He’s been treating patients with early stage prostate cancer for more than 20 years. So he knows his stuff!
Arnon Krongrad, MD is a highly experienced prostate cancer surgeon and former prostate cancer researcher. He practices at The Krongrad Institute 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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Is there information available anywhere that provides a doctor’s surgical experience and results, complications, minimization of side effects, etc.? I will likely be having surgery for prostate cancer in the next few months, and am trying to determine what facility and which doctor to use. As I am relatively young (46), I will be living with any possible side effects for many years and want to ensure I am getting the best treatment available. I’ve been to several urologists: the one I saw for my biopsy and initial consultation, and and three others for second opinions, and although they all seem professional and competent, I can’t locate this type of information for any of the doctors or hospitals (other than websites that want you to pay for the information).
I would appreciate any information you can provide.
Thank you,
Dave in Utah
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Dave,
I am aware of no such library. The closest I can think of is state measures of hospital outcomes. These are at best very crude measures of the hospital and a potentially misleading source of insights regarding surgeon.
This might interest you: How I Would Pick My Surgeon.
Best of luck with surgery.
Arnon
Dr. Krongrad:
Your website is most impressive and informative. I haven’t had the dreaded biopsy yet, but am obviously concerned. I cannot determine whether your laproscopic procedure is robot-assisted, like the da Vinci machine, or not. Please let me know, and thanks.
—
Dear Jeffrey:
On his behalf, I can tell you that Dr. Krongrad practices “direct” (non-robot-assisted) laparoscopic radical prostatectomy, which he introduced into the USA before the da Vinci equipment became available. You can find complete information about this technique on the web site of the Krongrad Institute.
Sitemaster
Dr. Krongrad,
I am 46 and in excellent health. My father died of prostate cancer when he was 75 (cancer was detected when he was 65, pre-PSA days, and had already spread) and my older brother had prostate cancer and had his prostate removed 4 years ago when he was 49. I think my brother had a Gleason 7 and PSA 9, and his PSA has been at near 0 since the operation.
I started getting screenings when I was 42 and my PSA was pretty steady at 2.5 until it jumped at my last physical to 4.7. I went to a urologist for a biopsy and of the 12 samples taken (6 each on the right and left sides) only one of the 12 was positive: Right side, less than 5% of the biopsy involved, Gleason 3 + 3= 6, T1c, Periprostatic Fat Invasion — not identified, Lymphatic Invasion — Absent, Perineural Invasion — Present, Seminal Vesicle Invasion — None Identified.
In addition to the urologist that I first saw and that did the biopsy, my wife and I have been to 3 other urologists for second opinions, and they have all basically told me the same thing: ttoo young for radiation treatment, too young for active surveillance, HIFU is still too risky, and my only option is surgery. Although I will likely choose surgery (robotic), I would appreciate any answers you could provide on the information that I have been overloading myself with the past few months regarding the other options.
Radiation Treatment — Is the main reason this is not an option for me because of the possible long term side effects of the radiation and difficulty it would cause if surgery was required afterwards?
HIFU — This is now being performed in Canada and Level III clinical trials are being performed in the U.S. Assuming the clinical trials are successful, how long would it take for this to become a standard treatment here. It sounds so appealing because there is no radiation or surgery, and of course you only see the positive testimonials on the HIFU sites, but why do most urologists seem to discourage HIFU as an option?
Active Surveillance — Of the opinions I received, they all seemed to discourage this for younger patients, mainly because of the psychological reasons rather than safety reasons. To me it is the opposite, I would gladly postpone surgery for 2 or 5 (or more?) years if I felt is was safe to do so. Would having another biopsy at 6 months provide any further indication if the cancer was a more aggressive type or widespread? Maybe even try something like taking finasteride? From reading your answers it sounds like you don’t think it would.
It’s hard to make a decision on what to do, especially with such a small amount of cancer detected. Did my PSA just jump for some unrelated reason and they just found cancer that 30-40% of men my age have? If I had skipped my annual screening, would I be going through this one stress-free year later, or did I catch aggressive cancer early? Unfortunately I would only know after my prostate was removed. Seems like you are basically playing the odds until the medical community can determine a way to identify if you have aggressive or non-aggressive prostate cancer.
Also for what it’s worth, my other older brother is 51 and has a PSA of only 1.7, and my father worked for the Atomic Energy Commission in Los Alamos in the 1950s.
Sorry for the long question and thank you for providing this service and website.
*****
Dave,
Good summary. Well organized. And I am not sure I can do this justice in a short email, but here are some thoughts:
Radiation Treatment — Is the main reason this is not an option for me because of the possible long term side effects of the radiation and difficulty it would cause if surgery was required afterwards? Yes, radiation increases the risks associated with “salvage” surgery if radiation fails. And yes, there are risks specific to radiation, including the risks of secondary cancers. However, there are no randomized data upon which to prove that one approach is superior to the other. There is in other words no absolute categorical argument against radiation. There is a world of habit relating to surgery as the choice for younger men. Among the reasons: Young men tend to tolerate surgery well and to recover functions very nicely.
HIFU — This is now being performed in Canada and Level III clinical trials are being performed in the U.S. Assuming the clinical trials are successful, how long would it take for this to become a standard treatment here. It sounds so appealing because there is no radiation or surgery, and of course you only see the positive testimonials on the HIFU sites, but why do most urologists seem to discourage HIFU as an option? If you are asking me to predict the future, I can’t; I can barely predict the past. Yes, HIFU is appealing and so is chicken soup. But you’re not selecting chicken soup. Why not? Because you don’t have long term data on its effects on prostate cancer survival. You might want to also read this HIFU case report.
Active Surveillance — Of the opinions I received, they all seemed to discourage this for younger patients, mainly because of the psychological reasons rather than safety reasons. To me it is the opposite, I would gladly postpone surgery for 2 or 5 (or more?) years if I felt is was safe to do so. Would having another biopsy at 6 months provide any further indication if the cancer was a more aggressive type or widespread? Maybe even try something like taking finasteride? From reading your answers it sounds like you don’t think it would. The real issue is what is your true stage, i.e. how big is your window of opportunity. Have a look at this discussion thread about two other men with seemingly low stage Gleason 6 cancer. There is absolutely a risk in active surveillance and making the assumptions that you have time and that you know when your time is about to run out.
It’s hard to make a decision on what to do, especially with such a small amount of cancer detected. Did my PSA just jump for some unrelated reason and they just found cancer that 30-40% of men my age have? If I had skipped my annual screening, would I be going through this one stress-free year later, or did I catch aggressive cancer early? Unfortunately I would only know after my prostate was removed. Seems like you are basically playing the odds until the medical community can determine a way to identify if you have aggressive or non-aggressive prostate cancer. Yes. The medical community has some work to do.
Dr. Krongrad,
Thank you in advance for your opinion.
52 y/o Caucasian. No family Hx of prostate cancer, but personal history of prostatitis (bacterial and non-bacterial) over many years. DRE results all negative.
Recent PSA results:
07/08: 1.6 (lab #1, Beckman Coulter assay)
11/08: 1.4 (same assay but at lab #2)
11/09: 2.0 (same assay, lab #1)
01/10: 1.9 (same assay, lab #1)
Culture taken 11/09 (1 week after above PSA test) positive for enterococcus — treated with Cipro for 10 days. Culture repeated in 12/09, negative.
Prostate is slightly enlarged (do not recall the number) per ultrasound.
PCA3 was 4.8 in 09/08 and PCA3 was 2.2 in 01/10.
The obvious concern is the PSA velocity and whether to biopsy. I know that PCA3 is still kind of experimental (but would be interested in your opinion on viability of the PCA3 test), but if this was your patient, what would you recommend?
Thanks again!
*****
Dear Larry,
Thank you for writing. I am not sure I understand what you mean by “velocity” since your PSA seems hardly to be moving. As a related matter, I would note that the likelihood of a positive biopsy with a PSA of 2.0 is approximately 15% to 20%. As a related matter, I am currently doing a study on prostatectomy for severe chronic prostatitis (I don’t know your symptoms and we may or may not be talking about the same thing) and in these patients the likelihood of cancer in the specimen, including with very low PSA, is shaping up to be around 70%.
I am really not sure how the PCA3 test helps you. If you like you can read more about it here: http://prostatecancerinfolink.net/?s=pca3
Arnon
I had a robotically assisted radical prostectomy on 11/24/09. In my recovery from impotence I discovered that now when I have an orgasm urine is ejaculated during the orgasm. Is this normal, is it permanent?
Jim
—–
Urine leak is not what I’d characterize as a normal event but it is not uncommon. It is also not necessarily permanent. I assume that you’ve already worked out that it may be a good idea to minimize hydration and to empty the bladder before initiating sex. You might also note that many of the vaccum devices for erections involve a constrictive rubber ring at the base of the shaft, which may have an effect on reducing the incontinence.
Arnon
Hi Arnon … I had my prostate removed years ago and have been getting the Vantus injection for 6 years. My PSA stays below 1 and wondering if there was any risk if I discontinued treatment. I am 77. Thanks, Tom.
—–
Hi Tom
The need for hormone therapy varies as a function of cancer stage and cancer grade at diagnosis and/or initial treatment. The need is tempered by the likelihood of side effects from hormone therapy: bone loss, weakness, mood changes, and the like. Not knowing all the facts in your case my first instinct is to remind you to put the decision for continued hormone therapy in this context.
The second issue is that many hormone therapies cause permanent testicular suppression after a period of 3 or more years of use. In other words, it may be that you have already been put into such a state by using Vantas for 6 years. So if you want to come off active treatment, one thing you can easily do is to come off treatment — in a planned way; with your doctor on board — and to then check serum testosterone periodically to see if there is even anything that needs suppression.
Arnon
Good morning Dr.
I have had an off-and-on pain in my right hip for a few months now. I recently was diagnosed with prostate cancer and I am scheduled for RP on March 4th. My prostate cancer was rated T2b with a Gleason score of 3 + 3 = 6. I have full right side involvement with all cores on RH side showing 60-80%. One core on the LH side showing 40%. Anyway, I never mentioned the hip pain to my urologist, as it hasn’t been that bad and it is intermittent, so I never really thought about it.
Maybe now I’m just paranoid, but what are the chances it could be associated with the RH side prostate cancer? Are there any tests I should be having just to confirm? I am going to tell my doctor this week, as well, but since I just came to this paranoid asociation this morning, I thought I would ask your opinion. I am 51 years old, maybe it’s just arthritis.
**************
Gregg,
The question we’re asking is if the hip pain represents spread of prostate cancer. If it does, then a radical prostatectomy almost surely makes no sense, in that it would not be curative.
Not knowing you, it is hard for me to assess the probability of metastasis. Among the variables I am missing are the pre-biopsy PSA and the physical findings. But in the grand scheme of things, any prostate cancer can spread, so without the full information I have no reason to believe that it has not (I am not saying that it has, only that I cannot tell based on what I know).
You absolutely should tell your surgeon — the sooner the better — that your hip has been hurting. And I would specifically raise the question of a bone scan as a next step: Does he think you should be having one?
Arnon
Dear Dr. Arnon:
I am 54. Following RP, my PSA fell to undetectable. However, after 7 months it had risen to a detectable level and by 12 months was just over 1 ng/ml. At this point I received salvage radiation of the prostate bed (33 treatments). Two months after the end of the radiation, my PSA is 3.4 ng/ml and the oncologist is proposing hormone therapy.
