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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Hi Dr Kongrad,
I am 77, had radical surgery in 1996, and radiation for recurrence in 2003. Since then my PSA had been under 1.0, until this January when it climbed to 7.8.
I am asked to go for a Prostascint test together with a whole body bone scan, but the cost is around $8,000 (only 50% paid by Medicare). Is this test neccessary as an only option, and is the quoted cost a legit amount? Thanks.
—–
Dear Fred,
I am not sure what you mean by a legitimate price for the scan. Which criteria legitimize a cost for a medical test?
Is it necessary? It would be if someone could show that its result had an effect on treatment choice that confers a meaningful clinical advantage. I’m not sure that such data exist. Is it necessary? Theoretically maybe, but in proven terms that’s less obvious to me.
Arnon
Dr. Arnon:
l had an RP 15 years ago (PSA, 12; Gleason 3 + 4).
Five years later my PSA jumped to 9.0 ng/ml after being undetectable. I got laser beam radiation and my PSA was between 0.5 and 1.0 until now.
Recently it rose again to 8.0. Before taking any decision, would you tell me what are my alternatives?
l am 78, in good health but for the past few months have been feeling very tired, mostly my legs.
Thank you for your help.
Regards,
Luc
—–
Dear Luc,
Perhaps the first order of business is to determine why you are suddenly tired. This assessment must broaden well beyond the prostate cancer and PSA. And, depending upon its conclusions, can affect your choices that are specific to prostate cancer. For example, hormone treatment, which is one choice, can cause fatigue and one has to ask if you could tolerate a double dose of fatigue. This issue really is best addressed by your primary physician in association with an oncologist.
Arnon
Dr. Arnon,
Approximately 3 months ago my father (76) was diagnosed with small cell carcinoma of the prostate. Two months ago he started chemotherapy (platinum drugs) and also hormone therapy (Lupron). He has completed his second round of chemo. I search and search for data on small cell carcinoma of the prostate and am not having much luck on finding data in general on this type of cancer, treatment, survival or anything that is recent. I just want to know anything possible on this cancer. Do you have any recent information on small cell carcinoma of the prostate? Thank you.
—–
Hi Annemaria,
Your father is lucky to have you helping him through this situation.
I suppose you’ve already looked in Google. Perhaps you may also want to search in http://pubmed.gov, which can be rather technical, and interact in the chemotherapy and other groups of the social network.
Thank you.
Arnon
Dr Arnon:
Thank you for your answer. It’s a good thinking that my fatigue may be clash with the elevated PSA treatment. This is not decided yet but l should see an oncologist in a couple of days.
Meanwhile, at the time of my first recurrence 8 years ago, as far as l can remember l felt the same fatigue invading me. After radiation treatment l was much better until …. a few months ago.
Your comments are most appreciated and include plenty of good information.
Sincerely,
Luc
Dear Dr Krongrad:
A recent ultrasound indicated my prostate is about 52 cc. My question is: Does a large prostate influence outcomes after prostatectomy? Is there a greater likelihood of positive margins or effects on potency and continence? Is neoadjuvant ADT ever recommended to reduce prostate size prior to surgery to improve outcomes. (My PSA is 7; Gleason 3 + 4; clinical stage T2b.)
Many thanks,
Joe
—–
Dear Joe,
Maybe, maybe, and maybe. But …
52 ccs is not that big. It’s actually pretty much the average for prostatectomy prostates.
Arnon
Dear Dr Krongrad:
I had a recently had a physical at 55 years of age. All my blood tests were fine except my PSA. It went from 2.62 in 2008 to 4.43 this year — exactly 2 years to the day.
I saw my urologist and he did a DRE and said everything felt normal. He suggested I have a biopsy (16 cores). I received the results on November 22. He said all the samples were clear of cancer, but he mentioned there was one which was ASAP and that he would like to repeat the test.
I retested in early January with another 16 core biopsy and unlike the first test there were no ASAP cells. All cores were normal; my question is what would you recommend I do now? I have quite a bit of fear from what I’ve read regarding ASAP. I have not had a PSA test since Oct 2010. How long should I wait to retest? Should I get a second opinion on the first biopsy test?
Regarding symptoms; I’ve noticed when I urinate I have some excess urine left and have to manually help remove by massaging my penis below and upward by hand. I told my doctor about this, but he expressed little concern. I have also had trouble with firm erections the last two years. I failed to tell my Doctor of the latter. Could these problems have anything to do with my prostate and the elevated PSA? I am considering going to another doctor for a second opinion. Hate to say I am confused and worried.
Thank you
Dear Frank,
Your worry and confusion are totally understandable. There is not an absolute clarity, even with so many cores of sampling. In this light, another opinion makes a lot of sense. But which kind? Have you thought about a second pathology opinion? In other words, having the atypia re-examined by another pathologist, perhaps a pathology reference lab like Bostwick (Dr. Bostwick) and/or Johns Hopkins (Dr. Epstein)?
Arnon
Dr. Krongrad:
My 70-year-old otherwise healthy father was just diagnosed with prostate cancer. His PSA went from 3 (Sept 2009) to 6 (December 2010) to 10 (February 2011). His Gleason score is a 9. His 12 biopsy samples were all positive. He has been complaining of lower back pain that he attributed to his mattress but now we think is related.
He is currently getting lab work and CT scans performed this week. His appointment with his urologist is next week. What kinds of questions should we be asking? What are important benchmarks to be looking for in our conversation with our doctor to make determinations for future action? What are key words to listen for that a doctor uses to formulate a treatment plan and/or a prognosis?
Thanks for your thoughts.
Christa
—–
Dear Christa,
1) Ask if a CT scan is enough. Ask if your father also needs a bone scan, independent of the CT findings.
2) The PSA seems low given the biopsy report and possible spine involvement. Ask if a testosterone level was done, and if having that would help to better interpret the PSA and the clinical findings. Is it possible that the PSA is artificially low due to a low testosterone and thus an under-representation of the clinical picture.
3) Ask the doctor to tell you which treatments he would recommend for any specific stage of cancer: a) With no spine metastasis and b) With spine metastasis.
4) Ask about the wisdom of consulting a medical oncologist. Ask if there is a medical oncologist in your father’s area who specializes in prostate cancer. Ask if the medical oncologist could guide your father about the role of surgery, radiation, hormones, and chemotherapy.
Take this step first. You need much more detail and a clear assessment of stage before your father can take any therapeutic action. Good luck. He’s lucky he has you to help him.
Arnon
Dr Krongrad:
I am 53 years of age. My PSA has gone up from 1.9 to 3.0 in 6 months. I do not suspect prostatitis as I have zero symptoms. I am seeing a urologist next week but am worried. I have no problems with urinating, and no pains or aches. I am an endurance athlete, train a lot but not on a bike or such. I have no problems with erection or ejaculation. I had no intercourse 24 hours before the most recent PSA test. There is no history of prostate cancer in my family.
From what I am reading I can’t think of any other reason for this sudden increase in my PSA, and a lot at that, correct? What would you do next?
—–
Dear William,
I’d present exactly the presentation you made to my doctor and ask him:
1) Does my prostate feel normal? Is there a nodule?
2) What is the chance that a biopsy would show cancer?
3) If cancer, what are the chances that it will be the “curable” kind?”
4) Given my health and family history, does it make sense for me to have a biopsy?
5) What are the risks of a biopsy?
Arnon
I am TC3 after RT; Gleason 3 + 5. The Gleason score seems very unusual and, obviously, if it is erroneous, I am 3 + 4 which is a very different kettle of fish on prognosis. Two questions:
1. Can post-op pathology be completely trusted to be accurate on the Gleason score?
2. Just how uncommon is 3 + 5? I have read the statistical probability is only 9%.
Thank you
—–
Dear Jim.
1. The pathology assessment is the only basis for the Gleason score. So it’s all there is and there is no other yardstick by which to assess accuracy.
2. 3 + 5 is rare, but at the individual level the fact that it’s rare makes no difference. It’s a 3 + 5 and there is no way to convert it to a 5 + 3, 4 + 4, or anything else. That score reflects the cell shape it represents and thus implies the biological activity that it implies, regardless of who had anything else.
Arnon
Dr Krongrad:
My husband’s PSA level was 3.42 in February 2010 and it is now 4.84 in February 2011. He had a biopsy performed in August 2010. It didn’t show any signs of cancer. How worried should we be about the rise in his PSA levels? Should he have another biopsy done? The doctor took 12 samples. How would we know if he went deep enough into the prostate for the samples to be accurate?
—–
Dear Nita,
Good question. The answer partly depends upon: 1) How important it would be to know if he has prostate cancer, which has to do with his other, competing illnesses and their overall meaning; and 2) His risk of actually having prostate cancer, which has to do also with his physical prostate exam, race, family history, findings of atypia on the first biopsy, and the like.
Assuming an adequate sample and a good pathologist (you can always get a second pathology opinion), and assuming that he is otherwise healthy, and knowing that a first negative biopsy does not get any man off the hook fully, then one possible next step — which you can discuss with his doctor(s) — is a repeat biopsy. A related question is when to do that. Not knowing everything about your husband makes it impossible for me to know more, but his doctor(s) will be able to advise directly.
Arnon
My husband is a 48-year-old male, Caucasian, doesn’t know of any one in his family having prostate cancer. But didn’t know his birth father. I am not quite sure what atypia is? Can you explain that please? All I know is the biopsy results said negative for malignancy on all the samples that were taken. He doesn’t have any other health issues. He has had chronic prostitis for quite a few years and has been seeing a urology specialist in Albany Medical for 2.5 years now.
Not sure if this helps you at all..
Thank You
—–
Nita,
Yes, age, overall health, and family history are very helpful to an assessment of what to do with a blood test result. Context always matters.
Atypia is a finding by the pathologist that is also referred to as atypical small acinar proliferation (ASAP). If it’s observed, then it indicates a higher chance of a positive biopsy. The report either indicates atypia or it does not. If you’re not sure, you can ask the pathologist who read it. “Negative for malignancy” is just that but it does not indicate if there was or there was not atypia.
Chronic prostatitis is a symptomatic illness that in Latin immigrants to California has been shown to associate with a higher risk of prostate cancer; you can click here to read more about chronic prostatitis and prostate cancer. If your husband is a Latin immigrant to California, then the chronic prostatitis goes to the assessment of risk of prostate cancer. Otherwise, I doubt it has any meaning on his risk assessment other than it is a possible underlying factor in raising the PSA falsely. This history, too, is critical to his doctor(s) assessment of risk.
