the same time as I, and the profile of whose prostate cancer is almost identical to mine — an aggressive T3 cancer with a Gleason score of 9 (5 + 4) score following a number of years on hormones, resulting in a PSA of 0.04 these days — was told by his oncologist that he could stop using hormones altogether unless or until his PSA increased.
Why would two radically different courses of action be advocated in response to the same conditions? The only difference between us is our age. He is in his very late 70s. I am 65. Could the age difference account for the different treatment advocated — and, if so, why?
P.S.: My next Zoladex implant is due in early May, and I am considering not taking it.
*****Answer*****
Michael,
Not knowing all the facts, including how long the other patient was on hormone therapy and which side effects he may have had, I am not in a position to give you a rational answer for the different approaches. That said, we do know that after a certain period of hormone therapy the testes are permanently suppressed in many men, such that continued administration makes no difference to testosterone production by the testes.
You present an interesting theory but I am not sure we have proof that hormone therapy selects for resistant cancers the way that antibiotics select for resistant bacteria.
Arnon
Husband diagnosed with BPH (no cancer) … Was told that prostate gland can be prevented from growing large. Some urinary retention — score 100 which is considered normal. Suggestion by doctor was to go on Proscar to prevent further enlargement of prostate. Looked at side effects and concerned about statement that there is a risk for prostate cancer. Took the Proscar for a month with uncomfortable side effects, i.e. slight dizziness and slight imbalance. Stopped the Proscar. Any suggestion for alternate drug or treatment.
Crystal,
If anything, there is evidence that finasteride lowers the risk of prostate cancer (click here).
Finasteride can certainly reduce the anatomical size of the prostate, especially if the prostate is large. So can other drugs, such as flutamide. The real question is why this is an important clinical goal. Is the goal not the prevention of symptoms? If so, and your husband is symptomatic, then the question can be redefined and posed again to his urologist. If he is not symptomatic, then one might ask if any action should be taken, all the more so because the last action caused uncomfortable side effects.
Arnon
Hello Doctor,
I have just recently had a blood test and my PSA reading was 11.58, compared to 3.9 in 2008. I am a 66-year-old, otherwise healthy man. Of course my Primary went into a state of panic, scared the heck out of me, and wanted to put everything on hold in my life and see a urologist ASAP.
I have made an appointment with the same urologist that gave me my first PSA reading in 2008. I will be seeing him this Thursday for consultation. Obviously I have been researching, and one thing I have confirmed from even urologists themselves is not to get a biopsy unless totally necessary.
When is that necessary? I know to ask the urologist for another PSA reading from a different lab before I receive a DRE, but can I get an MRI ordered for detection from him, or should I seek out a radiation oncologist and consider his alternative treatments? I do not want a biopsy, if at all, until all other less invasive procedures have been exhausted. Can you help steer me down the right path for this diagnosis?
Take care,
Tim
*****Answer*****
Tim,
A radiation oncologist can offer treatments. But before you have treatments of any kind it will make sense to have a diagnosis. To this end, radiation is not relevant. What is relevant is a biopsy. Is it necessary to have a biopsy? That depends upon your overall state of health as much as anything. If you are old and infirm, then arguably not. If you are young and healthy, then the simple question is this: Given that a PSA of 11.58 is associated with a 30% chance of a positive biopsy, and given that you are otherwise young and healthy, would you want to know if you have prostate cancer? If so, then it is necessary.
Arnon
Dr. Arnon:
This is Randy again. I first e-mailed you back on March 3rd with my possible recurrence situation. Since then we have had a 12-sample prostate biopsy which was negative: no cancer found and nothing suspicious on ultrasound or DRE; prostate size was still small — from the IMRT treatments 6 years ago the urologist commented.
We have now also got our bone scan and our abdomical/pelvic CT scan results back. They were both negative too; nothing abnormal was found.
My new questions are:
(1) Knowing all of the above test results, what is the possibility that microscopic cancer cells that have not shown up on any of these tests can have caused my PSA to jump from 1.8 to 12.5 in a year’s time? Hard to say, but it partly depends upon the nature of the original tumor: grade, stage, etc.
(2) Is it more likely to be something else like prostatitis or a UTI? Without symptoms? Not likely.
(3) Would you recommend any other tests or watchful waiting? I cannot make recommendations in this forum.