What are the chances that this PSA reading is wrong? Should I have it re-done just in case?
Thanks
*****
Wilson,
Yes, if there is ANY doubt, you should repeat it. At the same time, be careful and discuss a bone scan with your doctor. Don’t fall into the temptation of writing this off as merely lab error until you’ve exhausted other explanations.
Arnon
Do prostate cancer patients respond differently than typical patients to BPH-\type procedures? Are there any which should be avoided (likely to be ineffective, not heal properly, spread the prostate cancer cells)? Are there any (e.g., greenlight laser) which are optimal?
The patient (over 80 years of age) with locally advanced prostate cancer has chosen not to have curative treatment. Currently he is on intermittent androgen blockade therapy. My question concerns treatment for his symptom, severe urinary retention. He uses a catheter. Doctors have advised treatment to enable him to remove the catheter. Their recommendations have ranged from microwave to holmium laser. (Greenlight laser isn’t offered locally, so not mentioned.)
********
Hi Mary,
The objectives of “BPH type procedures” are to alleviate symptoms of urgency, frenquency, and obstruction. Generally speaking, unless we’re dealing with truly end-stage prostate cancer with hematological complications, a partial transurethral treatment of enlargement and obstruction should be straightforward and an effective way to relieve a patient of symptoms and obstruction. I can completely understand why in this case he heard a recommendation to proceed as you’ve described. And if these treatments you’ve described are ineffective, then TURP may well do the trick.
Arnon
Dear Doctor:
I am T. S. Reddy, from India.
My Dad (aged 59) was recently diagnosed with metastatic prostate cancer (PSA 8; Gleason score 3 + 3 = 6) that has spread to his pelvic lymph nodes and his left acetabulum (suspicious bone scan). He had an orchidectomy 26 days ago. He is also being medicated with Idrophos (50 mg), Biprosta (50 mg), a vitamin B complex, and vitamin D tablets. A follow up is scheduled ion 2 months time.
My concern is how long hormone therapy is likely to work, and whether any emerging drugs or other therapies (e.g., abiraterone) are available and appropriate before he may need chemotherapy.
Can you give me any idea about his potential future survival? He has never had any health problems until now.
*****
Dear TS
I am very sorry to learn of your father’s troubles. I am sure that at his relatively young age the diagnosis of metastatic prostate cancer came as a major surprise.
The orchiectomy will set his metastasis back, potentially for many years. I have seen some men go as long as 20 years without relapse. At the same time, orchiectomy can be associated with bone loss, muscle weakness, and mood changes. These are things that should be monitored closely. Your support will be important and if you can keep him active socially and physically this will help him function.
Thank you for writing.
Arnon
Dear Doctor,
I was diagnosed with prostate cancer in June 2009 at the age of 67 years; PSA 4.0.
Radical prostectomy was performed in August 2009 in the USA. Pathology report: Gleason 4 + 4; prostatic ductal adenocarcinoma type with minor component of small acinar with extraprostatic extension (3 + 3); seminal vesicles and lymph nodes clear; perineural invasion present; margins were clear.
My doctor advised no additional treatment but watch my PSA, and it increased from 0.11 to 0.19 in 5 months. I have now been advised to have LHRH and radiation treatment, and this treatment has been started.
Question: Why dfo both treatments need be undertaken simultaneously? This will preclude knowing whether the cancer is in the prostate bed or spread to some other organ. If it is in the prostate bed then radiation alone may suffice. If it is elsewhere only ADT may suffice. What are your personal views please?
Thanks.
*****
Harinder,
There are data to strongly suggest that hormone therapy potentiates the salutary effect of the radiation. So it strikes me that you are being treated for prostatic bed cancer by the radiation, which is being fortified by the hormones.
Thank you.
Arnon
Dear Doctor,
I am thankful for your reply about my father’s cancer.
My one more question is: Do herbal compounds, especially “Chinese herbal mix,” help my father for better survival for long time under hormone therapy, as I learned from some forums?
*****
This is tricky, TS. It may be that some mixes are completely benign, although they may offer psychological comfort to your father. But it may be that some mixes are harmful. I know of cases in which various unregulated supplements were clearly so. In any event, I suspect that if you buy him some tea, perhaps some Chinese green tea, something people safely consume in massive quantities, and you tell him it’s a special Chinese herbal mix (will he believe you?), that you will bring him the psychological comfort with little or no risk at all.
Arnon
I am curious about the anti-angiogenesis drug called “Linomide.” I have read about it on the Johns Hopkins website. Is it strictly experimental or is it being used as a treatment option? Who is a candidate for this therapy? My husband was diagnosed with PC in January. He is having cryoablation in March. I am worried that his cancer has spread outside of the prostate gland (locally advanced). This from the Partin tables showing only a 20 percent chance the cancer is organ confined. Who would we consult to find out about this treatment?
—–
Dear Janice,
My understanding is that Roberto Pili, MD has completed a study of a tasquinimod, a second-generation linomide. I also understand that Active Biotech is setting up new trials. My sense is that Dr. Pili is the best source of information for you. You may want to make contact with him.
Please let us know how it goes. You’re invited to join our social network for this purpose.
Good luck.
Arnon
—-
Dear Janice:
Just an additional comment to add to what Dr. Krongrad has posted above. The second-generation product that Active Biotech is developing is intended at this time for patients with metastatic, castrate-resistant prostate cancer (i.e., patients with very late stage disease). You can get more detail if you click here. If your husband has just been diagnosed, it is highly unlikely that he would need a treatment like this yet — and hopefully he never will.
Mike Scott
Co-Founder
The “New” Prostate Cancer InfoLink
My pre-op PSA was 8 and my Gleason score was 3 + 3 = 6 both before and after RP in Oct 2009. I am 61 and other than the prostate cancer in very good health. My surgeon was surprised when the surgery follow-up indicated (low level) seminal vesicle invasion. (There were no margins and nothing in lymphs)
MY first blood test post-surgery showed a PSA >0.1. I am due for my next blood test this week.
After what I’ve read about recent studies, when all things are considered (age, health, Gleason score, PSA level), seminal vesicle invasion is not necessarily ominous.
What’s your take?
—–
Dear Vinnie:
Prognosis is a function of grade and stage. So all things equal, a man with Gleason 6 and no seminal vesicle involvement has a better prognosis than a man with Gleason 6 and seminal vesicle involvement. And a man with a Gleason 8 cancer and seminal vesicle involvement has a worse prognosis than a man with a Gleason 6 cancer and seminal vesicle involvement.
Overall your pathology reports send a mixed message. Seminal vesicle involvement is not a welcome feature. But the grade is relatively low given your T3b stage (seminal vesicle involvement). And your margins are clean. So the only thing left to do now is watch and see what happens. To this end, you’ve started off on the right foot. The PSA is <0.1 ng/ml, which is what you want to see. I know there is uncertainty but little can be done about that. So … follow your PSA.
Arnon
Thank you Dr. Arnon and Mike. I will check those sources and let you know. I also found that Dr. Isaacs at Johns Hopkins is conducting trials on this drug. It sounds very promising.
Again thank you both. It’s nice to know someone is out there listening.
Janice C.
Dear Dr. Arnon:”
I have a question about my husband’s prostate cancer. My husband has cancer in 3 of 12 cores sent for biopsy. Both cores from the right base show diffuse adenocarcinoma, Gleason 3 + 4 = 7. His PSA is 19. The clinical stage of the tumor is T2b. CT scans of abdomen and pelvis show no mets. (My husband is a very vital 77. My concern is a spot that showed up on his bone scan on his spine. He has a great deal of pain in his back. He claims it is from a lumbar puncture that was not done well a couple of years ago. He does have arthritis in his spine. Would there be any benefit at this time for him to have a PET scan?
The treatment plan right now is for him to have cryoablation surgery. If the cancer had metastasized to his spine, would it change anything as far as treatment?
I am just so worried about all of this. I don’t want to lose him.
I would appreciate your opinion about the benefit of a PET scan.
Thank you Dr. Arnon
—–
Dear Janice,
I would be thinking about an MRI. You may want to discuss this with a radiologist who specializes in spine disease.
Absolutely. Metastatic disease completely changes the treatment choices. This is something you should definitely discuss with his doctors.
Arnon
Doctor:
I have just been diagnosed with prostate cancer: Gleason 3 + 3 = 6, 7 of 12 samples.
I am 67, white, male.
Should i be concerned regarding risk/exposure to my wife during intercourse?
Bill Kane
—–
Dear Mr. Kane,
To the best of my knowledge, your prostate cancer does not carry a health risk for your wife.
Arnon
I have low volume prostate cancer and I am doing active surveillance (PSA/PSA free every 4 months and
an annual biopsy) through a major medical center.
When I had my initial biopsy with my local urologist, it was somewhat uncomfortable — I felt the needle stick of the lidocaine, but not the actual biopsy. However, last year when I had the first surveillance biopsy at the hospital, the lidocaine injections were extremely painful. I also had some rectal bleeding and blood in the urine for several weeks. (I know this is normal but I did not have this with the initial biopsy.) I do know that
the medical center does a very extensive biopsy.
Is it normal to experience pain with the lidocaine injections or is this a reflection of the skill of the urologist. I am very concerned about the pain since I have a biopsy coming up soon,
Glen,
Pain is not common with the lidocaine. Since you had it once, not twice, and since we cannot explain the difference in response, it is not clear to me that you will have it the third time.
That said, it’s obvious that you are anxious. This should be addressed. It may be useful to consider anti-anxiety medication before the biopsy; Valium is one example. If you go that route, you’ll need to sign your consent before the Valium. You might discuss this with your doctor.
Arnon
Hello Doctor,
I just had DaVinci RP. Pre-surgery Gleason 3 + 3 = 6, 6/12 positive core samples, all on left side, possible left focal perineural invasion. Post-surgery, upgraded to pT3a due to tumor growth into bladder muscle, negative margins, no seminal vesicle involvement. My question concerns the “bladder muscle.” I haven’t been back to my surgeon for catheter removal yet, hence we haven’t really talked much about it yet. I know this means the tumor growth escaped the capsule, but he told me “negative margins.” I haven’t seen anything about growth into the bladder muscle in any other articles or letters to you, etc., etc., and I have been all over the web looking for anything about bladder “muscle.” With the info I have given you, what does that mean to you?
I am 52, and fairly fit ….
Barney
—–
Hi Barney,
Margins and muscle are two distinct concepts, wherein the margins are where the surgeon cut. Depending on where he cut and where the tumor was, the margin may be positive or negative. So if the tumor and muscle are together, for arguments sake, and he cut far from them, then the margin will be negative. This is possible.
Bladder muscle involvement is indeed unusual. And with a pT3a I find myself a bit confused. In my hands, pT3a is ordinarily tumor outside the capsule and into peri-prostatic fat, not bladder muscle; often with negative margins. And bladder involvement is really a pT4 tumor, which is very rare and all the more rare with a Gleason 6. The first thing I would do is get clarification.
Please let us know what you find out.
Arnon
Dear Dr. Krongrad,
First, thank you for offering this forum to discuss prostate cancer — appreciate your time and expertise.