Arnon
I had IMRT radiation for T3a prostate cancer in December of 2007 and a seed boost and 2 years of Zolodex injections. In March of 2011 my PSA moved from <0.01 to 0.04 and I discovered some blood in my urine one day. I went to my oncologist and she did another PSA check which came bac the same; T level was 280, and she did a urine test. We should get the results in a day. She said that if there was blood in the urine she would refer us to the urologist so he could look inside the bladder.
I am feeling that I would like to go into the urologist regardless because I fear that the cancer has spread to the bladder. What do you think? My PSA at the time of diagnosis rose quickly from 5.2 to 8.3 ng/ml; four cores out of 10 were positive (5% of two, 60% of one, and 70% of another). The Gleason score was 3 + 4 and from scans there was no evidence of metastases. Having not had surgery, this was all based on what could be seen from biopsies and scans. If surgery had been done I realize that the situation could have been staged differently. I am fearful of spread to the bladder. I know that I do not have an infection because I do not have any pain. The only other thing I thought that it might be is an after-effect of the radiation, but I suppose that that it not very likely 3 years down the road. Wouls like your take on the situation.
Thank you,
Lowell (Bud) Turner
—–
Dear Bud,
It is quite unlikely in general terms that prostate cancer went to the bladder. And while you have no pain, this alone does not mean that you do not have either a urine infection or radiation effects. In the event of infection and/or radiation effects, it’s quite possible that these are behind the very slight PSA rise to what is still a very low level. While your anxiety is totally understandable, your imagination seems to running ahead of the facts and, to the extent that you can manage to do so, it will be good to try to take only one step at at a time. Let your doctor(s) guide you.
Arnon
I have read that the use of bilateral orchiectomy has gone out of fashion due to introduction of LHRH agonists. But, then I read that bilaterial orchiectomy is becoming more popular due to the favorable reimbursement rates. What are the current guidelines (standard of care) for the treatment of metastatic prostate cancer?
Dear How,
I am not aware of a professional society or other organized group that has published a guideline that differentiates androgen deprivations surgically from pharmacologically. In any event, a guideline is but a line of general guidance that can easily break down in the bedside practicalities. Given that both surgical and pharmacological means can achieve androgen deprivation effectively, the practicalities are quite relevant. For example, orchiectomy is done once and does not require repeat administrations of medication. And so on.
Arnon
This question has to with prostate health and avoiding cancer. Is there any link or any study that shows that the frequency or level of ejaculations affects prostate health risk for cancer?
*****
Hi Mark,
There may be such a study somwhere, although I cannot immediately cite one for you.
However, even if it exists and it shows that orgasm raises risk, it’s doubtful that this kind of association would be quantitatively sufficient to keep men from taking steps to reaching orgasm. Conversely, if it showed that orgasm lowers risk, then it’s probably useless in that many men as it is are already trying to reach orgasm as often as possible.
In other words: I don’t know and even if I did I doubt it would be of any practical use at the bedside.
Arnon
Hi Doctor,
I am 65 years old, Chinese, came to USA 24 years ago. I was just diagnosed with prostate cancer with PSA of 20, Gleason 7 (4 + 3) , 6/22 cores positive, all from left side of prostate. Bone scan negative. CT and MRI show two abnormal lymph nodes in pelvic area. One is the left pelvic sidewall measuring 9 x 9 mm across
which is very round without anything to suggest fatty replacement or benign etiology and is not amenable to CT-guided biopsy, which is of concern. The other is medial to the external iliac vein, more oval (6 x 10 mm across). My question is: What is the normal size for pelvic lymph nodes and what else could cause the nodes there to be bigger except cancer? I feel everything is fine except these terrible test reports.
Thank you for your help
Peinan
*****
Dear Peinan,
Lymph nodes can enlarge for many reasons, including events that happened many years before detection. Among those reasons are cancer, infection, chemical irritants … So without pathological inspection, one cannot know the cause of the enlargement. Assuming that you are healthy and a good surgical candidate, one possible strategy might be to head to the operating room to sample these nodes and, if you are so inclined and the nodes are not malignant, to proceed with surgical treatment. This is one strategy that you can review with your doctor(s).
Arnon
This is a follow-up message on my husband. His urologist had another PSA test done, and his level went from 4.84 to 2.02 in less than a month. His level has not been this low in over 5 years.
After he had the first PSA test done (which was the 4.84 level), I had him start taking lycopene supplements at 10 mg/day, because I read it’s good for prostate health. Could the lycopene be what made his PSA level lower in such a short time? And if so is this a good thing? Or a bad thing? Meaning could lycopene mask his PSA results?
Could he have cancer even though the PSA went down? When he went to the urologist he didn’t do an exam of his prostate, since he had one done 6 months ago. He was happy with just the PSA results. Remember my husband also had a biopsy of his prostate 6 months ago also. And when his PSA levels had risen from 3.42 to 4.84 a month ago, that is when he decided to do another PSA.
So could lycopene be doing harm or good?
*****
Hi Nita,
Yes: The lycopene could be doing harm or good. Indeed, the very phenomenon you cite — cancer masking by marker reduction — is the theoretical mechanism by which any intervention, including lycopene, could cause harm. There is precedent to show that PSA is not what we term a “surrogate” for prostate cancer clinical outcomes. For example, flutamide, the first widely-used oral anti-androgen, has been shown to lower PSA without affecting survival. So … until we find data to show that lycopene not only lowers PSA but actually lowers cancer incidence and/or prolongs overall survival, it’s buyer beware.
Arnon
Dear Doctor,
I am a 46-year-old white male.
In January, I had a bladder infection, and was prescribed Cipro which cleared it up in a few days. For whatever reason, my doctor decided to check my PSA level, and it was a 10. Two weeks after the infection cleared, it was down to a 9. She decided I should see a urologist. The urologist did another PSA test, and this time PSA was a 7, but free PSA was only 6%. Of course, a biopsy was ordered. I got the biopsy results this week, and there were 2 cancerous regions: one had a Gleason of 3 + 3 = 6, and the other was 3 + 4 = 7. Of course, I was shocked because there is no known prostate cancer in my family. As far as treatment goes, what treatment procedure has the least chance for impotence? I am thinking of getting the radiation seeds, and if this does not cure me, then cryosurgery can be used as a secondary treatment. What do you recommend for someone my age who is in fine health, and does not take any medications?
*****
Dear Scott,
I am sorry to hear about the diagnosis and am sure that it came as a major surprise. Given that you are not facing an emergency situation, take some time to let some of the emotional intensity subside so that you can make the most informed, rational decision for yourself.
The likelihood of good erectile function after primary treatment to a huge extent depends upon patient characteristics before treatment: age, overall health, smoking history, obesity, depression, social situation, fatigue, work stress … In other words, factors that may be outside the control of his doctors. If you are a healthy, non-smoking, non-obese, well-adjusted, generally not depressed, reasonably rested, 46-year old man with good erections, then your chances of having good erections after treatment are much better than if you are 46 years old but not those other things.
All treatments of prostate cancer carry the risk of erectile dysfunction. However, for a patient in a favorable prognostic category as defined above, and given certain technical variations (nerve preservations, for example), the likelihood of a good outcome is high.
In evaluating which treatment to choose, one has to keep in mind not only the patient factors as a critical determinant of outcome, but also the skill of the operator (a surgeon, for instance, should be experienced) and the oncological nuances of the situation. For example, if the two positive biopsy cores are on the same side and neither has a lot involved and there is no vascular invasion reported, then at the very least the contra-lateral (opposite) nerve can be reasonably safely preserved and maybe the ipsilateral (same side) nerve can be preserved. Given that one nerve is often as good as two (think of the nerves as redundant, not additive), depending upon the specific, detailed facts of the biopsy (which we have not seen here), a patient, in consultation with his surgeon, can weigh his risk tolerance related to cancer non-removal versus his desire for erections (in the context of all the factors listed above), and arrive at a rational decision about which treatment and, if surgery, which nerve(s) to preserve.
Not having ever met you and not knowing all the facts of your case, I am in no position to make a medical recommendation to you. Maybe the conceptual framework provided above can help you to better guide your research on a path to an informed decision.
Feel free to join our social network to learn more.
Good luck.
Arnon
Hi,
My husband is scheduled for a prostate cancer MRI tomorrow morning. Unfortunately, we’ve had to argue with our insurance to get this procedure covered. After ongoing shenanigans by our insurer we thought we had it worked out, but when we got the approval the final approval letter yesterday morning it says they will not cover “contrast further sequencing.” It also says it’s for MRI pelvis, is the use of an endorectal coil considered a “pelvis” exam?
Is it worth it to do a prostate MRI without contrast? I’m wondering if we need to cancel to argue with our insurance company some more. I’m guessing paying for the contrast ourselves would be quite dear.
Thanks,
Tracy
*****
Hi Tracy,
Is endorectal considered pelvic? It’s not what you might interpret but what your policy covers.
This may be a good time to take a step back and assess the clinical situation. What is the PSA? Grade? Stage? Biopsy findings: Percent involvement, atypia, PIN … and the like? In other words, how do the MRI findings potentially change clinical decision making, if at all? These are questions your husband’s doctor(s) can help you to answer, perhaps before you decide what to do with that MRI.
Good luck.
Arnon
Based on the fact that chronic non-bacterial prostatitis places no bacteria in the urine, if a patient’s urine sample (swab color dye test) comes out negative, is there still a possibility that one’s PSA can mislead by indicating a problem (i.e., cancer) when the real problem is the effect of the non-bacterial prostatitis?
*****
Richard,
Asked another way, can there be a negative prostate biopsy in the setting of: 1) elevated PSA and 2) no bacteria in the urine?
Yes, it happens all the time, with and without symptoms suggestive of prostatitis.
I would not say the PSA is misleading. After all, the PSA and the biopsy are not the same test, wherein the former merely quantifies the likelihood of a positive result with the latter. Those who are “misled” are in fact really misusing the PSA test.
Arnon
Hi, Doctor,
My biopsy report shows cancer cells in 6/22 cores, all in the left lobe. The Gleason grade is all 7 (4 + 3), involving 2 to 15% of the lengths of the biopsy cores. Can you explain what these involvements of xx% mean here? Does it indicate an early development of cancer cell growth? Does it have anything to do with cancer spreading?
Peinan
*****
Hi Peinan,
The percent involvement is a literal quantification of the proportion of the surface area of the core that the pathologist sees in which there is cancer. So in a 10 mm core, if 5 mm is cancer, then cancer involves 50%.