(4) Should I consider hormone therapy to be on the safe side? You can discuss this with your doctor(s).
Thanks again for your responses,
Randy D.
My Dad, who is 70, has a PSA reading of 17. He does not want to go for a biopsy.
What would be other symptoms of prostate cancer we could look for?
*****Answer*****
Sam,
High PSA and an abnormal physical exam (prostate nodule, firmness, asymmetry) are the most common signs of prostate cancer. Certainly a PSA of 17 ng/ml, all other things being normal and without any symptoms, is associated with a risk of prostate cancer.
Arnon
Thanks — However, since he does not want to get a biopsy done, what are the other options?
How long before any other symptoms show up?
*****Answer*****
Sam
His options are limited to: (1) have a biopsy, and (2) do not have a biopsy. I am not aware of any other options. Likewise, I am not aware of any way to predict the possible future appearance of symptoms from a possible disease.
Arnon
Hello,
My Dad was diagnosed with prostate cancer at age 49 or 50. He had a radical prostatectomy, lived for 16 years after his treatment, and died in 2008. I am 47 and my PSA was 0.70 last April. I received my results back this April and it was 1.2. My concern is the jump in the reading; also I inject 200 ml weekly of depot testosterone. Should I be tested every 6 months since I am on the shots?
*****Answer*****
Derrick,
One immediate question: What is your testosterone level? Next question: Has it changed in the time frame you’re referring to?
Unrelated to the tesosterone, it would seem your risk of a positive biopsy is probably around 10% or so. The question is whether or not you want to have a biopsy given this level of risk. This is a fair question for your doctor(s).
Arnon
Derrick:
What did your father pass away from? Was it prostate cancer or something else?
Level was low normal 290 a year ago. When last checked, 2 weeks ago, it was around 480. The doctor increased the dose from 0.5 to 1.0 cc a week, 200 ml. He said my metabolism must be burning quickly … whatever that means.
Thank you!
My husband had brachytherapy 1 year ago. His PSA after 3 months was 1.2, after 5 months 2.6, after 8 months 4.2, 10 months 4.6 and now a year later it is 7.1. Our urologist wants to do a biopsy, but we got a second opinion and he said no … just wait. My husband is only 48 years old. Does this sound right?
*****Answer*****
Dear Sue,
Not knowing the initial biopsy findings, pre-treatment PSA, physical findings, and symptoms, it is somewhat difficult to interpret the PSA pattern and the recommendation. That said, if the brachytherapy didn’t work and your young (and presumably otherwise healthy) husband has biologically active cancer localized to his prostate, and given that time would work against him, then there is an argument to be made for a specific determination earlier, not later. These are considerations you can check with his doctors.
Arnon
I was diagnosed on 3/12/12. T1c, Gleason 4 + 3, localized to left base, 10% of gland involved, no neural infiltration. My urologist at UCLA Urology wants to do partial cryoablation. He’s done a lot of cryo and written on the topic. I’m age 66. I’m not concerned about impotence, though I’d prefer not to have permanent incontinence. (1) Why bother with partial/focal ablation — wouldn’t total cryoablation or total prostatectomy via robotic have a higher probability of going longer without recurrence? (2) If that were so, is there really enough long-term data on cryo outcomes to say that it’s comparable to RP via robotic in recurrence and/or mortality? Finally, my urologist/surgeon hasn’t mentioned any form of radiation (naturally, he’s a surgeon). Does the grade/stage I have make me a candidate for any form of radiation, or more generally, does it make me a particularly good candidate for any particular form of treatment?
Dear Andy,
First of all, many surgeons mention radiation. Why yours did not is not clear. Perhaps he had a reason. Perhaps you missed it. Either way, it’s easy to determine: ask him what he thinks.
Secondly, I am aware of no data to show that cryotherapy is comparable to RP (with or without the use of a “robot”). So overall, while I am cool to freezing, it does appear to me that what you are presenting would make you a pretty good candidate for surgery and radiation. To refine this assessment would require a thorough review of many other factors — health, height, weight, medications — which your doctors can do.
Arnon
Dr. Arnon:
On 10/28/09 I had a PSA level of 0.5 ng/ml. I went to my doctor again on 3/26/12 and my PSA level was 2.35 ng/ml. I did not have it checked in 2010 or 2011. I will be 51 years of age in July 2012.