I am a 44-year-old military member and healthy. Two weeks ago I was diagnosed with prostate cancer (stage T2a, 4 + 3 = 7; 6/12 cores cancerous, with one at 90% and a couple other ones above 50%; PSA 6.25; prostate size 20 cc). I’ve consulted with one urologist and two oncologists from a military medical facility. Two recommend surgery (da Vinci) and one recommends IMRT with ADT (2 injections lasting 3 months each). All three have stated that either option is viable, and in the end the choice is mine.
I am leaning towards IMRT, but am not sure whether I should agree to the ADT therapy due to the potential side effects. My main reason for favoring IMRT over surgery is that the surgeon has stated she will not be able to do nerve sparing surgery on the right side, which means I should expect impotency afterwards. At my age, that is not too enticing. As for the pro-surgery argument, that it is extremely difficult to do surgery after radiation, if cancer re-emerges, I am hopeful that medical treatments have progressed by then (e.g., HIFU, new medicines, etc). Finally, according to the nomogram, the chances of me requiring radiation after surgery are 45%. If radiation and surgery would be required, I am assuming that the potential for side effects are even higher.
My questions are as follows:
1. ADT specific: (a) I’ve read articles on the side effects of ADT. Do you know whether the intake (shot injection versus pill) makes a difference on the propensity for side effects? (b) Can the side effects (weight gain, loss of muscle, risk of heart disease) be reduced with daily exercise? (c) In general, is the purpose of combining ADT with radiation or surgery, to treat micromets?
2. Other combined treatments: I’ve read some literature such as by Dr Dattoli, that states a combination of brachytherapy and IMRT is a potential option; another one that Georgetown University has done is to combine IMRT with Cyberknife. My question is whether you believe these two types of combo’s actually improve the risk of re-occurrence or could they just be a gimmick to collect more money? I haven’t found any research to warrant these combos. They sound good in theory but I’m not smart enough to comprehend whether they really add value.
3. Finally, do you think that my above stated logic for leaning towards IMRT in lieu of surgery is reasonable?
My bottom line goal is to find the best treatment to balance longevity (still hope to survive next 40 years) with quality of life (minimum side effects). Apologize for the length of the e-mail but very thankful for your professional opinion.
VR,
Tony
Tony,
Lots of good questions and lots of well presented background. You are touching on many facets of prostate cancer, some of which are directly relevant to your situation. Given your expansive and systematic approach, I wonder if will not be best for you to join our social network and consider discussions in topic related groups there. That way we’ll be able to break apart the many issues and also get input from many others with direct and theoretical views of them. If you are open to this, please go to http://prostatecancerinfolink.ning.com , find the relevant groups (Surgery, Radiation, Hormones, Primary Issues), find the Discussion Forums, scroll down, and press the +Start Discussion buttons.
Arnon
Dear Doctor,
I am writing you from Germany. (Please excuse, my mistakes.)
In August 2009 my PSA was 6.5. I had a a biopsy that showed cancer in 1 of 8 samples.
On August 20th I had an RP: Gleason 3 + 4; pT2c; surgical margins negative; no extracapsular extension; no cancer in seminal vesicles; no cancer present in pelvic lymph nodes.
My PSA levels after RP have been: 2.4 at 2 weeks; 0.05 at 3 months; and 0.06 at 6 months. My doctor is proposing hormone treatment. I was shocked and could not yet agree. What should I do?
Thank you for answering.
U. Neuner
—–
Hi Uli
This is surprising. Your pathology report is very good. And your PSA is <0.1 ng/ml. I am not sure why you need any treatment at this time. Perhaps you can consider a second opinion.
Arnon
Many thanks. Your opinion was very helpful for me.
Hi Dr Arnon,
My husband had robot-assisted radical prostectomy in March 08. He is only 48 now. He seemed to be doing well, then in April 09, his PSA went to 0.5. They said it was a recurrence. He has now had 37 radiation treatments and is on hormone therapy for 3 years. Does he need to do penile rehabilitation for when he is off the meds? Also, do you think he will stop producing testosterone permanently with the length of time on hormone therapy? He takes Lupron shots monthly, with Casodex and Avodart daily. How do I approach our oncologist about these issues?
Thank you for your insight. I’m in the dark and don’t know what to do.
—–
Hi Lisa.
It may or may not be that he’ll have permanent testicular suppression. There is no real way to know in advance. And I am not sure what you mean by off the meds, in that in most such cases the meds are administered for a durable effect during these 3 years.
Please approach the oncologist as directly as you did here.
Thank you. Arnon
Dear Dr:
My dad (aged 59) was diagnosed with metastatic prostate cancer (PSA 8; Gleason score 3 + 3 = 6) that had spread to his lymph nodes, with involvement of the bladder trigone and a small lesion on his left acetabulum (suspicious bone scan). He had an orchidectomy on January 8. He is also being medicated with Idrophos (50 mg), Biprosta (50 mg), a vitamin B complex, and vitamin D tablets. At follow-op this month his PSA is 0.071; testosterone 0.33; creatinine 0.9 (compared to a normal level of 1.3 at the laboratory); ultrasound showed an enlarged prostate, no lymphadenopathy; bladder slightly thickened (7 mm); and void residue of 24 cc.
Both his oncologist and his urologist said to come for a further evaluation on Augustand to continue on the same medications. Sir, can he go for radiation?
T. S. Reddy
Dear TS,
Your father’s ability to have radiation really depends on his overall health and the logistics of the treatment protocol. These are matters that he can and should review with his doctors. Most men can have radiation, but it’s worth checking.
Arnon
I am a 64 year old C-6/7 complete quadriplegic, 28 years post-injury, using clean intermittent catheterization (CIC) to empty my bladder 5-8 times per day. I have been experiencing frequent urinary tract infections since June 2009. The two bacteria causing the UTIs have been Serratia and Enterococcus. I have been treated with Levaquin, ceftazadime (IV), and amoxicillin, but the infections always return 4 to 10 days after treatment. I have had cystoscopy, bilateral retrograde pyelogram, CT scan of pelvis, MRI of kidney, bladder, pelvis, and will be having a video urodynamics test in a few days. There is no enlargement of the prostate, and no abcesses have been shown in any of the imaging studies. The current speculation by my primary care, infectious disease doctors and urologist is that the prostate may be harboring and seeding these UTIs. My goals are: 1. To be able to discontinue CICs to empty the bladder and hopefully use an external condom catheter and leg collection bag and 2. Get rid of frequent and almost constant UTIs. Would I be a good candidate for complete removal of the prostate and the internal and external sphincters? Can you provide articles or citations of articles that you have authored that might be helpful to use to discuss with my urologists.
—–
Hi Gary,
The only material I know about related to your question is posted on the Prostatitis Surgery web site. There is one specific anecdotal report from a paraplegic who was surgically treated. See the list on the left, the story from Gerry Nishikawa.
Arnon
I was recently told by my urologist that I have a small soft spot, and he said he wasn’t that concerned. My brother was diagnosed with cancer and the treatment he recieved was a microwave probe through the penis. Is that treatment a current treatment?
—–
Hi John,
Microwave is a current treatment, though it is typically used for benign enlargement, not cancer.
Arnon
I had radiation two and 1/2 years ago. My initial PSA hovered around 0.3 for this time period … then increased to 0.4 for three periods and the latest 3-month period showed a rise from 0.4 to 1.9 ng/ml. There is no evidence of urinary infection. My urologist said “no” to a biopsy, put me on the hormone therapy, and said to come back in another 3 months for another PSA reading. The radiologist said he felt a felt a “bump” on the prostate when he did a DRE, and sent me to the urologist for hormone treatment. Should I go for a second opinion on whether to go for a biopsy? By the way, I am 83.
Thanks for your help.
Dear Steve,
Not knowing your original pathology and overall health, it’s a bit hard to recommend management. However, in general a PSA alone may not be a reason to treat. This is because at this level, the likelihood of active metastasis is now and the risks of hormone treatment are real and include: bone loss, fatigue, hot flashes, mood changes … That said, it may be worth discussing a bone scan to be sure that the rising PSA does not represent a metastatic site, especially in the spine.
Arnon
Dr. Krongrad,
I had RP 10/15/08 at Johns Hopkins by Dr. Partin. I was 42 years old. I am pleased to say that I had organ-confined, Gleason 6 disease with no adverse pathological features. My last PSA was < 0.1 on 10/15/09. From what I understand based on an article released by Dr. Epstien and from an e-mail he sent me, they claim that reccurence for organ-confined Gleason 6 is exceptionally rare. 4/1000 to be exact. Anyway. What concerns me is that first, I had prostate cancer at 42. My PSA was 2.76 when I was diagnosed. 4 years before that my first ever PSA was 2.4. I was 38 years old. My final pathology showed a tumor volume classified as moderate located in Right anterior, lateral, mid/Left anterior, lateral, apex, mid.
So here is my question. I would love to believe my prognosis based on the Johns Hopkins study of their organ-confined, Gleason 6 patients, but based on my young age and what I consider a large amount of cancer I really feel I have an aggressive form of Gleason 6 prostate cancer. I am further convinced of this by the fact that I am constantly reading about people with Gleason 6 cancer that behaves very badly. What is your opinion about my situation? Does my logic make any sense based on your experience? I am feeling that I will not fare as well as an older person that had the same pathology. This is primarily because I had so much at such a young age, even though my PSA barely moved in 4 years.
Thanks
—–
Chris,
I think you’re over-reading. This is not to trivialize your concern and you are right that, like all patients, you should stay vigilant with regular PSA testing as you’re doing. But overall, grade for grade and stage for stage, to the best of my knowledge age is not material to the assessment. It’s not at all clear to me that your prognosis is worse than that of an older patient.
You’re in good hands with Alan. Follow his advice. He’ll guide you well.
Arnon
Dr. Krongrad:
I was diagnosed with PC in January 2008. My PSA was 20.7; my Gleason score was 3 + 4 = 7; my clinical stage was T1c/T2a. The cancer was found in only one lobe, but in 50 % of 6 cores. High-grade PIN was also noted.
I decided to have IGRT (in February through April 2008), which went well. My PSA before IGRT was 20.7. After IGRT, in June 2008, it was 2.86. Subsequent PSA levels taken every 3-6 months have been 1.62, 1.92, 2.01, 2.21, and 2.37 (the last taken on February 12 this year).
On March 12 I had a Prostascint SPECT/CT fusion scan, which showed the following:
“FINDINGS
“Follow-up day four whole body imaging shows no altered biodistribution of radiopharmaceutical. Chest, abdomen and pelvis SPECT/CT fusion demonstrates ProstaScint avid nonenlarged lymph nodes in the right paratracheal and subcarinal mediastinum as well as within the central abdomen involving periaortic and pericaval regions as well as mesenteric regions. Findings are consistent with micrometastatic disease as the chest, abdomen and pelvis CTs demonstrate no pathologically enlarged lymph nodes. SPECT scan of the pelvis demonstrates concordant blood pool activity without adjacent lymph node activity. Therefore, pelvic nodes are considered negative. There is no increased activity identified within the prostate bed.
“IMPRESSION:
“NO RESIDUAL PELVIC DISEASE IDENTIFIED.
“MICROMETASTATIC DISEASE NOTED TO THE PERIAORTIC, PARACAVAL AND MESENTERIC ABDOMINAL LYMPH NODES — MICROMETASTATIC DISEASE ALSO NOTED TO THE RIGHT PARATRACHEAL AND SUBCARINAL MEDIASTINAL LYMPH NODES. RESULTS DISCUSSED WITH [patient's urologist] AT THIS TIME OF INTERPRETATION.