These measurements do not denote early-late and/or stage, which you term “cancer spreading.” From the PSA, DRE, Gleason grade, percent involvement, one may infer the clinical stage.
Arnon
Hi, Dr. Arnon,
Thank you for your information. I am thinking about taking radiation plus hormonal treatment for my case.
My another question is how the radiation is done on my lymph nodes. (There are two enlarged nodes in the pelvic area.). Is it done on all of the pelvic area for all the nodes there or just on the two enlarged particular nodes?
*****
Good question, Peinan. It’s best referred to your radiation oncologist. Thank you.
Arnon
Dr. Arnon,
My husband, 66 years old, was diagnosed with prostate cancer and will begin low beam radiation on May 5th. He completed a bone scan and other exams which showed no cancer beyond the prostate (2 cells on left and 1 on right out of 12). Radiation is to be 8 minutes for 6 months. Is this excessive or normal? The doctor states his success rate is nearly 100% with this stage of PC.
*****
Hi Scheryl,
Thank you for writing.
I am not acquainted with “low beam” radiation. Perhaps this should be clarified.
In any event, the treatment and prescribed dose should reflect PSA, grade, and clinical stage, none of which is provided above. The first two should be known to you and to his doctor(s), so they can better guide the treatment and dose.
8 minutes? Per day? Per month? This also should be clarified by his doctor(s).
You may want to ask for a working definition of “success.” Is this in reference to lack of treatment side effects, e.g., erectile dysfunction? fatigue? PSA recurrence? 15-year survival? Is this true irrespective of any possible coexisting illness?
Arnon
Hi Doctor,
I had a ProstaScint scan with CT fusion on 4/11 and the report indicates no abnormal uptake in the deep pelvic lymph nodes and the prostate bed where I was most worried before. However, it shows intense uptake in the non-enlarged lymph nodes in the abdomen, periaortic, and behind the inferior vena cava (several nodes max. size 1.2 cm) and even greater intensity uptake in the middle mediastinum between the azygos and innominate vein (three nodes, 8 mm). My urologist feels confused, saying he has never seen a patient like this case in which the cancer seems to be spreading to a distant area without going through the pelvic lymph nodes. Is such thing possible or something wrong with the testing itself?
Regards, Peinan
*****
It’s unusual. But anything is possible.
You’ll do best to work directly with your doctor. He’ll have a much better sense of your situation.
Thank you.
Arnon
My husband went to the doctor last fall, and it was suggested he follow up with a urologist. His PSA was 2, which was normal. He had a colonoscopy which resulted in the removal of three noncancerous polyps. He has no sex drive and I believe he suffers from impotence. The past 2 months, he has been c/o back pain and severe anal pain following a bowel movement. Could this be related? He will not listen to me anyways. He is 52 years old. I, however, am constantly worried about this situation.
*****
Hi Missy,
A PSA of 2 is associated with a risk of positive biopsy of around 20%. So all else being equal, he needs to know and to consider discussing this with his doctor.
Among the reasons for PSA rising is cancer. So is prostatitis. Among the symptoms of prostatitis are lower back pain and pain after defecation (and other symptoms, e.g. pain after sex). He may want to ask his doctor if his PSA and/or symptoms are from prostatitis.
Arnon
Just read the above posts. … I thought a normal PSA was 0-4. After seeing all the diagnoses of prostate cancer with a PSA below four 4, I guess I am mistaken. His PSA was zero 4 years ago and his next doctor’s appointment was at 2.0. He had only gone to the doctor due to blood in his stool which resulted in the discovery of the polyps.
*****
Hi Missy … See answer to your other post. Thx. Arnon
Recurrent prostate cancer with a PSA of 0.3 ng/ml 2 years post-RP. Treated with radiation + 6 months of Lupron. When will I know the radiation worked?
– First test 1 month post-radiation — PSA undetectable.
– Second test 6 months post-radiation — PSA still undetectable.
Is the Lupron influencing the result or has the radiation worked?
*****
Hi Gary,
The purpose of radiation is to destroy any viable cancer cell. The Lupron is meant to potentiate this effect of radiation; as a byproduct, the Lupron suppresses PSA levels. So the PSA is low probably as an effect of Lupron. So the only way to know what the radiation did is to stop the Lupron (which you’ve probably done by now) and watch the PSA. We’re talking about a process that can take years to unfold. For now, all you can tell is that something (probably the Lupron) suppressed the PSA and that radiation is being given a chance to work long-term.
Arnon
I am a 63, in good health, and have no prostate problems. My PSA levels for the past 10 years are as follows: 4/2001 = 1.5; 6/2004 = 2.2; 5/2005 = 2.5; 7/2007 = 3.1; 3/2009 = 4.4; 2/2010 = 4.3; and 2/2011 = 4.8. I went to a urologist for a checkup. DRE revealed a small prostate and no nodules. He wanted another PSA and on 3/11 (which was 2 days after the exam) it was 5.6 ng/ml with a free PSA of 0.35 (6.3%). He put me on an antibiotic for 2 weeks to rule out infection and it dropped to 5.4 ng/ml and 0.38 (7%). Can DRE raise PSA and is a biopsy in order? My father had prostate cancer diagnosed at age 63; he had radiation therapy and lived another 18 years. What about MRI spectroscopic imaging as an alternative to biopsy? There are only a few places that do this and can you recommend one?
*****
GP,
Yes, DRE can raise PSA if sufficiently (painfully) vigorous.
You have (and have for some time had) a PSA that even without the family history puts you in a 25% or higher risk of a positive biopsy. You are otherwise healthy. Is a biopsy in order? You have a one in four chance of having a positive biopsy. If you had cancer, would you want to know?
I cannot recommend MRI services.
Arnon
Thank you for the information. I have been reading a lot about the potential for biopsies to spread (needle tracking) whatever cancer that may be found. Is this a legitimate concern? Is MR spectroscopic imaging able to spot cancer more precisely and reduce needless biopsies as claimed or is it a waste of time/money? I wasn’t sure from your reply if you couldn’t recommend a specific MRI-S center or didn’t recommend the technology. Thank you for your time.
*****
GP,
All concerns are legitimate. But maybe that’s a philosophical point. I guess the operational question is if the risk is quantifiable and if it presents a barrier to action. I am aware of absolutely no data that would help to quantify the risk of a needle tracking cancer. None. Furthermore, I am aware of no case in which cancer implanted in the rectal wall, through which the needle traverses on its way to and from the cancer. Finally, given that essentially all prostate cancers are diagnosed with biopsy and that a great majority are “curable” with local treatment (surgery, radiation), the basis for believing in tracking as a real clinical problem is akin to the basis for believing that the tooth fairy really visits your pillow after you loose a tooth.
I’ll recommend an alternative to biopsy when a study shows it has better sensitivity and specificity than biopsy. If there are such data, I’ve missed it. If you find such data, please start a discussion on the Biopsy and Other Tests group on the social network.
Thank you.
My husband had a prostate biopsy and then was ordered a bone scan more than a month after the biopsy. I don’t understand why he has to wait so long for the scan. He said the doctor said something about waiting for the effects of the biopsy to dissipate, but what does that have to do with bones? Please illuminate me.
Thanks,
Laura
*****
Hi Laura,
We do wait for 4-6 weeks before doing surgery. It’s not clear to me what the thinking might be in relation to the bone scan.
Thank you.
Arnon
Hi. My dad has a re-occurence of prostate cancer which has caused his kidneys to fail. The doctors are saying there is nothing they can do for him now. Any suggestions?
*****
Hi Wacira,
This kind of situation requires considerable detail, far more than would ordinarily be possible to transmit by this medium. You might consider an in-person, second opinion, which is commonly how these questions are answered.
Thank you.
Arnon
Dear Dr. Krongrad:
I had the prostate removed and am now receiving 40 sessions of radiation treatment. I am also taking the hormone shot.
My PSA is 6, Gleason is 3 + 3, clinical stage T1c. A biopsy found one sample that was cancerous. My radiation oncologist recommended watchful waiting with PSA tests every 4 months. What are some of the risks of this option, given my low-grade case? Thanks.
*****
Hi Robert,
The only risk of watchful waiting is missing the “window of opportunity” for effective action. Otherwise, if the approach does not cause undue inconvenience of a periodic blood test and/or anxiety, then it’s fine. So the real question is: how does the prostate cancer stack up against the rest of your health? Of course, part of answering this relates to the degree to which the biopsy is representative of the real situation. (Last month I operated on a patient with very much this kind of biopsy finding whose final pathology was bilateral Gleason 4 + 4 = 8 cancer into prostate capsule.) One needs much more information than you have provided in order to answer these questions with any level of confidence. But your doctor(s) can help you with it.
Arnon
Hi Dr. Krongrad,
I am 57 and in good health and no history of prostate cancer in my family.
In the summer of 2009 I had a PSA of around 5. We did an immediate followup that was 3.9. A few months later it was 7.8 and I had a biopsy in November 2009. 12 cores were sampled: 9 were benign, 2 were high-grade prostatic intraepithelial neoplasia, 1 was “atypia”: minute focus of mildly atypical glands, favor atrophic focus, close clinical follow up recommended.
Roughly 3 months after the biopsy I had a PSA of 16. I then took Cipro once a day for 30 days and then had a PSA of 2.9. Three months after that I had another PSA of 2.75 (no Cipro). Now, about 8 months later my PSA is 17.5. I’m back on Cipro for 30 days and will then have another PSA test.
I’m thinking of going to Duke Medical Center to see a urologist there to help me sort this out.
What are your comments/thoughts on my wildly fluctuating PSA?
Thank you very much.
Jeff
*****
Hi Jeff,
Wild fluctuations usually happen with trauma and/or infection. So you may be dealing with some such combination. At the same time, even your lowest PSAs put you at the 20% risk category of positive biopsy, which your previous results (PIN; ASAP) raise further. So among the steps to discuss with your doctor would be the wisdom of a second opinion on the first set of biopsies (by a reference pathology lab) and/or repeat biopsy (with good antibiotic coverage, in case it’s infection and/or abscess).
Arnon
Thank you so very very much for your advice Dr. Krongrad. Your comment about “good antibiotic coverage, in case it’s infection” makes me wonder if it’s possible that if I had an infection during the first biopsy and maybe there wasn’t good antibiotic coverage, could that have possibly contributed to the subsequent PSA of 16? Just curious if that is a possibilty?