My primary care doctor wants me to see a urologist. Is that a big jump in PSA level in 3 years?
Mike McM
*****Answer*****
Dear Michael,
“Big” is in the eye of the beholder. What is not so subjective is that the risk of a positive biopsy increases substantially as a PSA moves from 0.5 to 2.35 ng/ml.
Arnon
Dear Doctor:
My name is Yara. I am a 65-year-old male, and I am having difficulty with urination and have blood in the urine. I am also a smoker.
What should I be concerned about? What type(s) of clinical condition could I possibly have? Can you recommend a treatment?
Thank you
*****Answer*****
Hi Yara,
Before treating, it will be useful to make a diagnosis. Many things cause bleeding: stones, hemaglobinopathy, infection, trauma, TB, bladder cancer, large benign prostate … A urologist specializes in figuring this out and this is whose evaluation you should seek.
Arnon
Dear Arnon,
I had my prostate removed 19 days ago. I’m feeling pretty good considering.
I am scheduled for my first follow-up visit 6 weeks after the surgery. Due to scheduling conflicts, I asked for an alternative date and the first available was 10 days later. is it OK to wait that long?
David Z
*****Answer*****
David,
Not knowing the facts of your case, it’s impossible for me to know the pros and cons of waiting 10 days. You might ask your surgeon to advise.
Arnon
Dear Doctor,
My name is Sani. I am concerned about my father. He is 54 years old.
On January 1, 2012 we went to urologist suffering from a UTI. He was referred for PSA test and it came back as 14 ng/ml. He was referrd for a biopsy, but our local physician told us to get the PSA repeated again after 1 month. He also has mild prostate enlargement. For 1 month he took herbal Ayurvedic treatment and on February 16 his PSA was 2 ng/ml. On April 6 it had again fallen — to 0.4 ng/ml.
He has no bladder problems but sometimes complains of back pain and pain in leg. He is very active and works 10 hours a day at his office. We are confused about what we should do. Is there a chance he has prostate cancer?
*****Answer*****
Dear Sani,
There is always a chance. But how big a chance? Assuming there is no prostate nodule or other physical anomaly on his prostate, then the chance is low.
Arnon
Dear Doctor,
I have prostate cancer with a Gleason score of 9. I also have had two bilateral hip replacements. Is robotic surgery possible bearing in mind possible interference with vision caused by the metal components in the hip prostheses? CT and bone ccans indicate no migration of the cancer.
*****Answer*****
Dear Andrew,
The metal can causes artifacts with the scans, but, unless I’m missing something, I can’t imagine it would interfere with pelvic surgery. Certainly this is something your hip surgeon can advise your prostate surgeon about.
Arnon
March 2011, Gleason 9, PSA 1,913, stage IV, lungs, nodes, marrow, bones. August 2011, PSA 0.05. PSA now 7.8. Radiologist says can expect 6-12 months (unasked infomation). Would you agree?
*****Answer*****
Dear Sewsewbittersweet,
Without knowing the treatment history and/or functional status, it’s impossible to try assess. You may want to run this by the patient’s treating physician, not the radiologist.
Arnon
Dear SewSewSweet:
If you join our social network, we can discuss this specific situation in more detail. Dr. Krongrad is completely correct in noting that the patient’s treatment history is an important factor.
Dear Doctor:
Re: a relatively healthy 67-year-old man recently diagnosed with a serious form of leukemia, who’s had two sessions of chemotherapy and who has been free of any carcinoma for one week, what could a possible prognosis be for such an individual — particularly his longevity given such a limited amount of info?
*****
Dear Mr. Berkowitz:
Dr. Krongrad is a specialist in prostate cancer, not leukemia. He could not give you any meaningful guidance in relation to this question.
Sitemaster
Hi Dr. Krongrad.
Hopefully you live fine with good health. My name is Rizwan and I am medical student going to submit my final year thesis report. I want to copy simplified drawing of five Gleason grades for prostate cancer; actually my project work is on prostate cancer and I am a student at St. Olav’s Hospital, Norwegian University of Science and Technology. Can you please allowed me to include this diagram in my thesis report. I will be really thankful to you.
Looking forward to hear from you.
Kind regards
Rizwan
*****Answer*****
Hi Rizwan,
I don’t have a version of the Gleason diagram that I can give you.