What should I look into now? I’m only 55 years old.
—–
Dear Michael,
Thank you for writing. Two things come immediately to mind:
(1) Bone scan. You don’t mention it and maybe you’ve had one. In any event, I think it’s important you have one now to establish that there is nothing going on in the bones.
(2) Oncologist. You should strongly consider consulting a medical oncologist who specializes in prostate cancer.
You may also want to join our social network, which has a lot of smart and experienced patients in it.
Thank you.
Arnon
Dear Dr. Krongrad:
My husband had cryoablation for prostate cancer on March 22nd. He came home the next day with a suprapubic catheter. He went in for his post-op follow-up visit on March 30th. They could not remove the catheter because his residuals are too high. They said they have to be 3 ounces or less for 48 hours in a row. Can you give me some idea how long it takes on average to get back to “normal.” I would appreciate your input on this. Thanks so much.
Janice
*****
Dear Janice,
Thanks for writing. Your report implies that your husband is retaining urine. One wonders how much he retained before the cryo. This partly relates to your questions of “normal” and how long it might take to get back to it. Not knowing his age, prostate size, and pre-op function, it’s hard to assess his best potential, let alone how long it might take to get back to it. Your best bet is to ask his treating urologist.
Thank you.
Arnon
Dr. Krongrad,
I’ve had 2 bone scans done and both are negative. I will be seeing someone at Sloan-Kettering this month. None of my doctors will give me any real information. They just send me to others. Should I really start to worry or continue with treatments, whatever it maybe? Just seeking advice.
—–
Dear Michael,
Not knowing the context (why bone scans? twice?), it’s a bit hard to interpret. In any event, interpreting physician behavior is a tricky endeavor.
Knowing doctors and, perhaps more importantly, the health care climate, which involves doctors, administrators, lawyers, insurance bureaucrats, scheduling clerks, and even Congress, it may simply be that the climate, not your clinical status, is the main driver in their behavior. So no, you’ve provided me with no data upon which I can advise you to worry. See what you can do to nail somebody down to an answer.
And by the way, you may find some rather direct commentary if you post your story on our Social Network.
Good luck.
Arnon
To whom it may concern:
My husband was diagnosed with prostate cancer using MRIs, at the end of March. We are very reluctant to have the biopsy done due to the risk of needle tracking.
Loma Linda requires a biopsy to be eligible for their proton beam therapy. Do all clinics performing proton beam therapy require this?
If so why with (1) the risk of spreading cancer, (2) the trauma it puts on the prostate making someone ineligible for 2 months after a biopsy, and (3) what does the Gleason score matter if the end goal is to kill the cancer? Who does a biopsy and can guarantee they will not spread the cancer in doing so?
Thank you.
—–
Hi Karen,
Diagnosis requires biopsy. Period. Anything else is ambiguous at best. And there are no established benefits to “prostate cancer treatments” in the absence of diagnosis.
“Needle tracking” is a concept for which there is no evidence. Consider that many thousands of men are diagnosed with biopsy and, to my knowledge, none has ever been found to have cancer tracking back along the needle route.
Guarantee is not a concept existing in medicine. There is risk in everything. If someone gives you a guarantee, get a second opinion.
Gleason scoring, along with PSA and DRE, is critically important to an assessment of tumor stage. Without this assessment, there is no rational treatment planning. A PSA of 3 ng/ml, normal DRE, and Gleason 6 is very different from a PSA of 3 ng/ml, normal DRE, and Gleason 9. The latter definitely leads to further staging workup, whereas the former probably does not (depending upon tumor burden, which is also observed in the biopsy).
Arnon
Dear Dr. Krongrad:
I am 53 years of age. I had a robot-assisted prostatectomy on 12/10/09 for biopsy Gleason 6 with 6/12 cores positive; very small prostate and PSA of 3.3 at diagnosis. Adverse pathologic features post-op include extracapsular penetration and three positive surgical margins. The Gleason score was upgraded to 7 and the stage to T3a. My post-op PSA at this time is 0.0. I am doing well post-op in all areas, including continence and potency.
My urologist recommends salvage radiotherapy only if this is indicated by a biochemical recurrence as he believes the +ve margins are pathologic “artifacts” at the base of the prostate at the site of anastomosis. A radiation oncology specialist thinks I am at high risk of recurrence because of the +ve margins and the extracapsular extension and should have begun IMRT adjuvant radiation treatment a month ago. I cannot get a consensus treatment recommendation. The urologist thinks radiation will compromise that progress and that the risks outweigh potential benefits associated with adjuvant vs. salvage treatment. The radiation oncologist counsels that the best long-term outcome is associated with adjuvant treatment while local cancer cells (if any) are “negligible” and I should not wait for PSA progression as it signals rapidly multiplying cancer cells. Any recommendations/thoughts would be appreciated.
********
Dear Daniel,
Let’s get into the details. Not all “positive margins” are the same. And indeed when one lumps them all together one sees that in some cases they are associated with recurrence, but not all.
Note further that the surgeon may have a better feel of what’s going on. This is by virtue of having been involved with you pre-op and seeing your biopsy reports and of being involved intra-op and getting a feel for what actually happened in terms of the integrity of the technique used. Here the radiation oncologist is a newcomer. In general terms, and I don’t actually know what happened in yours, the surgeon is much more likely to pick up on the subtleties of the situation.
In any event, the pathologist can help to shed important light. He can tell if the margins are focal, cauterized or vast, clean cut, for example. This kind of hair splitting can be somewhat useful in assessing risk of recurrence. Also in his report would be the tumor burden and other potentially interesting features, including the severity of extra-prostatic disease and vascular involvement.
You need more detail before you can decide. Ask your pathologist and surgeon to elaborate. Then re-consult both urologist and radiation oncologist.
Arnon
I read in the national press: “A pioneering treatment that blasts prostate cancer with sound waves can cure the disease without the need for invasive surgery.”
Is this just media hype?
*****
Dear Mr. Coates-Stephens:
I am responding to this question on Dr. Krongrad’s behalf since it is a non-clinical question. I was unable to find the original article to which you make reference, but the answer is, “Almost certainly, yes.” It would appear to be some form of reference to high-intensity focused ultrasound or HIFU, which so far has not provided sufficient 10-year survival data to convincingly claim it can cure anyone who actually had progressive disease and really needed treatment. For more detail, please click here.
Sitemaster
Thanks
THANKS indeed Dr. K. My father has what I’d call moderately advanced hormone refractory PC. Although your blog can’t provide personal medical advice, its still great. For one thing, the existence of the blog re-affirms the hope that between caring, intelligent physicians and ongoing research, there will be better prospects for prostate cancer patients in the future.
Dear Dr. Kongrad:
Can you provide any info about Provenge? I have seen it mentioned on some of the other blogs about prostate cancer. Is it a vaccination or a possible cure? If approved, will it provide any help for advanced prostate cancer? Any information you provide is greatly appreciated.
Thanks Dr. K
Janice
*****
Dear Janice:
Dr. Krongrad has asked me to respond to this question because he is aware that I am very familiar with all of the relevant data, so:
1. The FDA is currently expected to approve sipuleucel-T (Provenge) very soon — and probably on or before May 1, 2010. It is likely to be approved to treat only men with metastatic forms of prostate cancer (i.e., men with prostate cancer that has already grown way beyond their prostates and into their bones and some other tissues).
2. Treatment with Provenge will require a patient to undergo a process called leukapheresis on three occasions. The plasma cells extracted by leukapheresis will first be processed by the manufacturer (to turn them into Provenge, which is custom-made for each patient) and then reinjected back into the patient. The entire course of treatment will take a matter of a few weeks.
3. People are calling Provenge (and similar types of product also in development) a “cancer vaccine” but is is more accurately described as a form of personalized immunotherapy that appears to stimulate the patient’s immune system.
4. There are no data to suggest that this form of treatment can “cure” men with advanced prostate cancer.
5. The available data suggest that Provenge can extend the survival of men with metastatic prostate cancer to the bones and to certain other types of tissue by an average of 4.1 months compared to treatment with a placebo — i.e., a similar series of three injections but of a similar-looking but non-active agent. (For details, click here.)
6. It is hoped that if treatment with Provenge is given to men with potentially or actually progressive prostate cancer long before there is any evidence of metastatic disease, it may be able to delay progression of their prostate cancer for much more than a few months, but trials to investigate this possiblility are only just beginning.
The Sitemaster
Good afternoon.
I have been a cancer registrar for over 15 years and there have been so many changes over the years.
Due to new changes in our line of work, cancer registrars will be having to record information on “Gleason’s Tertiary Pattern Value.”
For the past 1.5 hours I’ve been searching the Internet looking for a description and answer that makes sense. We know about the Gleason’s score up to 10 which is combining the 2 scores. Where does the third number come from?
Can you assist?
Thank you.
*****
Dear Mr. Sirard:
I have answered your question on behalf of Dr. Krongrad since this is actually a very straightforward, non-clinical question.
A tertiary Gleason pattern refers to:
ANY amount of Gleason pattern 5 cancer tissue reported by the pathologist in a prostate cancer specimen (whether a biopsy specimen or a surgical specimen) from a patient whose overall Gleason score is 8 or less
or
ANY amount of Gleason pattern 4 cancer tissue reported by the pathologist in a prostate cancer specimen (whether a biopsy specimen or a surgical specimen) from a patient whose overall Gleason score is 6 or less.
So, for example, imagine that you are provided with a pathology report or a clinical report that contained the following information “Left apex: Gleason pattern 3 + 4 = 7; tertiary Gleason pattern 5″ then you need to record the fact that this patient truly does have tertiary Gleason pattern 5 in addition to the dominant patterns of 4 + 4 = 8. The same would be true if the information had said “Left apex: Gleason pattern 3 + 3 = 6; tertiary Gleason pattern 4.” In this case you would need to record the tertiary Gleason pattern 4 in addition to the dominant patterns of 3 + 3 = 6.
You might want to look at the article titled “An update on Gleason grading system today” and more specifically the recommendations of the International Society of Urological Pathologists that is referred to in that article.
The Sitemaster
Question: I am now a 70-year-old white male. Over the past 6 years my PSA has gone from 4.7 to 41.4 with a gradual increase each year, though sometimes it has also gone down. I have had three biopsies, none of which have detected prostate cancer. Now my urologist wants to do another biopsy, but a recent digital exam indicates no enlargement, with normal size and tissue. Digital exams have indicated the same condition over the past 6 years with no change. I have mild BPH. Do you have any wisdom for me on this situation?
Thank you.
Nick
*****
Hi Nick,
1) Depending upon your overall health, it may or may not make sense to even do a PSA, let alone a biopsy. So if, for example, you are obese, diabetic, having had 4 strokes, then this is all an academic exercise. In other words, the decision on biopsy has to be made in overall context.
2) Assuming you are perfectly healthy and let’s add in family history of prostate cancer for good measure, then you would probably not want to miss a cancer, especially if it’s high grade. Your three negative biopsies, assuming good quality technically and that “negative” means negative — not atypical small acinar proliferation — still do not get you fully off the hook. It’s not likely, but yes, 4th biopsies can reveal cancer and that cancer can be clinically meaningful.
My suggestion is that you look at your decision with your doctors in the context of your overall health, your overall risk of prostate cancer, and the technical quality of your biopsies.
Thank you.
Arnon
Dear Dr. Krongrad — I have a question.