Jeff,
I wouldn’t over-think this. We don’t know if you have infection at all. It’s just a consideration if you decide to have a 2nd biopsy.
AK
A biopsy has confirmed that I have prostate cancer. My prostate in enlarged (68 cc). I underwent a total colectomy in 1973 and have no anus. I have been told that this eliminates surgery as a cancer treatment option. Is this true?
*****
Dear Dean,
I’d need more anatomical detail, including your height and weight and scars. But yes, previous surgery does potentially complicate things. Find a really good surgeon with lots of experience and trust his judgment.
Arnon
I have a similar situation, please share any information you acquire and I’ll do the same.
I am 64. My PSA rose from 0.5 to 1.0 in the one year since my last physical. Before that, it had been 0.4 for several years. Is this doubling something to be concerned with? I’d just like your personal opinion. I am very squeamish about medical procedures. Can a biopsy be done under general anesthesia at a patient’s request, or is this something that common practice decides for you?
*****
Hi Dennis,
Assuming you are otherwise healthy, that there is no physical abnormality on the prostate, and that you do not have a family history of prostate cancer, then the risk of a positive biopsy is approximately 10% if the PSA is stable at 1.0 ng/ml. Sure, a biopsy can be done under anesthesia.
Arnon
Had RP 3 months ago with PSA 11.8. Post-op pathology says outside margin in vascular & Gleason 6 upgraded to 7. PSA post-op, 60 days, is 5.0. Started hormone therapy and will start IMRT. Friend had surgery/RT 5 years ago has severe stricture. Have you found that current IMRT has mostly eliminated stricture issues?
*****
Dear Dave,
Strictures happen with/without radiation. So the question is if varying radiation techniques correlate with higher risk of stricture, beyond what is seen with surgery. To the best of my knowledge, there are no data that would permit us to answer this question.
Arnon
Hi Arnon,
I had a prostatectomy on March 1st of this year with the da Vinci. Per the urologist / surgeon, I had a positive margin after the surgery but an undetectable PSA after a month. I was concerned so I went to an oncologist to ask questions about radiation treatments. Come to find out, I had a positive margin because the surgeon left part of the prostate and that part had the cancer. The cancer did not break out of the prostate, he cut into it and left a piece. My surgeon failed to tell me that.
My questions: (1) Is it common to leave a piece of the prostate with a da Vinci procedure? (2) Since he left a small piece of the prostate, can we go back for round two?
*****
Dear Mike,
1) To the best of my knowledge, there are no data by which to answer this question.
2) This is a technical question best answered by your surgeon.
Arnon
Dr. Krongrad,
In January 2010 I was diagnosed with prostate cancer (PSA = 4.8, T2a, Gleason scores 3 + 3, 3 + 3, 3 + 4). I completed external beam radiation treatment in May 2010. Subsequent PSA readings were 1.9, 1.4, and most recently 2.8. the radiation oncologist suggested the rise in PSA could be attributed to a “bounce” caused by dying cancer cells, or could be a return of prostate cancer. He refered me to a urologist, stating that he could do nothing further for me, and doesn’t do hormone therapy.
The urologist wanted to do a blood test for PSA immediately to determine if it had gone up further. I declined since it was only two weeks since the previous test (the radiation oncologist had recommended waiting 3 months).
My questions:
– Is a “bounce” common?
– How long does it last?
– If I have a PSA test so soon after the previous one, and the results are the same, or higher, how do I know they’re not due to the same “bounce”?
Michael
*****
Dear Michael,
– Yes, PSA bounce is a known phenomenon.
– Bounce varies by radiation technique. I am not sufficiently experienced with it to clarify any further.
– Good point. I don’t think you can interpret closely spaced PSA tests.
You may want to join the Radiation group on the social network and +Start Discussion (bottom left side of discussion threads) about PSA bounce. We’ve got some radiation oncologists on the site and maybe they’ll chime in. It would be useful if they did.
Arnon
I recently had a PSA test conducted; the results showed a level of 4.2.The urologist wanted a retest 2 weeks later just to verify original results; the test came back at 4.6 ng/ml. Being 57 years of age, getting physicals yearly, is a PSA of 4.5 ng/ml an approximate level worth getting a biopsy for, given possible side effects?
*****
Robert,
A PSA of 4 is associated with a 25% chance of a positive biopsy. Is this chance of any meaning to you?
If you are 57, diabetic, smoker, obese, depressed …. in other words, very unhealthy … why find out if you also have prostate cancer? If you are perfectly healthy but are growing a Gleason 4 + 3 = 7 prostate cancer, why find out if you have prostate cancer?
These are questions you can answer with the help of your doctor(s). Remember to answer them in context of your overall health.
Arnon
18 months ago my cancer treatment left me with a blockage (scar tissue) in my urethra located in the middle of my prostate. it was up to an inch long but now is about 1/4″. I self-catheterize daily to void my bladder. Is there a good procedure to destroy the blockage without causing damage to the sphincter muscle or valve? My doctor thinks it’s improving and I need to be patient. In fact he said I should be urinating soon. Really have my doubts and feel some other way is possible. I feel I don’t know how to urinate!
*****
SteveE,
Yes, there are techniques for increasing urethral caliber, ranging from soft dilation, as perhaps you are now doing, to cold and laser incision. All carry some risk of hurting the sphincter, which depends upon the location and nature of the stricture. In any individual case, the risk has to be assessed by the urologist. What you are describing sounds potentially very reasonable, depending upon the specifics. If you are not sure, you can always go for a second opinion with another urologist, who may have to scope your urethra to really know the benefits and risks of further action.
Arnon
Hi:
What is the difference between adenocarcinoma and prostate cancer?
Thank you.
*****
Adenocarcinoma is the most common type of prostate cancer. It represents probably 99.9% of all prosate cancers. Other types are prostate lymphoma (I’ve seen 1 case in 25 years), sarcoma (I’ve seen none), and others. So for all practical purposes, the terms are interchangeable.
Arnon
Dear Dr. Arnon,
I wrote you a question back in January, you answered it, and I thank you. I have another question.
Briefly, I am a 46-year-old white male with no history of prostate cancer in my family. I had a bladder infection in January which was treated with antibiotics, and it cleared up. However, my family doctor also ordered a PSA test which was a 10 and dropped to a 9 after antibiotics. She sent me to see a urologist, and he did a PSA and free PSA which were 7 and 6% respectively. He ordered a biopsy, and as could be expected with a 6% free PSA, it came back positive in 3 of 12 cores, all 3 + 3 and less than 5% in each core. The pathologist was Dr. Epstein at Johns Hopkins, so chances are the pathology report is correct, and a second opinion agreed. Well, the urologist suggested removing the prostate which I find to be a bit too barbaric. I did my research, and want to do some watchful waiting for a while, and then possibly go with seed implants. Neither the oncologist nor the urologist see watchful waiting as an option due mostly to my young age. Now my latest PSA taken last week has dropped to a 3.6. In your opinion, given my age, PSA reading, and biopsy score, how would you feel about someone like me doing watchful waiting for a year or so? I honestly do not want to lose the quality of life I now have; the “plumbing” works perfectly both for urination and sex. I cannot see taking a chance with seed implants and end up being impotent at 46, nor do I want the cancer to spread. I am at an impasse, and your knowledge would help. Thanks.
Dear Scott,
I appreciate your ambivalence and understand it fully. What seems missing from your equations that could make the difference is a full analysis of the likelihood of the adverse outcomes you mention. For example, with relatively young age and good baseline function, the critical factors will be overall health (diabetes, smoking, obesity) and the possibility of nerve preservation, which your doctors can address. You may want to revisit your decision in light on this context and have another go at it.
Good luck. I know this can be hard.
Arnon
About a year ago I had a radical prostectomy. I have had PSA tests every 3 months. My urologist is not overly concerned that the PSA has increased but not more than a 50% increase. At the moment my PSA is 45. Do you think that I should take mushroom extract?
Dear Selwyn,
The role of mushroom extract in the management of prostate cancer is not known to me. Accordingly, I cannot advise you on its use. At the same time, you may want to review your PSA level, PSA rise, and pathology findings (grade, stage) with your doctors to see if there is a need to do something other than taking mushroom extract.
Arnon
Here is the background: At my last annual physical (I am 73 and have been in good health) I found out that my PSA score had increased to 5. Primary care physician prescribed antibiotics, but after I completed the medication, my PSA increased to 6. I was referred to a urologist who performed a biopsy. Results were “carcinoma” Gleason score 7 with perineural invasion on left side. At the time, I did not know what PNI was, but I left all that to the radiation oncologist I was was referred to, who proposed a treatment plan: hormone therapy (a Firmagon shot every 28 days) and 9 weeks of IMRT on a daily basis for 5 days a week.
Here are my concerns: The radiation oncologist who set up my treament plan left the practice after my third hormone shot and third week of radiation, giving me only 1 day notice that he was leaving. I know nothing about the doctor who is coming in to replace him, so now I have begun reading lots of info about prostate cancer, including articles on PNI which make me wonder about the type of treatment plan I am on and the fact that I will have no continuity to monitor results of my treatment. Does this seem like a reasonable treatment plan, or should I have had surgery? Do I need to go back to ground zero and start again? Also, I have recently (2 weeks ago) broken out with itiching bumps the size of insect bites.on my arms, shoulders, stomach and back that I scratch constantly. Before he left the original oncologist said he thought I was having a reaction of hives due to the hormone drug Firmagon. However, no website I have visited mentions hives as a side effect of Firmagon. Given the odd lack of communication re the oncologist’s departure and his casual assumption re of the cause for hives, I am seriously doubting this diagnosis and now I am concerned about my treatment plan in general. Any advice or opinion you can give me will be appreciated re plan of treatment I am now on, and any thoughts about drug reactions to Firmagon causing hives. The doctor suggested we might try another hormone drug, but I don’t like the idea of a trial and error process to resolve a problem that might not be related to the drug at all. Should I consult a dermatologist?
Thank you,
Mark Loftin
*****
Mark,
Radiation generally is a reasonable strategy for prostate cancer, so in itself it seems appropriate. So the remaining questions are if your rash is related to your prostate cancer treatment and if your cancer treatment requires that you continue on a hormonal component. Yes, a dermatologist can and should advise on the former and, of course, your radiation oncologist can advise on the wisdom of continuing radiation without the hormonal component in light of the answer from the dermatologist.