Arnon
Dear Dr. Arnon,
I read a lot of your thoughts and feelings from the book you wrote. I have recently been found to have early stages of prostate cancer. From a biopsy done by Dr. Aaron Geswaldo in Albuquerque, where I was living, the result of a biopsy was a Gleason score of 3+4. (I had a PSA of 7.7 ng/ml.) The biopsy was done about a month and a half ago. I had been working at a hospital there for a year as a respiratory therapist and plan to go back to school to become a physician assistant this Fall. Aaron suggested I have my prostate removed. He said 4 to 6 months would be fine, but not to wait one year.
I will be 65 years old in June. I am in excellent health and feel like I am in my 40s. I was an athlete both in high school and college. I am now living in Vandalia, OH, which is a suburb of Dayton.
I asked Dr. Geswaldo if it was okay for me to run and work out. He said “no problem.” Do you feel that would be okay as well?
My brother and I have a friend with whom we went to school. He is a cardiologist in Little Rock, AR. He had his prostate removed at Vanderbilt, where I worked for 4 years as a trauma therapist. He said the best and most sure thing to do is to have your prostate removed. He also stated that I should find a surgeon that has done at least 300 a year, one that I feel confident with and have talked to at length.
From looking at the top ten urology clinics and hospitals in the US, a good choice is the Cleveland Clinic which is about maybe 6 hours from here. What do you think? I plan to go there next week and talk to a urologist / surgeon.
A couple questions I wanted to ask you is “how to pick prostate cancer surgeon. What are your thoughts?
You mentioned “Minimally Invasive Surgery”. Could you tell me a little about it and how does it compare to prostate removal?
Dr. Arnon, I look forward to hearing from you.
Respectfully,
Bob Neely
*****Answer*****
Dear Bob Neely,
Lots of questions. Lots of tangents. I’ll try to hit a few:
(1) Prostate cancer is not in itself a contraindication to exercise.
(2) Clinics don’t do surgery. Surgeons do surgery. Forget the clinic. Remember the surgeon.
(3) Minimally invasive surgery is prostate removal but without the big incision. There are benefits.
You may want to do some more reading. There are some useful Q&A’s on http://laprp.com
Arnon
My dad is 79 and had prostate cancer about 20 years ago. His PSA recently spiked (not sure of the numbers); he will be tested more next week. I live far away and just wanted to know if this could be a false positive being that his prostate has been removed and if so what is the likelihood of a recurrence? What follow-up tests should take place now?? Should I be overly concerned?
Thank you,
Stacie
*****Answer*****
Stacie,
Yes, false positives are possible, which may be why he’s being retested. The likelihood of a real, true positive relates to his original diagnosis: PSA, grade, and stage. You may want to review those features with him and/or his doctor(s), because this will give you a better assessment of what is going on.
Arnon
Hello.
My husband had robotic prostectomy 2 weeks ago. He had a biopsy in February with only two of the 12 cores positive (Gleason score 4 + 3). He is 68 years old. DREs by three different doctors appeared to show a smooth prostate. His PSA level had risen from 3.6 to 5.1 in a year and a half. Everyone thought this was going to be a good result. Pathology shows a meaty multi-nodulated prostate with positive surgical margins on the right and left lobes; 50% of prostate involved; Gleason score now 3 + 4.
We have to wait a few more weeks for a first post-surgical PSA, but we are very worried. Do we have reason to be overly concerned? Can he live another 10 years with this?
*****Answer*****
Dear Edie,
I appreciate your concern and understand the anxiety that comes from not being sure and having to wait for PSAs. That said, the term “meaty, multi-nodulated” has no prognostic significance, so please put that out of your mind. As for margins, there are margins and there are margins. In other words, if, for example, these are microscopic (<1 millimeter), cauterized margins, then they are probably of no real significance. Furthermore, a great many patients live just fine for years and years after a finding of positive margins. So you can try to get more detail about the exact extent and nature of the margins, but either way, there is no way to get around waiting for PSAs.
Arnon
Dr. Arnon
I am 56 years old. Sometimes I get an extreme urge to urinate but it is a different-feeling urge, seeming even more urgent than a normal urgency. I need to get to the bathroom right away, because if I don’t, I start to leak semen. And when I urinate the urine is preceded by a small amount of semen. Recently while I was running down the street (I don’t normally run) I found that I was leaking semen with each footfall! What is this very annoying and inconvenient condition?