I have been reading Dr. Walsh’s book on prostate cancer. In it, he explains that there are two kinds of prostate cancer cells — those that are dependent on testosterone and those that are not. My question is about treatment. If a patient is starting on androgen deprivation therapy, within a short period of time, the androgen-dependent tumor shrinks. However, the androgen-independent cells continue to grow. So why don’t they treat the patient immediately with Taxotere (or some other treatment) that would kill the androgen-independent cells at the same time. Why do they let them get “a head start” before they start treating them.
From everything I have read, it seems that the “big guns” don’t come out until it’s almost too late to do any good anyway.
I would appreciate any light you can shed on this subject.
Thank you,
Janice
*****
Hi Janice,
You propose a testable hypothesis: Early Taxotere prolongs survival. To the best of my knowledge, there are absolutely no data to demonstrate that this hypothesis is true. One would not willy-nilly give Taxotere to early-stage cancer patients for many reasons. Until the data convincingly show that to do so is useful, such practice will almost surely not become common.
I like your approach. I like the question you asked.
Arnon
*****
Janice:
I would add that your hypothesis has actually been tested, and early use of Taxotere does not appear to have the effects that one might hope for. You might like to read this commentary, which is based on an article published a few weeks ago and includes very specific commentary on the issue of giving Taxotere (docetaxel) early in the disease process.
Sitemaster
Dr. Krongrad:
I am 61 years old and, generally, in excellent health. In July 2007 I was diagnosed with prostate cancer (PSA 2.84) and had a robotic RP that September. The pathology report indicated “several” positive margins, a Gleason score of 7 (3 + 4) but no cancer in other areas. My PSA was 0.10 after the surgery then climbed to 0.28 six months later. In April 2008 I had adjuvant radiation (36 treatments) which dropped my PSA back to 0.10 (July 2008). Since then, my PSA score has slowly climbed to it’s present value of 0.25.
For many years I’ve exercised regularly and have tried to follow a “heart-healthy” diet. The past couple of years I have been taking several nutritional supplements and have taken a statin for high cholesterol (prescribed since age 55).
At this point, I’m looking to make sure I’m doing whatever I can through lifestyle and nutrition to slow (or stop) the rate of PSA progression.
I have read Dr. Mark Moyad’s “The ABC’s of Nutrition & Supplements for Prostate Cancer”, but realize that it’s now 10 years old. I would appreciate a source to guide my efforts to alter my cancer’s progression through lifestyle and nutrition. What would you recommend?
Thank your for your advice.
*****
Dear Jamie,
Let us define progression as survival, arguably the most meaningful, if not the only meaningful clinical endpoint. Using this definition, to the best of my knowledge there is no specific knowledge that would permit a rational action aimed at delaying progression.
As you have implied, there are dietary and lifestyle changes that may be useful vis a vis such things as mood and coronary disease. As such, they are useful. Obviously many people find value in such actions as weight loss, yoga, and exercise. These are valuable objectives in themselves and for any man, including a man with prostate cancer, can be considered.
You may want to join our Social Network and find out more from the many interactions available to you there.
Arnon
Dr. Krongrad:
Even though I have previously asked for your advice, I would appreciate it again.
I am a 71-year-old white male who had my prostate surgically removed almost 13 years ago (Oct. 2, 1997). My doctor said that the lab report showed “clear margins” (forgive me if I do not use the proper terms). My PSA stayed at less than 0.001 but gradually started to increase, and in Dec. 2007 it reached 1.0. By Dec. 2008 it was 2.7; Nov. 2009 it was 6.8; and the one I just had in April was 10.4. I had a Prostascint scan in 2005 and again in 2009 and the results were “negative.” I had a full body scan in Sep. 2009 and it came back “negative” but with a comment about what looked like a darkened area in the “L-5″ region of my spine. I had a biopsy of that region and it also came back negative. My urologist, at our last appointment, did not like the idea of waiting until we found something with other tests in a year or two to began treatment. (I had suggested this.) So he made me an appointment with a radiation oncologist at a local cancer center. During the appointment the radiation oncologist went over my history and checked my lymph nodes and gave me a very thorough rectal exam. It was his opinion that the cancer cells or ? are probably not in that area and that a radiation series would not bring my PSA level down. He obviously thinks that the cancer has spread to another area and that the tests I have had so far have just not picked it up. My urologist had asked me to consider being treated with “hormones,” which he thought might bring my PSA down for a while and then maybe we might find something with other tests? At the moment I do not wish to follow the “hormone” treatment route. Other than the PSA readings I am in very good overall shape, I weigh 198 lb, I am 6 foot tall. My health would probably be considered above average for someone my age. I would sure appreciate your suggestions as to what path I should follow.
Thank you for what you do
Bill
Hi Bill,
It really sounds as if you’ve made a decision: To not have treatment now. I will assume for now that you are partly opposed to treatment now because of the potential for side effects: Bone loss, muscle loss, mood changes, fatigue, and the like. If so, and you’ve completed a thorough restaging, and it seems as though you have, and you are prepared to stay under strict surveillance including with PSA and repeat imaging as required and to immediately report to your physician any changes, e.g. new bone pains, then what is the argument against what you want?
Arnon
My 82-year-old father was diagnosed with stage T2b prostate cancer and underwent brachytherapy a few weeks ago. Shortly before the procedure, he was injected with goserelin. He was told the injection was to “freeze” the cancer until a suspicious spot on his colon could be scanned. No additional cancer was found on further investigation. About 2 weeks have passed since the brachytherapy, and he was told that he would have to have another injection next week. I have tried to find out whether goserelin is used concomitantly with brachytherapy to prevent cancer recurrence, but can’t find information about both types of therapy being used together. Is this a common thing or is this some type of error? He was recently prescribed Levaquin, a drug that caused a severe reaction following colon cancer surgery 5 years ago (but luckily the error was discovered), so I am worried that this is again some type of error on the part of his doctor(s). I have read that goserelin is associated with cardiovascular side effects and diabetes, and since he is also diabetic, I’m very anxious.
*****
Dear Barbara,
Yes, anti-androgen therapy is used in association with radiation, especially in high-risk cases. Not knowing the specifics of your father’s case, which you can review with his doctors, the argument for anti-androgens is either solid or not.
Anti-androgens are associated with many potentially serious side effects, especially in the elderly. Not knowing your father’s situation, it’s hard for me to put this risk in perspective. Among the things to be considered are bone loss, muscle wasting, mood changes, hot flashes, and the like. So the question is: What would justify the risk? In other words, how much benefit (e.g., longer survival) would he get if he paid with these risks?
You cannot reasonably make an informed judgment without looking simultaneously — in his case, not generic cases — at the benefits and the risks. His doctors are the ones to ask to help you.
Arnon
Hello. I’m looking for advice.
I was 42 years old last March. I had a urination problem. My PSA was 3.8 and when retested 1 month later it was 1.8. Prostatitis was diagnosed. I had a normal DRE test. Recently I saw a new urologist. My DRE again showed a normal size and feel; my PSA was at 2.6. He advised a biopsy to be safe. I refused because to me it is obviously the prostatitits that has elevated my PSA level.
Please give me your opinion.
Thanks
Bob Fuller
*****
Dear Bob,
If the diagnosis is really obvious, why are you asking my opinion? Is your question not a confirmation that you doubt yourself?
Don’t be your own doctor. You are a young man with a PSA of 2.6 ng/ml, which means a risk of positive biopsy of at least 25%. Unless you have some major over-riding explanation, e.g. active urinary tract infection or recent cystoscopy, there is no reason to believe you are not at risk.
Go back to your urologist. Ask him again what your risk of a positive biopsy is. Let him put all this into context with all things that I do not know about you. And strongly consider following the advice of the medical professional who knows you best.
Arnon
I don’t really know him. I went to him because my prostatitis problems were not going away after about a year of all the symptoms (weak stream, pain in the rectum). Really the first thing he said is, “We should do a biopsy.” He is the second uro that I have seen. The the first just said that it will take time but within 18 months it should go away. But it has not. I guess I am second guessing myself!!
I had a (positive) biopsy done a little over 2 years ago, due to a continuous rise in my PSA to 5.88 at the time.
One biopsy core (out of 10 taken) showed positive, with 0.5 mm (3%) cancer, Gleason score 3 + 3; prostate size 31 cc. I am presently 72 years old, approaching 73. Up to now, all DREs have been negative.
I’ve been on “watchful waiting” ever since the positive biopsy. After 1 year I started experiencing BPH symptoms, and also came across a urologist’s report (from a cystoscopy 10 years prior) stating that he encountered BPH symptoms when trying to view the bladder entrance. He was trying to find the cause of blood in my urine. It subsequently turned out that ceasing extreme exercise (i.e., inclined bench sit-ups) stopped the detection of blood. I was 61 at the time.
I had another total PSA test and “free PSA” test done recently, and it showed: total PSA 6.66; free PSA = 1.45.
My question is, basically: How do you differentiate PSA levels when both BPH and prostate cancer are present?
*****
Dear Erwin,
I am not sure what you are asking.
The basic clinical task is to differentiate diseases from normal states and from each other, not PSA levels. So in this case you’ve provided evidence of two coincident diseases: BPH and cancer. The PSA is certainly consistent with both. Given the biopsy finding of cancer, I suppose the immediate clinical question is this: What should be done in response to the biopsy finding?
Thank you.
Arnon
I enjoy occasional anal/prostate stimulation during sex. How will this be affected post radiation treatment of my prostate cancer ?
*****
Dear Christopher,
There are two issues, I think:
1) How does radiation affect any enjoyment? Because radiation can cause such side effects as fatigue, it can interfere with any/all enjoyment, including sexual enjoyment.
2) Does radiation affect tactile sensations in the anal and rectal areas? The answer is yes, it can. Specifically, radiation can cause rectal bleeding, urethral bleeding, anal erosion … so in theory yes. I do not know to what extent the phenomenon you are concerned about is a real issue.
Perhaps some of the members on the Gay, Bisexual, and Transgender Women group have insights. I am not saying you’re in those categories but the group leader, Darryl, has published a book on gay men with prostate cancer that specifically touches on the issues of anal sex. You might post a discussion on that group (+Start Discussion) and see if that adds insights.
Arnon
Sorry I wasn’t clear in my first message. My urologist is making recommendations based on my PSA level.
I have been on watchful waiting for a little over 2 years. Recently (about 4 weeks ago) I had a basic PSA done (which I have approx. every 4 months), which was 7.19.
My urologist’s nurse called and said, “The doctor recommends surgery or radiation.” I went to see him about a week later, and asked what the criteria were behind the recommendation. He responded that it was a PSA rise of 0.75 or over in a given period.
It was at this point that I requested a free PSA test, the results of which were: Total 6.66; Free 1.45.
My question to you was, if PSA levels are being used to make determinations on whether or not to continue watchful waiting, and BPH can also cause the PSA level to rise, how do you differentiate between the PSA that the prostate cancer is causing, and the PSA that the BPH is causing (or is this even considered)?
*****
Erwin: I am not aware of any way to distinguish the PSA that comes from a malignant cell from the PSA that comes from a benign cell.
Arnon
QUESTION: Gleason score rating 4 + 4 = 8 , only 1 cancer, adenocarcinoma, found, 90% of chip area. No second cancer found. If second cancer found, and chip area = 5%, the GS would be 4 + 3 = 7. Does this mean that 2 cancers are better than 1? Please explain.