Arnon
Arnon,
As I read many of these posts, I feel like I am in familiar company. Let me fill you in with my situation:
I am a 50-year-old male that was diagnosed with prostate cancer January 16th of this year. At time of biopsy, cancer was found in two of 12 needle cores with a Gleason score of 3 + 4 = 7. It was recommended that I undergo RP. On March 16th of this year, my prostate was removed and was biopsied again and it was upgraded to 3 + 5 = 8. Margins were clean and I was told that there was a 99% chance it would not spread.
First post-op PSA was a surprising 10.6. This completely shocked me and thoroughly undid me. A follow-up PSA a little over 2 weeks later revealed it to be 6.9. A very significant drop that also shocked everyone. I am having a PET scan and probably a third PSA. My urologist feels that the PET scan will reveal nothing; that the numbers are too low.
Here are my questions:
(1) Do these numbers definitively mean that it has spread? No, especially since the PSA is dropping.
(2) In your estimation, is this sudden drop a good sign? It’s hard to interpret given the detail supplied.
(3) Should I begin hormone therapy with these numbers? Or should I wait for a few months and see what a third PSA reveals before treatment? You should consult with your doctor about what to do. A 3rd PSA seems reasonable to me.
(4) If the stage 5 disease is that prevalent, wouldn’t the PSA go up instead of down? You mean grade 5. But if there is disease outside the prostate, then yes, one might expect the PSA to go up. (
(5) Do I need to include an oncologist in this discussion? A second opinion by a specialist oncologist seems reasonable.
My PSA to the best of my knowledge never got above 4.00 ng/ml prior to surgery.I was told that, if it has spread, it might probably spread through the blood which I have have been told is the most dangerous kind of spread. So, with all of this … is this a death sentence? It’s very curious. Why is your PSA dramatically up after surgery? Cancer usually doesn’t behave this way. Is there another explanation? Urinary leak (and urinary PSA leak) into the blood? If so, this could explain the sudden jump and drop. All of which leads overwhelmingly to the need for more time and PSA tests.
If you could get back to me, it would mean the world to me. My life hangs in the balance. Dennis
Dear Dr. Krongrad,
My husband is a 53-year-old Indian (from India).
A week ago, his biopsy result came back: PSA 4, Gleason’s 3 + 3 = 6 and 3 + 3 = 6, with 11 out of 12 cores positive — the highest on the right = 50% (others varying from 10 to 45%). His doctor has advised treatment, and we’re thinking about da Vinci surgical removal of the prostate.
I have two questions and would really appreciate a response. Thank you in advance.
1. With such a high volume, how likely is it that the cancer has spread beyond the prostate? How can we find this out? I am told that a CT scan may not detect this.
2. If the cancer has spread, what use will it be to remove only the prostate. Should we then be thinking about more radical treatments.
How can we make a decision about surgery or radiation for only the prostate (the two options the urologist gave), if more is at stake?
I’m worried sick. Please advice.
Meena
*****
Dear Meena,
I am sorry that you are feeling such strong distress. This is obviously perfectly understandable and also obviously something that deserves attention. I hope that you have a friend with whom you can share your feelings and that this will help you to cope and function to your maximum as you seek to help your husband.
The stage of his cancer is a function also of his pre-biopsy PSA. In other words, the implications of a PSA of 4 are different from the implications of a PSA of 57. You surely will want to also track down this value. Also track down the findings of a pre-biopsy physical exam (digital rectal examination; DRE). With PSA, DRE, and grade you can begin to assess the stage.
If the cancer has spread away from the prostate, then presumably there is no real and measurable value in removing the prostate. At issue, therefore, is the fact that the question of distant spread has no direct answer and comes down to uncertainty, which is somewhat reflected in the analysis cited above. So the task to you is to first integrate the items above and then to face the residual uncertainty about their implications, which no matter which test is done will be with you at every step. It is this uncertainty that can seem so emotionally daunting, which brings me back to the opening of this response.
I wish you and your husband well. He is lucky to have you at his side.
Arnon
Dear Meena:
I saw the question you left for Dr. Krongrad.
It might really help you to join our social network. We can help you there with the questions you will need to ask your doctor and perhaps more details about how to find answers to your questions … although there may not be “perfect” answers to some of them.
I was having frequent urinary symptoms; Flomax and Uroxatral didn’t help much, and my PSA has been 2.4 to 2.8 ng/ml for years — so my urologist convinced me to have a biopsy: 63 years old, gleason 6, T1C , 5% of 1 of 16 cores malignant.
After several consults and soul searching, I’m on active surveillance, with a PSA test every 3 months. I’m thinking of Avodart to reduce the urinary symptoms, and to possibly reduce the cancer. Is there something else I should be doing? Any suggestions on reducing the frequent urination?
*****
Jerry,
The concept of “reduce the cancer” is not clinically useful. Sure, 5-alpha reductase inhibitors and GnRH analogues (and castration) may reduce the volume of the prostate and/or a cancer within it. But the real issue is survival, not volume. What we’re after is reducing the harmful effect of the cancer, not the volume of the cancer. Please don’t lose sight of this.
There are lots of causes of urinary frequency: Benign prostate enlargement, urinary infection, bladder cancer (higher risk in smokers), Parkinson’s disease, and more. This is a differential diagnosis that your urologist can help you walk through. Once the probable cause is identified, your urologist can help you to select strategies that are most likely to offer relief.
Arnon
Dear Dr. Krongrad:
I am age 53, in good health. Only positive family hx of prostate cancer in brother dx at at 65 via PSA (low Gleason score).
I have a normal DRE and my PSA results have been as follows:
– 12/2008 — 2.1 Lab A (normal range 0-3.5)
– 11/2009 — 2.8 Lab A (normal range 0-3.5)
– 03/2011 — 3.5 Lab B (normal range 0-3.1)
– 05/2011 — 3.4 Lab A (normal range 0-3.5)
Labs A and B use different kits.
A doctor says the interval decrease in values from 03/2011 to 05/2011 is really greater than 0.1 because the labs use different kits. (The value of 3.4 would probably be high normal at Lab B.) We are going to repeat the PSA in 4 months.
I am reluctant to open Pandora’s box with a biopsy. What about a PCA3 test?
Thanks,
Mark
*****
Mark,
One can always rationalize an action or non-action. Your PSA is firmly in the 25% risk range, which is probably actually higher given a brother with prostate cancer. The real question is at which point in which test would you choose to have a biopsy?
Arnon
Dr. Krongrad:
I am “castrate resistant” and metastatic. I would like to get into a clinical trial, but am having difficulty learning about the drugs being used. For example, there is a trial (NCT01283373) using a drug called DSTP3086S. I have searched the web for information on this drug and found nothing. Is there a good way to find information on new drugs?
Thanks
Jerry Kattke
*****
Dear Jerry:
I am answering this question on behalf of Dr. Krongrad since he does not usually see or treat patients with very late-stage prostate cancer.
First, the only way to get significant information about a drug like DSTP3086S, which is in very the earliest stages of clinical development, is often to talk to the developers and the people doing the trials. With regard to this trial and this drug, I would therefore encourage you to call the Genentech trial hotline at 888-662-6728 or e-mail the Genentech trials coordinators. They will be able to help you know whether you might meet eligibility criteria and set up an appointment at one of the clinical trials centers if you want to do this … but do remember that this type of Phase I trial is largely designed to test one thing and one thing only … Can the drug in question be given safely to the target group of patients? Any additional information garnered from such trials is a bonus, and most Phase I trials are not structured to consider the effectiveness of the drugs.
For competitive reasons today, companies like Genentech tend to not publish or even present much data about development stage drugs until these drugs get to a stage at which the company is reasonably confident that they may have a potential winner on their hands. This makes it hard for patients to get a good handle on all of the drugs in the earliest stages of development. However, if you monitor the web site of the Prostate Cancer Clinical Trials Consortium, you will be able to garner guidance about many of the very earliest stage trials of drugs that look promising in late stage prostate cancer. You may also find it worth joining our social network, where there are other patients like you who will willingly share information about trials they are participating in.
On this main web site of The “New” Prostate Cancer InfoLink, we report regularly on new and interesting drugs and the initiation of significant clinical trials, but it would be impossible for us to report on all of the Phase I trials and every drug that goes into such Phase I trials. The volume of such drugs is now enormous, and many of these drugs are unlikely to make it even into Phase II. Even the Prostate Cancer Clinical Trials Consortium is highly selective about the very early stage drugs that they are willing to work on. However, you will note that DSTP3086S is one of those drugs!
Sitemaster
Hello, Dr Krongrad. I was hoping you could give me your opinion on the following.
A year ago I had a PSA of 1.8. This year it was 5.3 and the doctor noted a enlarged prostate; I was also having some symptoms. My doctor had me take ciprofloxacin 2x a day for 30 days and then have it re-checked. The test came back with a 14.3 PSA level. He sent me to a urologist, who then prescribed Bactrim and Flomax for 30 days and then re-check. I have some pain in that area, trouble urinating, and low flow.
I’m 55. My brother is 54 and had prostate cancer diagnosed last year. My father also had it. My concern is if this latest test is right I might be waiting too long if it is cancer, and thus giving it a chance to spread. I should add that I’m now going to see another doctor because I was not happy with the first urologist’s attitude, manners or professionalism.
Thanks, Rob
*****
Hi Rob,
My opinion is that with an elevated PSA and a family history of prostate cancer, any man would have to be aware that he is at risk of prostate cancer, a potentially progressive and fatal illness. My opinion is that under such circumstances, he has every right to seek a second opinion if he is unsure about the first.
Arnon
Hi Arnon,
I have a question about the use of Trunature Prostate Health Complex. It contains zinc 15 mg, selenium 55 mcg, saw palmetto extract 320 mg standardized to 85% (272 mg) fatty acids with active sterols, pumpkin seed oil 480 mg, palmitic acid 66.7 mg, stearic acid 27.8 mg, oleic acid 115.2 mg, linoleic acid 266.4 mg, lycopene 300 mcg. My husband is 62 years old and his prostate is healthy (one doctor said slightly enlarged another said it was not, but he has no problems with urination); his last PSA (after a retake) was 1.65, staying about the same for several years. He has been taking this Prostate Health Complex for years just to support his prostate. My question relates to the saw palmetto distorting his PSA. Some information says it can cause a false low reading, other information says it has no effect. I would not want him to take it and get false PSA readings, thinking he is in the safe zone because the PSA reading was distorted. I would very much like to know what your position is on this subject.
Thank you very much.