BTW I have had an enlarged prostate for about 25 years.
Mike
*****Answer*****
Hi Mike,
This is new to me. I’ve not heard of something like this one. Is it semen? Is it lymph (chyluria)? No idea. You may want to see a urologist. And if you get it sorted out, please let us know what this is.
Thank you.
Arnon
Hi,
I am a 67-year-old male. My dad had prostate cancer in his 70s and was told it was slow growing and not a threat.
My PSA has been steadily going up for 7 years. I have had three biopsies — 2 x 12-core and a third state of the art 20 core using MRI imaging at UCLA — which were all negative. I have also had three PCA3 tests which were all low scores.
My question is … now that the PCA3 test has been accepted by the FDA, are you giving it more weight than the PSA test, which has many weaknesses, and if my PCA3 test scores remain low, should I ignore my rising PSA levels?
*****Answer*****
Dear Ron,
The FDA is a body meant principally for first of all to make sure that drugs, devices, and tests do not pose undue and undisclosed toxic effects. The fact that a urine test is approved by the FDA does not in itself mean that it is more precise in its purpose than any other test.
PSA has few weaknesses. The way people common apply it is full of weaknesses. Ditto all other tests.
Ignoring tests is usually not a good idea. Putting them into perspective is usually a good idea. Most importantly, in your case, the 3 negative biopsies (44 negative cores) is a very useful bit of information that can help to guide all further actions and decisions, e.g., should there be a 4th biopsy. On this, your urologist can guide you.
Arnon
Dear Sir,
I have been diagnosed with mild prostamegally and have been under medication for the last month, with any improvement I am taking Norflox now I had stopped.
During my investigation I had high pus cells — it was 100 — and I had difficulties in passing urine. I am treating with ms surgeon. He is a specialist urologist. I am following up still but no cure. Do advise me by return which are the tests to be done. During my test my CBC was 14,000.
Regards
Wilson
*****Answer*****
Hi Wilson,
It sounds like you are describing prostatitis, urethritis, and/or cystitis, possibly with urine infection and/or stone [i.e., probably not prostate cancer]. I would need more details to sort this out. Perhaps the best next step is to visit the urologist again.
Arnon
Hi Doctor.
I was diagnosed with metastatic prostate cancer 2 months ago. My PSA was 7.7 ng/ml; initial examination of the prostate demonstrated normal contours; the prostate volume was 22.9 ml; there were no hypoechoic areas seen and the contour was regular; the seminal vesicles were “unremarkable.”
A total of eight biopsy cores were taken from the peripheral zone of the prostate — four from each side. A further two cores were taken from the transition zone. The cancer was staged as T1cN0M1 based on the results of a bone biopsy from one rib, which was positive for cancer. The Gleason grade was 3 + 4 = 7.
I am currently taking Zoladex injections (10.8 mg) once every 3 months. My PSA level after 6 weeks of treatment was 1.8
I have been amending my diet as much as possible so that I try to control the cancer as much as I possibly can. I read some research on leucine and how this may be detrimental to my condition. To be honest, I am reading so much conflicting information on diet and food that I am finding it hard to know what to do. Do you know of a really good/reliable web site I could access?
Thanks, Philip
*****Answer*****
Hi Philip,
You may want to check out the Diet group on the social network, where you can also post your own discussion threads (click on the bottom of the discussion forum, where it says “+Add a Discussion”).
Arnon
Dr. Arnon:
My husband is 41 and just diagnosed with early stage prostate cancer. His father is 67 and has prostate and colon cancer. My question is what treatment is most likely to achieve a 100% cure?
I am hoping he decides to select a treatment that will provide the best possible cure outcome. I’m not at all confident in the watch and wait idea. Saving his life and giving him the best possible chance of a cure is the most crucial priority.
Of course we want to continue our sex life so what ED treatments can he begin to use as soon as possible? We have a very active sex life and he does not have any problems achieving an erection. Also what potential incontinence problems will he face if he undertakes your recommended treatment?
As I get more specific result details I will post again. I understand without specific results my post is rather vague.
*****Answer*****
Dear Melanie,
Thank you for writing. The likelihood of cure varies by PSA, grade, stage, and technical factors relating to treatment, e.g. nerve preservation. It will help you to review these details with his doctor(s), who will then be best able to help you navigate the course between maximizing potentials for cure and functional preservation.
Arnon