*****
Charles,
Across populations of patients there is an inverse association between Gleason sum score and prognosis.
To the best of my knowledge, there is no evidence that in an individual case having more cancer is better than less cancer. So — and not that any of this is open to patient modification — if a patient has a 4 + 4 = 8 prostate cancer, there is absolutely no data to support his adding cancer so as to improve his prognosis. The primary pattern (4) will drive his prognosis no matter how much more lower grade cancer he adds. To follow your reasoning, if he was substituting a Gleason 3 for the Gleason 4 pattern so as to dilute the Gleason 4 instead of simply complementing it, then yes, across populations of patients we might see an improvement in prognosis.
Great academic question. Too bad its implications are not actionable.
Arnon
My husband was recently diagnosed with prostate cancer. Two years ago his PSA was 4.3, the biopsy came back with no cancer. This year his PSA is 12 and the biopsy shows 5% cancer (2 mm). Now just trying to educate ourselves and make an informed decision about treatment. The urologist made NO recommendations. What are your thoughts about scans for further diagnosis and what treatment would you advise if your son had the same PSA/biopsy report and a Gleason score of 6.
Thanks.
Dear Dr Krongrad:
I just found your website, and would like to ask you some questions.
My uncle (age 55) was diagnosed 6 months ago with prostate cancer — Gleason 5 + 4, bone metastasis (skull, vertebrae, ribs), two positive pelvic lymph nodes, PSA 15. This diagnosis came as a major surprise to us, due to his relatively young age.
He has been treated with goserelin, bicalutamide, zometa and vitamin D. His PSA level dropped to 6 then 2 in 4 months. But his last test came with a score of 5.7! He did the test again one week later, to find it has increased to 8! Though his alkaline phosphatase, and chromogranin A are now within the normal range.
The doctor suggested a certain low polyamine regime (Nutrialys) before starting chemotherapy with docetaxel. What about abiraterone? MDV3100? TOK 001? TAK 700? do you think we should give them a try? at least one of them? For the TOK and TAK, it will be difficult for us since they still don’t exist in France (because we are living there).
Do you think docetaxel will do the job? or it is better to try alternative androgen deprivation therapies?
Another case: my father (58) did a routine check up PSA test: 2.7. Do you think we should worry or do another test or is this a normal Level for his age?
Sorry for the long question and thank you for providing this service and website.
Best regards
Youakim
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Dear Youakim:
Assuming he’s healthy, I think your father should have a prostate biopsy. The risk is real and given his brother’s situation you’d want to detect a prostate cancer early.
As for your uncle, unfortunately I am just too far removed from this situation to give you any real advice. This is the sort of situation that really requires an experienced oncologist, one who specializes in prostate cancer. If you want, you can also join the social network, perhaps the chemo group or others, and see if you get any useful feedback. You can start a discussion by finding the Discussion Forum and clicking on +Start Discussion.
Arnon
Hi Arnon.
Well, here we are … 13.5 months post-op da Vinci prostatectomy. To re-summarize … Bruce’s findings were: Gleason 4 + 3 = 7; surgical margins: positive (rt posterior, 1 cm linear length); extraprostatic extension: positive (rt. post. unilateral, extensive); seminal vesicles: negative; lymph nodes: negative; apex: negative; bladder base: negative; TNM pathologic stage: pT3a; pre-op PSA: 6.9; post-op PSAs: <0.05 (x3 tests) UNTIL NOW: PSA 0.104.
Bruce is feeling well. Age 68 years in July. Totally continent when awake. Rare incontinence during night. Total erectile dysfunction. Slightly overweight, not presently exercising at the gym; non-smoker x 30 years. Has established relatioship with internist since our move to Kentucky. Sees prostate cancer surgeon on June 25th. Has not had oncologist or radiologist consultation.
I'm nervous now. PSA has doubled at least. If this were YOU, what would your next step be, Arnon? We will of course confer with his surgeon, but being a member of your network, I am very interested in your opinion. Thanks again for your input.
Warm regards,
Judy Yoakum
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Hi Judy,
Sorry for the late reply. I have just returned from a lengthy trip.
So if this was me — and it is not me — I would first get a bone scan to establish a baseline. The likelihood of a metastasis under these circumstances is very low but I still want this. Then, assuming it’s negative, I’d repeat the PSA in 2-3 months. If it keeps on climbing, I’d find a radiation oncologist who’s done a lot of work with these situations and very strongly consider pelvic radiation.
Thank you.
Arnon
Dear Molly:
You don’t give your husband’s age, which is an important consideration in prostate cancer management. That is a big rise in PSA over a relatively short time, but your husband still appears to have limited disease based on the biopsy results.
If I was in your husband’s shoes, I would ask about the possibility and appropriateness of an MRI of some type to see if it is possible to get any further information prior to making treatment decisions, but you would want to make sure this MRI was being done at a center that had experience in carrying out MRIs on patients being treated for prostate cancer (using either an endo rectal coil or some other form of MRI that was clearly good at optimizing the visibility of tumor in the prostate and surrounding tissues).
My husband has had his prostate removed and had a positive margin (though very small). And his radiation oncologist recommends watchful waiting, with PSAs every 3 months. They have been fine the first two times. My question is … a relative recommends grapefruit pectin for my husband. The relative reports that my husband’s uncle took this and it stopped his prostate cancer from spreading. His PSA started at 27, went to 17, then to 12 … then? This relative also says that he takes it and it has cleared blockage in his arteries from 50% to 0.
What are your thoughts about grapefruit pectin for prevention of prostate cancer spreading?
—–
Dear Lynn,
I am aware of no data to support grapefruit or any other pectin for any medicinal purpose, including for prostate cancer treatment.
Thank you.
Arnon
Thank you. My husband is 57 — forgot that part. According to the Partin table there is a 41% chance the cancer has spread outside the prostate — or at least I think I’m interpreting that correctly. So, certainly, the MRI makes so much sense.
Hi Arnon,
I hope your trip was successful and enjoyable.
Regarding Bruce (see June 1st entry) … he did have a full body bone scan, on Feb. 5, 2009, prior to his RALP on April 14, 2009. It showed “Arthritic distribution of isotope but no evidence to suggest neoplastic metastatic disease.” Would you consider this to be a [sufficient] baseline scan or would you personally want another post-op scan at this time to look for metastasis since it’s been nearly 14 month since his surgery?
Thanks, Arnon, for your input and for this network.
Warm Regards,
Judy
—–
This is a judgment call. Since I like to know, not assume, I’d repeat the bone scan in the setting of rising PSAs. My guess is that it will be unchanged. But as I said: I like to know.
Hi Dr. Krongrad — I have a general question to ask you. In regards to recurrence of prostate cancer, when is it time to see an oncologist? If one is looking for an oncologist, is there a specific type of specialty one should seek, i.e. medical or prostate or other. Just curious.
Thanks in advance for you input!
—–
Janice
Hi Janice, Have a look at this article by a prostate cancer oncologist. It should help you. Arnon
Thanks, Arnon. I like to know as well.
Judy
My husband had a radical prostatectomy about 7 months ago. He had cancer which spread outside the prostate, and a positive margin (I believe it was 0.1 mm). We were told that at this level he may have a 50% chance of re-occurrence, but the radiation oncologist said we could wait on the radiation. He is having his PSA checked every 3 months and so far it has been negligible. His uncle had prostate cancer, and we just received a letter from another uncle recommending a supplement with grapefruit pectin. My question is … is there any valid information, or research out there that would recommend taking this supplement to decrease prostate cancer re-occurrence risk?
Thank you.
—–
Dear Lynn:
Dr. Krongrad has been traveling but did answer your question from June 1 yesterday (see above), when he wrote, “I am aware of no data to support grapefruit or any other pectin for any medicinal purpose, including for prostate cancer treatment.” We are sorry for the delay in responding to your original question.
Sitemaster
My recent biopsy showed 1% cancer in 1 out of 6 cores, Gleason 3 + 3, 94% probability of confinement to the prostate. I am considering cryosurgery because it seems to promise the least downtime/quickest recovery. If I go this route I would decide between focal cryotherapy, deadening only part of the prostate where cancer was detected, or complete cryosurgery, leaving only a “shell” if I understand this correctly . Do you have thoughts on this? The urologist who would do this surgery said that if only partial surgery is done now, it is likely that complete surgery would be necessary at some later time. Thanks! (I’d like to search through this website for remarks by men who have had this but haven’t yet figured out how.)
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Steve,
You’ve hit on a critical issue: The uncertainty of staging prostate cancer. In other words, how do we know where a prostate cancer starts and ends? We don’t, not in microscopic terms. This is fact is the serious limitation in all approaches to focal therapies.
My PSA in January 2009 was 2.6. In January 2010 it was 4.5, and I was biopsied (10 cores). Each core had some cancer. Right side: all Gleason 6 with perineural invasion in right base and right apex. Left side: 3 of 5 cores were Gleason 7. On date of biopsy, my PSA was 2.9.
Questions: (1) I am leaning toward surgical removal, but have read that if the cancer has already spread, surgery may not be the best option. Is this a valid conclusion? (2) Are robotic-assisted laparoscopic surgeries now routinely performed, and, if so, where?
Thank you.
—–
1) Yes and no. Obviously at some stage no local therapy is useful. On the other hand, there are numerous examples of microscopically advanced tumor — stage T3a — that does well with surgery along.
2) Laparoscopic surgery is done many places. But the question you want to ask is this: Who does it well? Don’t focus on where. Focus on who. This article may interest you.
Hi Arnon,
My husband John is 56, fit, healthy, a non-smoker, and only a social drinker. John has always had PSA tests at his annual medical checkup; his doctors have watched his PSA rise each year, with it doubling twice since he was 50. His last PSA prior to diagnosis was more than a doubling at 16 ng/ml; a DRE was performed [that was positive and seemed to confirm the probability of] cancer, however biopsy was needed to determine the grade. His Gleason score was 3 + 4 = 7. He then went on hormone therapy for 6 months, and during this time had 39 sessions of pelvic external radiation. We were told at first instance that the stage was a T2 — but just recently when we checked the registrar oncologist said John was a T3. We are now more confused not to mention worried. John has had bone scans and MRIs, and at that time was all OK.
Q: What do think would be the prognosis and/or next regime of treatment should the PSA not be where it should be?
Eagerly waiting your opinion.
Thank you
—–
Dear Jo,
Thank you for writing. The positive DRE puts this as not a clinical stage T1 tumor but in itself leaves open the possibility that this was a clinical stage T2 or T3 tumor. This can be clarified by his doctor(s), especially whoever did the first DRE. The treatment certainly does sound appropriate based upon the limited information provided. And as to future treatments: My best advice is to take one step at a time, monitor early responses, and learn more as you go. It’s very unlikely he’ll need any additional treatments any time soon (if ever).
I wonder if you’ll find value in joining our social network.
Arnon
I hope patients are told the utmost truth by their doctors concerning any major treatment.
Correct me if I am wrong: (1) No scanning method is nearly accurate enough to detect prostate cancer precisely enough (“micro mets” could go undetected easily and do so … thus [some of] the failures we see). (2) There is no guarantee [of a cure] with any modality, but patients with low stats and ‘indolent” prostate cancer come closest to getting almost a guarantee. (3) Many patients are improperly assessed or their doctors did not use all tools at their disposal for optimal assessment. (4) CT and bone scans on low risk/low stats patients are almost always a complete waste of money and time. (Our system is wasteful and stupid.)