Nancy Dunbar
*****
Hi Nancy,
My general position on supplements is revealed in:
(1) Death by supplements
(2) Selenium and prostates
You can watch a video relating to health claims if you click here.
Thank you.
Arnon
Hello. I recently had radical prostate keyhole surgery in Edinburgh, Scotland. Surgeon said that cancer was small and totally enclosed and the lymph nodes were clear. That was 10 weeks ago and I had my first PSA results and they showed a PSA of 0.2 ng/ml. Surgeon had said he expected 0.01 to 0.02 result. My general practitioner says that 0.2 is normal. I am not sure.
Gordon
*****
Hi Gordon,
It’s not uncommon to see PSA drop in the first few weeks, so the obvious next possible step is to repeat the PSA in a few. You will in the meantime also want to arm yourself with the knowledge not only of the stage (small, totally enclosed, so presumably pathological stage T2), but also the grade, typically expressed by the Gleason scoring system. The grade has bearing on interpretation of all post-op PSA results.
Arnon
I am 63 years in good health? Two years ago had I had a radical prostatectomy (Gleason 7, PSA 3.6, family history). Surgery went great and was doing well. Now I find PSA 6 months at 0.03, 3 months at 0.04. Talking about oncologists. What would you recommend?
Thank you.
*****
Hi Jim,
Your PSAs are well below the 0.1 ng/ml level at which we normally like to see post-op PSAs. Unless there is something missing in your report, like new spine pain or highly aggressive pathology findings, e.g. vascular invasion, it’s not clear why there may be a need to talk with an oncologist. Your surgeon can advise.
Arnon
Hi Arnon,
I have been experiencing free PSA results of 8 and higher for around a year or so. I see my urologist at Kaiser Permanente, and he seems to be shrugging his shoulders at this. I have had two needle biopsies by him in the past year, both have been negative. What should or can I do further?
Dennis E. Nelson
*****
Dear Dennis,
I am not sure what your objective is, so I am not sure what more you can do. Obviously, among your options are to do nothing, to have a repeat biopsy, to get a second opinion, and to have the slides re-read … Again: What’s your objective?
Arnon
Hello Arnon.
My father is 92 and was diagnosed with prostate cancer in his late 80s. He’s had surgery, radiation and chemo and was told to continue goserelin acetate 10.8 mg Injection/Implant for the rest of his life every 3 months. In 2008 (for unknown reasons) his injections were stopped by his new doctor. He started bleeding from his bladder and is back to the urologist with cancer that has returned. My question is: Can stopping his implant shots cause this? He has never had any problems until now. We asked why shots were stopped and no one can answer that question or won’t answer it. We just want to know why they were stopped and if this is why it is back!
*****
Dear Melanda,
It’s hard to see how stopping implants would cause bleeding, which may be from cancer, radiation, or any other cause. Without knowing the specifics of the case (Gleason grade; stage; current PSA), the duration of treatment, and his hormonal function (serum testosterone), it’s actually even hard to know why he needed and/or needs implants at all.
Arnon
Dr. Arnon:
I am approaching 70 years of age, and in December 2010 I had a prostate biopsy (12 samples). Only one sample was positive, so a “wait and see” approach was taken with periodic PSA tests. From that time until now I have had ED (or better said EN, erectile nonfunction). Prior to the biopsy, I had no problem with ED. I have been able to find only a couple of articles associating ED with prostate biopsy and they seem to point to disburbance or damage of the neurovascular bundle during the process. They report that the incidence seems to increase with repeat biopsy or an increase in number of samples per biopsy.
Questions: (1) What is the incidence of ED following prostate biopsy? (2) If damage has been done to the NVB, how can that be determined? (3) What if anything can be done to “retify” the situation?
Regards
Coy
*****
Dear Coy,
I do not know the incidence of ED after prostate biopsy. I do not know how one can determine damage done by the biopsy to the NVB, especially since no specific tests of the NVB were done before the biopsy. The usual assessments and remedies would seem to apply, including assessment of all medical and psychological factors, including any possible new psychological factors that may be at work since establishment of a new diagnosis of prostate cancer.
Arnon
I haven’t seen this topic among the postings. My partner has raised the concern that she can have my prostate cancer cells transferred into her via my ejaculate and contract cancer.
Is this the case or would her immune system deal with any such cells? Can you provide me with citations should that be the case?
Bill
*****
Bill,
I am aware of no case in which prostate cancer has implanted in a sexual partner.
Arnon
Dr. Arnon: Thank you in advance for your help.
I’m 64 years old and in generally good health. At a recent physical my GP found a nodule on my prostate that he felt needed further investigation. My PSA is 2.8. Upon seeing a urologist he felt nothing out of the ordinary but took a PCA3 test and it came back with a score of 42. With that said and 35 being normal would you recomend a biopsy, or should I take a re-test and wait 6 months and retest then?
Guy in FL
*****
Good question. The test may have use more in the setting of repeat biopsy, which is not your reported situation. That said, one of the risks of relying upon the test is that cancers, including higher grade Gleason 7 cancers, can be missed. So in the real world, and specifically in a situation such as the one you report, it’s not clear to me that the PCA3 test is a sufficient tool for not doing the biopsy. And with a PSA of 2.8 ng/ml, leaving aside the question of physical abnormality as here, the chance of a positive biopsy is approximately 25%. In a healthy man who may have Gleason 7 cancer, is it wise to forgo the biopsy? This is somewhat a subjective and personal answer.
Arnon
Doctor:
Is it possible to get a PSA bounce after RP and radiation?
*****
Yes, but the key is to sure that a “bounce” is not a recurrence.
Arnon
Was diagnosed with T1c back on 4/15/11 which was based on a PSA of 3.2 ng/ml and was on Advodart for 5 weeks but had to stop because of bad reactions on 5/20. Went back for a follow-on PSA which was 1.9 ng/ml. It should be doubled because of the Advodart use, and the fact that Avodart can remain in the system for 200 days. So the PSA should be read as 3.8 ng/ml. Correct?
*****
Will,
In theory, correct. But we can over-interpret these things. Overall, the guide to action really has to rely more at this stage on overall health, general circumstances, and what the biopsy showed: grade, extent of involvement, perineural invasion.
Arnon
Dr. Arnon,
My healthy, 70-year-old father’s pathology results after his RP showed tumor invasion in left seminal vesicle (extraprostatic portion), perineural invasion, and focal extension to the inked margin. Right seminal vesicle and margin negative, and no lymphovascular invasion. His Gleason score is 9 and PSA at time of biopsy 4.1 ng/ml. Clear bone scan and clear bone marrow.
He participated in a clinical trial that included a daily dose of abiraterone for 3 months along with one injection of lupron prior to surgery. This brought his PSA to undetectable. He has an appointment in 2 weeks to discuss his treatment options, however, we would like to start gathering information prior to that so that we can be prepared with the right questions to ask. So after that long intro … What treatment options are there for my father and also does participating in the clinical trial prior to his surgery have any influence on what treatment options would be appropriate for my father?
Thanks, Elizabeth.
*****
Dear Elizabeth,
I do not think that a little hormone therapy before surgery would preclude any treatment after surgery, unless you are again talking about a trial with very strict inclusion criteria. That said, the first question would seem to be this: Does he need any more treatment at all at this stage or can he just be monitored?
Arnon
Dr. Arnon:
Thank you for your response. If it is recurrence, what is your opinion on triple androgen blockade and how long can I wait as far as PSA number is concerned to start. I am a Gleason 9. My current PSA is 0.32 the increase was from 0.2 ng/ml. I understand that this is just an opinion. Thanks for your time.
*****
Hormone manipulation is one of the options. However, the decision of which treatment and which cut point to use on the PSA really has to be made in coordination with a specialized prostate oncologist, taking into account not only more PSAs but also your general health, potential side effects, etc.
Arnon
Good morning Dr. Arnon,
My friend who is 52 years old was diagnosed with prostate cancer in May of this year and is scheduled to have it removed this month. July 19th to be exact.
My question is, because he is already taking Levitra for his erectile dysfucntion, what are his chances of him remaining the same or will he be left completely impotent.
The only thing he does for exercise is play soccer. He is 6ft 2 ins and approx 232 lbs.
Please help with this answer. Thank you in advance.
*****
Dear Mary,
The probability of good erectile function varies with age, baseline function, obesity, aerobic capacity, illness (e.g., diabetes), smoking history, surgical nerve preservation … it’s a huge list and consequently it’s impossible to know with certainty. Overall, a man of his age and health obviously has better chances than a 72-year-old diabetic smoker. That much we do know.
Arnon
Dear Doctor Krongrad,
I experienced PSA recurrence (PSA = 0.2 on Sept 2010) after RP in March 2007 (T2aNOMx pathology clean except for margin < 0.1 cm).
Under the care of a medical oncologist, I'm on active surveillance to give PSA stabilization a maximum chance so as to avoid side effects from planned 6 month hormone + SRT treatment to potentially cure my prostate cancer. The trigger point to start treatment is PSA = 0.4-0.5. I'm getting close to that trigger with PSA on June 2011 = 0.33, Sloan-Kettering nomogram PSADT = 13.4 mos. So now I'm making sure this course is as good as it gets.
I checked with a second oncologist who suggested I should wait for actual clinical recurrence (which he said may not happen) and, if local (e.g. in the prostatic fossa), then and only then get SRT which can still cure. If not local, then of course ADT.
The most interesting/important part of his view is that the SRT can still cure after actual disease recurrence if localized — therefore why even consider preemptive SRT.
Doctor Krongrad, is there case history or research to your knowledge that suggests I should seriously further explore/consider the second oncologist's opinion "to wait to treat only if actual recurrence with SRT with a possibility of cure”?
Thanks very much for your advice.
Cram Samut (pseudonym)
*****
Hi Cram,
It’s always a bit hard to make recommendations in the absence of knowledge of such relevant factors as age, concurrent other illness, social situation, and the findings at surgery and the pathology (grade, stage, vascular invasion). That said, there is certainly a legitimate rationale both ways. Early treatment, with or without hormones, is most likely to have the desired effect — and its side effects. Observation is most likely to permit a period, perhaps a very long period, without the inconvenience, cost, and risk of treatment. Try to put this decision in the context of the factors listed above as you discuss it with your doctors. If you’re old, obese, and otherwise sick, why even have any more treatment? If the converse is true, you still have the decision to make.
Good luck.
Arnon
Hi Arnon,
Thanks for your quick response and factors to decide for early treatment versus observation. I’m struggling with this as I am still a working executive at age 67 with other morbidities that are now not disabling and under control with medication and exercise.
If I may, to help in my deliberation, I would like to ask my question more precisely.
Is there evidence-based medicine or case history that SRT can still cure after verified localized PCa disease recurrence postprostatectomy ? If so, why would one chose preemptive SRT on the basis of PSA-only recurrence?
Thanks again.
Kind regards,
Cram
*****
Cram,
The argument for early action is the risk of missing the opportunity to make a difference.
Arnon
Hello Dr. Arnon,
I had robotic prostatectomy in March 2010. Margins clear, last 2 PSA’s negligible. My biggest problem has been bladder capacity. Sometimes I have to pee every 15 to 30 minutes. Sometimes I get the urge and not a lot of volume comes out. I have sometimes had to get up several times a night while sleeping. I was told this would improve, but it seems as if it has gotten worse, not better. Due to poor insurance, I have not been able to have the follow-ups with my surgeon that I really should have, and my primary care physician has been treating me. My question to you is, can I expect this to improve down the road? What is going on down there that causes this? I would ask my surgeon but have to pay cash to see him right now and can’t afford it, and I thought you might be able to give me some insight.
Thanks,
Barney
*****
Barney,
Hard to say, but it could be anything from a simple urinary tract infection to a bladder neck contracture. Among the easy and inexpensive tests to do is a urinalysis and culture, which might provide you with some useful insights.
Good luck.
Arnon
Dr. Arnon,
I had da Vinci removal of my prostate in July 2007. All margins were clear together with surrounding lymph nodes. In July 2010 my PSA level was 0.40 and in June 2011 it is 0.86. Since my surgery I have noticed an increase in what appears to be seminal fluid prior to and at orgasm. My question is this. Could the increase in PSA level be from a partial regeneration from a possible remaining piece of prostate gland after surgery or is this something to be concerned about? I am 61 years old and, aside from normal aging problems, I am in otherwise good health.
Ken
*****
Hi Ken
A number of glands produce PSA, including urethral glands of Littre and Morgagni. But why should this PSA be going into your blood? That’s the question that does not have an answer. You really have to go back over your pathology report carefully, looking at grade and tumor volume and other features, e.g., vascular invasion, to get a sense of the likelihood of recurrence. And put that into the context of your PSA followup.
Arnon
Thank you for the reply. I will talk to the surgeon about this. I am just worried that he wants to send me to an oncologist as he suggested that about 1 year after my surgery when my PSA level was at 0.03. At that point I no longer needed the Cialis.
Ken
Dear Dr Krongrad,
I am a 70-year-old Indian male residing in Kenya. I had a radical prostatectomy and a cystoscopic pelvic lymphadenectomy in 1999 in the U.S.A. My Gleason score had been 4 + 5 = 9. My testes were removed in 2005 (in India). In 2008, I had a bone scan in 2008 in India with normal results.
My recent PSA readings have been 0.19 ng/ml (2008), 0.66 ng/ml (2009), 0.856 ng/ml (2010), 3.17 ng/ml, 4.65 ng/ml and 5.21 ng/ml (2011). I am lately experiencing lower back pain and frequent urination (x 8 daytime, x 4 nighttime). No urine infection has been found.
I am concerned about the rising PSA readings and frequent urination. I live in a part of Kenya where there are no specialists. Any advice would be greatly appreciated.
Thank you,
VB
*****
Dear Mr. Patel,
It seems to me that you would do well to confer with a specialist in urology and/or oncology. My only contact in Kenya is a health advocate by the name of Lucy Mutuku. You may want to make contact with her to see if she has any suggestions.
Thank you.
Arnon
Hi Dr Krongrad.
A month ago I had a radical prostatectomy (bilateral nerve sparing). The pathology indicates:
1. Invasive prostatic adenocarcinoma, acinar type, Gleason 3 + 4 = 7
2. Tumor present both lobes, all 4 quadrants, tumor extends from apex to near superior aspect of gland; tumor occupies 6% of prostatic parenchyma
3. Tumor shows extensive perineural invasion, negative for lymphatic/vascular invasion
4. Tumor shows established extraprostatic extension into periprostatic adipose tissue in right posterior quadrant
5. In this same location surgical resection margin is positive for tumor, all other resections are negative for tumor
6. Multifocal high grade prostatic intraepithelial neoplasia is present
7. Benign unremarkable prostatic urethra
8. Benign unremarkable left seminal vesicle, Benign unremarkable stump of right seminal vesicle, both negative for malignancy
My questions … What are my options as the tumor has spread outside the capsule to the adipose (fat?) tissue? Would subsequent PSA testing indicate further spread? Or how else can this be monitored?
Your opinion would be greatly appreciated.
Thank you,
Bogdan
*****
Dear Bogdan,
Your action options range from surveillance to radiation. But yes, PSA testing would be the most sensitive indicator of tumor persistence and/or recurrence. That is also the easiest way to monitor the situation and the most sensitive guide to initiating or not initiating any action.
Arnon
Arnon,
I had RALP on March 1. ED is still an issue, and I am taking Cialis. I am looking at getting a vacuum device. My insurance won’t cover it even though I have a prescription from the surgeon.
My question: Is there a major difference in effectiveness/safety in getting a top of the line prescription VED that runs $500-$600 vs. a less expensive quality OTC device that runs $150-$200? Is the extra money worthwhile spending?
Thank you,
Keith
*****
That’s an interesting question. To the best of my knowledge, there has not been any comparison of these devices. Indeed, I am aware of some non-prescription variants being sold in sex shops with no prescription and presumably low cost (are they effective?). I have also heard of one of my patients building his own in his garage, though I am not sure what good it was (especially since his erections have since then returned to 100% of preop function). So … I’m really not sure how to advise you.
Arnon
Keith:
You will find some patient input and discussion on this topic in the section on ED and incontinence post-treatment on our social network.
I have had three biopsies over the last 5 years. Two were 10-core MRI-guided and the last one was a 3D MRI-guided 20-core biopsy using the Artemus System at UCLA. All were negative for cancer. I have also had three PCA3 tests with scores of 6.5, 11.3 and 14.0.
The issue is that my PSA has been consistently rising with the last two being 9.7 ng/ml in November 2010 and 11.5 ng/ml in July 2011. I have been diagnosed with BPH and my prostate is approximately twice the normal size.
My doctor, who is renowned in the field, keeps making statements like, “You don’t have to worry about this for a very long time,” after the
last “state of the art” biopsy and then says “I am concerned” 6 months later.
What do you think about my chances of having cancer?
*****
Dear Ron,
The chances of a positive 4th biopsy after three negative biopsies is low, but not zero. Have a look at this paper, which relates directly to your question.
Arnon
Dear Arnon,
My father-in-law has prostate cancer. A biopsy was carried out 7 days ago; we got his report today and it stated
Histologic type: adenocarcinoma (acinar, not otherwise specified)
Primary (predominant) pattern: grade 5
Secondary (worst remainng) pattern: grade 4
Tumor quantitation number cores positive: 3
Total no of cores: 5
% of prostatic tissue involved by tumor: 26
Can you please tell me what’s the stage of cancer from this report and what therapy needs to be done?
*****
Dear Roshni,
The pathology report can only establish the grade, in this case a Gleason 5 + 4 = 9. The clinical stage comes from the urologist and is based upon his physical findings (digital rectal examination) and/or additional staging tests, e.g. bone scan. Please refer your question on the stage and therapy to your father-in-law’s urologist.
Thank you.
Arnon
Ron again.
Thanks.
The last biopsy, as I explained, was using the state of the art Artemus 3D MRI-guided system where they take an MRI of the prostate and focus on all suspicious areas including those with more blood flow (20 cores). I did this because it is touted as the best of the best with much more accuracy than standard “blind” 10-core biopsies.
Since statistics show that 97% of cancer is found on first three traditional biopsies, do you think this improved system lowers the odds of finding anything on the fourth?
*****
Hi Ron,
I really have no idea. In either case, the chance of a positive biopsy is at most 3%, as you imply. And there are no data upon which one can generate an answer your question scientifically.
Arnon
Dear Dr. Arnon,
I am taking daily 2.5 mg of finasteride for an enlarge prostated. Am I having risk of higher-grade cancer for using the finasteride? Also, is there a difference in results if you change the finasteride or tamsulosin hydrohloride from one company to another?
Thank you sooo much for your help and time.
Yours,
Nasser Elgouyushi
*****
Hi Nasser,
Finasteride (Proscar) is a 5-alpha-reductase inhibitor. Tamsulosin (Flomax) is an alpha blocker. They are NOT interchangeable. But if you mean can you change finasteride or tamsulosin to similar medications, then yes, you can get similar effects on voiding symptoms.
Some studies have suggested a higher risk of high-grade cancer, which has been the subject of controversy over recent years.
Arnon
Hi Arnon,
My husband wants to know how long is an average time for the testosterone level and his libido to come back after 2 years on hormone therapy (Lupron once a month, Casodex and Avodart). He initially had a robotic prostatectomy, then radiation therapy and the 2 years of hormone therapy. He is only 49.
*****
Hi Lisa,
I can’t easily cite a reference on this. Regardless of his actual serum testosterone level, his ability to have erections after prostatectomy and radiation (and hormones) will probably be impaired. So leaving aside the question of libido, which is usually profoundly affected by serum testosterone, if his objective is to have erections and is not yet able, then he may want to consult his urologist about what may be done: Injections, supplemental tesosterone (which would be tricky in this setting), and the like.
Arnon
Lisa:
You or your husband might benefit from joining our social network, where you could talk to other men who have been through similar treatment to your husband at a similar age. Some of them have had good recovery of their libido and their sexual function within 2 or 3 years. This does appear to be a very individual recovery process.
Sitemaster
Ron, once more
I did some research and found that in the study done at UCLA they found the Artemus 3D MRI targeted prostate biopsy was 5 times more likely to find cancer than 3D non-targeted (no MRI) biopsies. This should make it much more reliable than 2D traditional biopsies.
Just thought you might be interested.
Dear Dr. Arnon,
Once a patient stops taking finasteride, how long does it take before the drug has NO effect on a PSA test result?
Thank you,
Nasser
*****
Hi Nasser,
That’s an interesting question with potentially important clinical implications. Unfortunately, I have no idea. I have never seen anything on this topic.
If anyone has a reference on this, please post it.
Thank you.