Now the hard question: Would you agree that when it comes to decisions about sampling lymph nodes, there is a great deal of variation among surgeons, and that perhaps the docs have to use a high degree of guess work as to which ones, how many, and if any? \
My sense is that patients in general need to have a better understanding of what they are “signing up for” when they start to think about prostate cancer treatment.
—–
Dear Bob,
Thank you for pointing out some of the imperfections inherent to clinical medicine, administration, and human behavior. I agree with your general position: We want things better.
Arnon
Quick question — If my husband opts for radiation and at a later time his PSAs are not normal, indicating there is prostate cancer, can he have a successful prostate removal surgery?
*****
Molly,
You are referring to salvage radical prostatectomy, which is possible. Salvage RP is associated with higher risk of incontinence and injury to adjacent organs, e.g. rectum, than first-line RP.
GCMAF seems to me to have the best potential to eliminate prostate cancer altogether, even in advanced cases, with simple weekly injections. Why has this product been ignored and why is it not available in the US? Also, is it true that nagalase secreted by prostate cancer cells causes deglycosylation of the GC protein, thus preventing activation of macrophages, and if so, why are we wasting time with other ineffective immunotherapies? Third, can you circumvent the nagalase by injecting GCMAF directly? These questions are really important to me, because I have stage 4 ductal prostate cancer that has metastasized to a soft tissue organ (lungs).
*****
Good question. For our readers, we’re talking about Gc Macrophage-Activating Factor, about which there are some early data relating to prostate cancer (click here). I really have no idea what its status is. If you find more information, please share with us. Thank you.
*****
The sitemaster has added the following information:
Dear Mr. Crary: There are three prior articles about the status of Gc-MAF on this web site. Please click here to find the links to these articles. We have no further information about the potential development of Gc-MAF for the management of prostate cancer. The only known source of any additional information is The Socrates Institute for Therapeutic Immunology in Philadelphia.
Dear Arnon:
I have two simple questions. First of all, what does perineural invasion mean? (I was thinking something to do with nerves!?) Second, regarding the Partin tables, what is the difference between a cancer being organ confined and extraprostatatic extension? I thought that if the cancer had broken out of the prostate capsule, it was not organ confined. But then what is extraprostatatic extension? Just trying to be a better informed partner. Thank you in advance for your time.
Janice
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Hi Janice,
Yes, perineural invasion relates to microscopic nerves inside the prostate. Prostate cancer cells are commonly found in association with these microscopic nerves.
“Organ confined” is just what it says. The “extra” means outside the prostate. So “extraprostatic” means “not organ confined.” The terms “extraprostatic” and “organ confined” are mutually exclusive conditions.
Arnon
Dr. Krongrad,
At my last checkup my GP thought she felt a “dimple” in my prostate. The urologist said he felt a little lump and that one side of the prostate felt firmer than the other. PSA of 2.5. He recommends a biopsy which I intend to have done.
I noticed on the Internet the possibility of having 3.0 Tesla MRI with endorectal coil. This is gives a 3D image that combines data from MRI and spectroscopy. It’s purported to be a way to get more information non-invasively which would sometimes result in choosing no biopsy. If there is a biopsy (the route I would expect to go) the doctor knows where suspicious areas are, so the samples taken are [supposedlty] more apt to get tissue from the tumor.
Two questions:
(1) While there is probably no data yet to support the notion that MRI is a useful prelude to biopsy, does it seem logical to you that there might be some value in the MRI image as a way of guiding the biopsy?
ANSWER TO Q1: Prostate cancer is often multi-focal. Indeed, we often find it away from the nodule, which often turns out to be benign. Accordingly, in most cases all locations are biopsied. Accordingly, it is not clear what the value of MRI would be vis a vis targeting the needles: All regions would probably be biopsied.
(2) My urologist wasn’t able to point me toward any information about the increased risk of metastasis from delaying the biopsy for a few months while I research this. Do you know of information on this? I would have thought that such information would be the basis for deciding the ideal frequency of screening tests.
ANSWER TO Q2: It is not clear that you have cancer. If you do not have cancer, then there is no risk in waiting. It is not clear that you do not have a Gleason 10 cancer. If you have a Gleason 10 cancer, then it may already be too late to do anything, no matter what you do. All other scenarios fall somewhere between it being too late and having all the time in the world. So until one knows if there is cancer and what grade and stage cancer, there is not even the minimal construct for assessing how much time one might have; even with that information it would be very hard to do. On top of which, the detection of prostate nodules is a wholly subjective enterprise. Who’s to say you really have one? In general, the only practical path to informed decision making is with a biopsy.
Hello Arnon
So if I may clarify … If the cancer is NOT organ confined, does that mean the cancer has spread to other organs or tissues? Does extraprostatic extension means the cancer is outside the prostate capsule, but may not have learned how to grow on it’s own just yet? I don’t know why I’m stumbling over these terms, but I appreciate your help.
Thank you,
Janice
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Janice,
Extraprostatic is a somewhat loose anatomical term that means the cancer is outside the prostate. It does not specify where outside the prostate. So prostate cancer in the liver and prostate cancer in the fat just adjacent to the prostate are both extraprostatic.
Arnon
Thank you Arnon — I’m pretty sure I’m clear on this now.
Janice
If you have had the robotic surgery and the PSA level remains high, what other option is there if the cancer remains. What are the effects of radiation at this point?
—–
Vic,
Among the options are surveillance, radiation, and hormone treatments. The choice depends partly upon the pathology at surgery, the rate of rise of PSA, the re-staging findings, and the overall health of the patient.
Radiation carries numerous possible side effects, including fatigue and urinary urgency. The patient should review these with a radiation oncologist before making a decision.
Arnon
1. Are there any data responding to the question of metastases risk secondary to the biopsy itself? (There is breast cancer research showing a higher rate of metastases after mastectomy for those who had had a biopsy.)
2. There are clinics claiming their 3 T level MRI equipment can do a more definitive job of diagnosis than a biopsy? More thorough, less risk of mets, 2-3 times the discovery rate.
PSA 4.2/Free PSA .94 (22%)/67 years/Family history/no digital findings/scheduled for a biopsy but concerned.
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Clark,
That’s a lot of claims for imaging. I’d love to see the data upon which they are based. Until I do, my skepticism remains on high alert.
Keep in mind that to quantify the relative risk of metastasis from biopsy alone one would have to treat patients who had and who did not have biopsy. They’d have to be randomized to these two arms. I am aware of no such study.
Arnon
My PSA has gone from 0.8 to 2.6 in 2 years. My urologist wants to do a biopsy. I would prefer to have the PCA3 test done first, but he says regardless I will need to have the biopsy. I was under the impression that if I had a good PCA3 test result, I wouldn’t need a biopsy.
Any comments would be appreciated.
—–
Stuart,
Not knowing your situation (age, health), it’s very hard to form a specific impression. Having said that, assuming you’re not 95 years old, diabetic, obese, having had a 4-vessel coronary bypass, it does intuitively feel that you are getting solid advice from your doctor and I cannot imagine a test that would get you off the hook.
Arnon
Dr. Krongrad:
I have asked and received your expert opinion a couple of times before, the last time being May 8th of this year. To save you looking back. I am a 71-year-old white male (weight 200 lb, 6′ tall). I had prostate surgery in October 1997 with clear margins. No chemo or radiation needed. PSA <,001 for about the first 6 years and then over the next 3 or 4 years it climbed to 1.0. Since then, every time I get a blood test (about every 6 months), it goes up 2 numbers. 2.8 to 4.8 to 6.8 and as of the last blood test in May 2010 it was 10.4 + or -. In the last year or so I have had a Prostascint scan, a full body scan, a biopsy of the L5 region (the body scan showed a shading in that region). All of the scans and tests found nothing that would account for the PSA increase. In the last month I have had a CT scan w/o contrast, a CT scan w/contrast and last Friday a whole body PET CT scan. (I get an X-ray and go to a lung specialist once a year and this year the radiologist saw a change in my lungs since last year so he recommended that I have these tests.) When I went for the PET/CT scan I took all the info and discs from previous tests and my prostate cancer history for him to look at. There was only one focus of hypermetabolism and this is significantly elevated. It lies in the left hemiscrotum. It is 2.5 cm transverse, 1 cm AP and approximately 2 cm in height. It appears to overlie the area of the left testicle. The impression was “Intense activity is present in the left testicle. The uptake values in the left testicle are approx. 9. The findings are concerning for malignancy involving the left testis and further evaluation with sonography of the testes is advised.” I will be seeing my urologist in the near future and I would appreciate your input on what you think my options will be and which one or more would you suggest that I follow.
Thank you for your time!
—–
Bill
This is an unusual situation. Some general points:
(1) Even though it’s not common, you can have testis cancer at age 71. A physical exam and ultrasound are common first diagnostic steps. With testis cancer, time is of the essence. In this, testis cancer is different from prostate cancer. Patients at risk for testis cancer are generally brought to a urologist today, not next month.
(2) Prostate cancer can metastasize to the testis. It’s rare, but it’s possible.
(3) PSA is prostate non-specific and can be found in things as seemingly different as the glands of Morgagni, fetal thymus, and human milk. PSA can also be found in cancers that are not prostatic.
It seems you have an interesting clue that you’ll be pursuing. Good luck. And please keep us posted. If you don’t mind, please join this group and when you are ready and maybe start a discussion that lays out what all this was about.
Thank you, Arnon.
Thanks for the response — I am 60 and in good health.
My PSA was 0.8 ng/ml 2 years ago. I guess I didn’t have it taken last year and then at my physical [this year] it was 3.2. Four weeks later I had it redone and it was 2.6.
My question is, wouldn’t it be prudent to have the PCA3 test first? If that number is good, then could I wait 4-6 months to have another PSA before the biopsy?
—–
Stuart,
You’re asking if the PCA3 result negates the risk as assessed by a PSA result known to be associated with a 25% risk. I am not aware of data that would say it does. The closest I know of is for patients who had at least one negative biopsy in the past (see http://bit.ly/bquOVv). In those patients the PCA3 provides a sliding scale of inverse risk but not to zero. In any event, this is not your situation, in that as I understand it you have not had any kind of prostate biopsy. Keep in mind also that to the best of my knowledge the test is not FDA approved and that it is tricky to carry out, which raises the practical questions of why isn’t it approved and where could you have it done with confidence?
Dr Krongrad,
On September 29, 2009 my PSA was 6.4. In 2008 it was 2.6. I was referred to a urolgist, which resulted in a biopsy, with a Gleason score of 3 + 4 = 7. After bone and CT scans (results negative) I was referred to the [radiation] oncology department.
At the appointment with [radiation] oncology on February 1, 2010, I was placed on Androcur-100 for 5 months. My PSA was also taken. On June 12 my PSA was 0.51. On June 29 I attended [radiation] oncology to be (measured up) for external beam radiotherapy, to commence on July 29. At the [radiation] oncology department, I spoke to the doctor in charge about how my PSA had dropped from 6.4 to 0.51. He said it was only the Androcur keeping it down. I also found out that the PSA reading they took on February 1 read as 4 ng/ml.
Between September 29, 2009 and February 1, 2010 my PSA dropped 2.4 ng/ml. (I wasn’t on Androcur then.) I questioned the doctor about this. He said, “Sometimes it fluctuates.” I didn’t think the PSA level was like blood pressure. What do you think?