Arnon
Dear Arnon and Nasser:
We know that it takes up to 6 months of treatment for finasteride to exhibit its full potential impact on reduction in the size of the prostate in treatment of benign prostatic hyperplasia (BPH). I am not aware of any published data on the time it takes for the effects of finasteride to wear off either. However, given the above information, it would probably be wise to assume that it might take as much as 6 months for the prostate to return to its normal state after stopping finasteride therapy.
Mike
Hello Dr. Arnon,
My father recently had a PSA test because he was showing symptoms of possible prostate cancer. He’s 57 years old and showed a 6 on his first PSA. They then conducted a second test 1 week later and it came back a 2.5? The doctor said he was “baffled” and claimed he had never seen this before. He told my dad to come back in 3 months and they will take the test again. I’m afraid that this is too long, and want him to go into Boston and see a specialist. He is showing symptoms. Painful urination, joint and back pain, and recently lost 10 lbs in 1 month! Have you seen a test fluctuate that much before? And should he seek a specialist or wait 3 more months for yet more blood work? I’m so confused, please help!
Thank you,
Tom
*****
Hi Tom,
Sure, PSA can fluctuate, especially in the presence of trauma and/or infection. Given your concern, why not get the second opinion now? You’re going anyway, so why delay? Especially if he has symptoms that may be infection.
Arnon
My husband recently had a biopsy and 11 of 12 nodes tested positive for cancer. His PSA went from a 3 to a 6 and his Gleason is a 3 + 3. We have an appointment in 4 days … but I’m a nervous wreck. Is there a strong possibility that this has spread beyond the prostate with so many of the biopsy specimens being compromised. Thanks for any feedback. I just need to know …
*****
Hi Barbara,
Your anxiety is understandable. Most patients and their families feel it, especially in the early days after diagnosis. With information and support, it usually subsides.
There is no absolute answer to your question. Moverover, without knowing the findings of the digital rectal exam and the extent of involvement of the cores, it is all the more difficult to know. For this reason, the diagnosing urologist is the best person to help you with your very relevant question.
Keep one more thing in mind. “Spread” is relative, in that a few cells outside the prostate and into the adjacent fat, which is one scenario, can be associated with long-term cure with single treatment, e.g. surgery or radiation. So as you ask your questions, ask the doctor(s) you consult if they mean local or distant spread when they use that word.
You may find some value in this group: http://prostatecancerinfolink.ning.com/group/wivesandpartners.
Arnon
I am healthy (not overweight, etc.) and 74 years old. Because of high PSA (10 ng/ml) I got a random biopsy. 12 samples, 11 unremarkable, 3% of one sample carcinoma, but Gleason was 8. No neural involvement, no protrusion. Urologist said gland is LARGE (100 cc). No digital nodules. I do not know how to interpret the Gleason of 8, when only 3% of one of 12 samples is positive. Sent for a second opinion. Is this Gleason score a major factor in determining treatment in this situation? Thanks.
*****
Dear Jon,
Yes, the Gleason score is always a major factor in assessing the need for treatment. If confirmed by the second opinion (4+4? 5+3? etc), it is something that cannot be dismissed as irrelevant to your health.
Arnon
I have advanced, metastatic prostate cancer. I recently read about a Dr. Burzynski and something he calls antineoplastons, which he claims are some sort of miracle cure for all kind of cancers. What can you tell me about this?
*****
Dear Richard,
I have no specific information about antineoplastons, other than what one might easily find by searching the internet. I’d want to know if there are data specifically on their effect on prostate cancer. And the risks and cost associated with having treatment.
Arnon
Dean C Kaul, on May 5, 2011 at 10:36 pm said:
“A biopsy has confirmed that I have prostate cancer. My prostate in enlarged (68 cc). I underwent a total colectomy in 1973 and have no anus. I have been told that this eliminates surgery as a cancer treatment option. Is this true?”
Dean, given your situation you may want to investigate options at the Brady Urological Institute at John Hopkins.
Frank
In 2009 my PSA was 1.9 ng/ml; test results from last week indicate 3.8 ng/ml. I am 67 years old. I have never been told of any cancer. My mom had breast cancer. But does my new PSA reading indicate prostate cancer, cancer of pancreas, etc.? I am worried about this. Also, is biopsy always necessary, I’ve heard it is painful.
*****
Hi Charles,
All else being equal, a PSA = 3.8 ng/ml equates to a risk of positive prostate biopsy of approximately 25%. Yes, a prostate biopsy can be painful, for which reason you can discuss some local analgesia and/or anti-anxiety medication (e.g., Valium) with your urologist.
Arnon
Do you think women would be ok with the male wearing a strap-on because he cannot get an erection due to prostate cancer?
*****
Dear Tony,
I don’t suppose it’s my opinion that really matters in the relations between remote consenting adults. Accordingly, I might suggest that any man considering the maneuver to which you are alluding discuss it with his partner before its implementation, for such a surprise might be hard on her.
Arnon
Dear Dr. Krongrad,
My 53-year-old husband had a prostatectomy 3 weeks ago. The pathology report came back that his primary tumor was a Gleason 3 with some 4 and 5 cells. Fifteen percent of the prostate was involved., and his original PSA test was 5.52. His margins were clean and there was nothing in the seminal vesicals. However, he had cancer in 2 of the 15 lymph nodes removed. Ten days after surgery, he was given a PSA test, and the doctor started him on a 6-month shot of Trelstar. We just received the PSA results — 0.82. This seems high to me after a prostatectomy. Should he have radiation? Does he need a PET scan? Is this an aggressive cancer?
*****
Dear Susan,
It’s a little difficult to interpret the PSA result, coming as it does 10 days after surgery. This is especially so given that I don’t know how long he had his catheter (most surgeons leave it in for 10 days, which is when he had his PSA test; some surgeons actually leave it in for 3 weeks) and that urethral trauma, which surgery represents, can increase serum PSA from non-prostatic sources, e.g. urethral glands of Littre.
It is not clear to me which direction the surgeon is pursuing: hormones permanently, hormones as prelude to radiation, one-time hormones … It’s also not clear because apparently the surgeon prescribed hormone shots even before getting back the PSA result (same day as it was drawn). Does the surgeon know something that is not in your report? I doubt it, but I want to know. You may want to ask your husband’s surgeon for a clarification of status and recommendation.
Arnon
Dear Dr. Kongrad:
My husband was recently diagnosed with prostate cancer. He has a Gleason 6 (3 + 3) in 2 out of 14 cores. One core showed 3% cancer and the other had 9%. He also had PIN in one other core. His PSA was 2. My question is that I am confused as to why his PSA level is not higher. Could this indicate a more aggressive type of disease that has mutations that do not allow for the cells to produce PSA?
Thanks so much,
MS
*****
Dear MS,
PSA is not a perfect correlate of presence or stage or grade of disease. It is affected by many variables, including prostate size, inflammation, infection, trauma, and unknown. So while your speculative mechanism might be at play, there is no evidence to support it in this case nor any particualr reason to invoke it.
Not knowing anything more about your husband (overall health, race, family history, prostate size, history of UTIs, presence of nodule), it’s impossible to interpret what this might mean and/or to suggest a course of action. Overall, assuming he’s young and healthy and that there is not a prostate nodule, the good news would appear to be that his prostate cancer has been diagnosed at a very early stage and that all his options for effective treatment have been preserved.
Arnon
Husband had RP in 1998 at age 49. Two years later had radiation of the area. Two years after that PSA starting going up and we did watchful waiting. He was diagnosed in 2009 with several bone metastases and has tried several medicines. Each one worked for about 3-4 months. He gets Zometa every month. He just finished 6 months of weekly Taxotere. WHen he stopped it in June his PSA was 15.1 and it is now 52.7 ng/ml 6 weeks later. His oncologist suggested Jevtana but hubby would like a chemo break. So oncologist suggested Provenge. We would have to travel because oncologist doesn’t do it. We were referred to Moffitt Cancer Center (from Tallahassee) but they told me today that it is taking 9 weeks for them to get the drug and five people are in the queue. They also said Provenge doesn’t do anything to the cancer. What are your thoughts on Provenge? Hubby has intermittent pain and is off the steroids that he took with the ketoconazole.
*****
Dear Babs,
There is a lot to the Provenge story. You may find some value in these articles.
Arnon
Dr. Arnon,
It is exactly 5 years since my husband, now 65, had an RP for his Gleason 8, stage T3a (PSA 2.2 ng/ml) prostate cancer. You gave me good advice post RP and — now somewhat bewildered — I ask again.
We had a couple of years of very slowly rising PSA and when it hit 3 ng/ml, we did salvage radiation. It never dropped much below 3 and shortly thereafter we began Proscar and Casodex. Initial positive response was strong — for 2 months, then failure again (a rising PSA). Switched to Lupron and same thing — positive initial impact and then rising PSA. This last time the rising PSA was accompanied by some bone and joint pain and there were mild metastases on his spine, rib, and back. We then went to two rounds of Taxotere with prednisone. Same pattern: initial positive response then rising PSA although no increase in bone pain. Then we switched to abiraterone and again initial great positive response then rebounding PSA 2 months after starting treatment. His PSA is now 12 ng/ml. That is the highest it has ever been. We are depressed. We see a pattern here and are just not sure how to deal with it. We are awaiting new bone scans this week. Is this the Gleason 8 come to rear its ugly head or are we missing some pattern. Larry is healthy, active, Olympic swimmer — the worst I’ve seem him is after chemo. Is it time to turn to a leading edge facility or expert who sees enough of this that they can make a more intuitive diagnosis as to what is happening? What options are left if the bone scan shows further metastatic disease? Where would you go next?
Thanks,
Claire Bugen
*****
Dear Claire,
Yes, it is time to get your husband to an oncologist who specializes in prostate cancer. There are some of those in Houston, at M. D. Anderson, at the Nevada Cancer Institute, and many other places.
I don’t generally deal with prostate cancer at the stage you’re describing and don’t want to shoot from the hip and potentially mislead you. You’re asking the right questions.
Arnon
My husband had a prostate cancer biopsy. One lobe was Gleason 3 + 4 and it had a M by it, but nothing staged. The information says it could or not mean metastases. Please advise.
*****
Hi,
I have no idea what the “M” means. Probably your husband’s urologist can help you understand.
Thank you.
AK
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
I would like to know if the new drug JX-594 is a good treatment for lung cancer? Please reply thank you.
*****
Dear Roland:
Dr. Krongrad is not an oncologist and he does not treat lung cancer. At this time our understanding is that there are no clinical data on the use of JX-594 in lung cancer.
Sitemaster
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.