Many thanks,
William Jones
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William,
PSA is like BP in that it can fluctuate. It is unlike BP in that it can drop to zero. So the radiation oncologist is right on both counts: (1) The baseline PSA level can spontaneously oscillate a bit and (2) the hormone treatments can bring it to new low levels.
Arnon
My husband is going to have a bilateral orchidectomy operation. Once he has this, will he still have to be on Casodex and Zoladex or will that stop? He also has a lot of back pain. Has this got to do with the pills he is taking at the moment? If he has this operation, will the pain go away?
Please can you help before he has this operation in July in South Africa.
Dear Ria,
Zoladex aims to reduce testosterone, which is produced by the testes, to very very low levels. Sometimes Zoladex does not do this. So an orchiectomy, a surgical removal of the testes is a very effective way to accomplish the same thing. I cannot think of why he’d need Zoladex once his testes have been removed.
Back pain can be from many causes, including cancer, osteoporosis, and fracture. Indeed, it may be that lowering the testosterone to reverse cancer growth can predispose to fracture. To in this complicated setting, back pain has to be better explained so that treatments can be targeted. If his pain came on suddenly and/or it worsens after the orchiectomy, you really should talk with his doctor about the possibility that it’s caused by osteoporosis and/or fracture. Especially especially if he has any neurological symptoms, such as weakness.
Arnon
Dr. Krongrad:
I just received the report from my ultrasound and must admit I am more confused than before? My urologists scheduled this scan due to the impressions from a PET scan a week ago. (My post about the pet scan was 6/30/10.) After reading my PET scan indications and impression and with the rise of my PSA in the last few years I though that surely the PET scan had located the area where the prostate cancer had returned. Then, in reading your reply (and also the comment of Mike Scott), I thought that you all might not believe the “impression” of the radiologists who read the PET scan — or at least what was found being the return of prostate cancer?
The “findings” of the ultrasound were as follows: “There is no definite testiculan mass appreciated in either testicle. The epididymis measures 6 x 6 x 6 mm. There are small bilateral hydroceles. There appears to be a left varicocele. There is symmetric color flow.” “Impression: No definite testicular mass, small left hydrocele and right hydrocele, small left varicocele. Abnormal PET scan findings are not well accounted for by this image?” What should I take from the results of these two scans, as to me they appear to contradict (or at the very least not support) one another?
Again your response and others are appreciated.
Bill
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Bill,
I have absolutely no idea how specific are PET images of the testis. So it picked up something suspicious but what is it? Cancer? Inflammation? Infection? I have NO idea. What I do know is that ultrasound has a fairly lengthy record of clinical application in the evaluation of the testis, although no test has a negative predictive value (NPV) of 100%. So even a negative ultrasound may not be truly negative. In a case like this, it’s up to the radiologists to guide all of us. Please present this to your radiologist(s) and have them advise. And please report back. We’d all like to know how they interpret all this.
Arnon
Hi
I am 16 years old and I have been experencing a burning fealing when I take a piss. I don’t know if I actually have prostate cancer because I don’t have any other symptoms besides wanting to go to the toilet more often, but that stopped. Can you please tell me if I need to see a doc or its just nothing.
—–
Max,
There is absolutely no way for me to know why you have dysuria and why you had a period frequency. The list of possibilities is endless and your doctor will be able to help you sort through them.
AK
What is the latest treatment on the market for advanced hormone refractory prostate cancer?
—–
Barbara:
The most recently approved product is cabazitaxel (Jevtana), which was approved a few weeks ago for the treatment of men who have a rising PSA level after treatment with docetaxel (Taxotere) + prednisone (click here to see more). Sipuleucel-T (Provenge) was also approved earlier this year (click here to see more).
Hi Dr. Krongrad — I’m back again with another question. My husband just had his first post-op PSA. It was 1.98. To review for you, my husband is 77, pre-op PSA 19, Gleason 3 + 4 = 7, tumor stage T2b. He received cryotherapy on March 22nd. I was a little disappointed with his PSA, but the doc said it is OK. Next one should be the same or lower. If it is not, that is, if it is rising, he will do another biopsy of the area. What can be determined from a post-op biopsy? I am thinking if the prostate is dead, what is there to show on a biopsy? Will it show any cancer in the prostate fat, or seminal vesicles? I would appreciate your comment. You are always so helpful.
Thank you,
Janice
—–
I like how you think: “If the prostate is dead.” So the question is, how do we know if it’s “dead?” I would argue that one knows the functional implications of a pathologist’s interpretation only through long-term follow-up. Have we seen that with post-cryo biopsies? If so, please share because I don’t remember such a thing.
Plus: What if it’s not “dead?” What if the biopsy shows “living” cancer in the prostate? Would this not cast the PSA into a new light? And the future course?
Arnon
Thank you Dr. Krongrad — I see your point. So post-op biopsy is to make the determination. And then, as you say, we review the PSA in a whole new light. For now, then, just more watching and waiting.
I’m so grateful for your input.
Janice
Dr. Krongrad — On April 24, 2010 I had posted you a question and some medical history re prostate and you had helped me with your response.
I have switched my MD now to the CUMedcenter Urology/Oncology Clinic. They have been fantastic but I still respect you wisdom on all of this. In April my PSA was 42 and 5 weeks ago a new PSA was 50. Ultrasound indicated size of prostate was .98 (3 times normal size). They did a PCA3 urine test which was very low number. Put on Levodart to reduce size so can do biopsy better. Also, had gamma scan to check for bone cancer.
Saw MD yesterday — PSA now is 36 due to Levodart and size reduced. MD still concerned because not sure what is going on in there — scheduled for a special biopsy they do at this clinic which is a grid combined with prostate-specific MRI. Biopsy is 40 to 120 samples to make a 3D digital picture, access to prostate through the perineum lower scrotum. General anesthesia is used.
My question is this — this MD keeps stating I have had 3 biopsies in the past and he is concerned, as well, about too many biopsies. What is the danger? I have read about where the needle can carry the cancer, if any, to the outside of the prostate and generate it spreading into other parts of the body. Is there research to confirm this? And any other wisdom you may have to offer me. Again, I am a 70 year old white male and about 15 lbs overweight though doesn’t show do to my height (6′ 4″ tall).
Thank you again. I honestly do not know how you respond to all of this. Nick
Nick,
There are certainly risks with biopsy, which you should review with your doctor. Among the risks are bleeding and infection/sepsis.
I am aware of no research to show that biopsy spreads cancer.
Good luck out there.
Had my check up with urologist last week. My PSA jumped from 1.4 to 3.0 in 12 months. When he performed the DRE he said my prostate was “lumpy/bump”. PCA3 tomorrow. Cipro for 4 weeks and then recheck PSA and fPSA. I am 50 and I have had one prior biopsy 2 years ago — negative. Doctor said [the limp/bump] could be scar tissue from biopsy. Could that be?
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Sam,
Sure, a lump could be scar. But the DRE is notoriously subjective, too, so maybe another urologist would not even feel a “lump.” Or maybe feel that it’s really suspicious.
Is that really the issue, though? You’re 50 and your PSA is 3.0 ng/ml. So your risk of a positive biopsy is at 25%. Isn’t that the real issue?
Arnon
Dear Dr. Krongrad,
I am 66 and have been recently diagnosed with ACP and advised either RALP or LDR brachytherapy for curative treatment. Since then, I have been trying to find (statistically) robust comparisons between the two in the literature … it hasn’t been easy.
However, following a notice on this site, today I have seen the article by Malcolm et al. in the Journal of Urology in May 2010, which states that RRP, RALP, brachytherapy and cryoablation are basically equivalent as far as HRQOL is concerned.
Do you have an opinion on this issue? Are they also oncologically equivalent?
Thanks for your wonderful work,
Kabir
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It hasn’t been easy? You’re being generous. I think it’s impossible to find scientifically valid treatment comparisons. So this answers your question on oncological equivalence.
The trouble with interpreting data on HRQOL across treatment arms is that the patients are self-selecting; they are not randomized. So the possibility of selection bias cannot be eliminated, much as drivers of Kia cars select for those cars and are pleased just as drivers of Mercedes cars select for those cars and are pleased. What would happen if you randomized drivers to Kia and Mercedes? Would they be equally pleased as before?
Do I have opinions? Yes, who doesn’t? One opinion: You’d better find a doctor who’s really good about prostate cancer treatment and who actually takes the time to listen to you. Another opinion: You should share your decisions with people who can provide real support, be it tangible or emotional. Finally, it is my opinion that you should join our social network: http://prostatecancerinfolink.ning.com
Arnon
I have an RP scheduled for ~ 1 month following positive diagnosis: T2c, Gleason 3 + 4 = 7, age 62, PSA 4.9 I would like to have at least one more PSA test at least 2 weeks prior to surgery or ~ 3 weeks after the last PSA test. Is this a normal request for my doctor who is doing the surgery? Thank you.
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Rick,
Your request is common. Is it wise? That’s a wholly different matter. Given that you had a biopsy, how will the PSA be interpreted? What if it goes down? What if it goes up? How will this matter?
My patients get PSAs commonly before surgery, which normally serves to confuse and distract them, but no more than that.
Arnon
Hello, I have a father diagnosed with a high grade prostate cancer at age 63. I’m 40 years old today, when should I start my PSA testing?
Best regards
Christophe
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Dear Christophe:
We apologize for the delay in answering your question.
You should go and discuss this with your own doctor. In America, many people would suggest that you get a “baseline” PSA now, so that you can use it as a basis for comparison for other PSA data later. Other physicians would say that you could wait a while before you started to get regular PSA tests. There are no fixed “rules” about this that everyone follows.
Sitemaster (for Dr. Krongrad)
Dear Dr. Krongrad:
Me again! My husband has been experiencing an ongoing UTI since April. (He had cryo on March 22nd.) We have been told that the UTI is because of poor emptying of the bladder due to tissue sloughing. He was being treated with Macrobid. As of last week, a decision was made to try a new medication, but first they must determine what bacterium we are dealing with. We should know by Thursday. I have two questions.
First of all, how long does this tissue sloughing last? I mean, roughly — 6 months, or is it undeterminable?
Secondly, my husband usually feels like his bladder is empty, even though two ultrasounds have shown more than 8 oz remaining after he thought he was empty. A friend of mine, who is a nurse, says that this is probably due to some nerve damage at the sphincter of his bladder. Have you ever heard of this and is it fixable?
Thank you in advance for your advice.
Janice
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Hi Janice,
I have NO idea how long sloughing can last. I’m frankly not even sure how one would measure that.
Nerve damage at the sphincter explaining why he doesn’t feel his bladder? That makes no real sense to me.
Arnon
Dr. Krongrad,
I am 66 years old and had a successful RP 14 months ago with full recovery. I am doing fine after quarterly check-ups with undetectable PSAs. My incontinence lasted about 3 months, after which I was able to eliminate the need for male guards. I have performed nightly Kegel exercises ever since my post-surgery catheter removal. Should I discontinue these exercises and, if I do, can the incontinence return? Thank you.
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Bob,
It’s not really clear how much incremental value was provided by the Kegels in the first place. As to your question: There are no data that I know of upon which to base a rational answer. Is your continence dependent upon ongoing Kegels? And could its cessation permanently set you back? I don’t think anybody can say. You should probably discuss this with your surgeon.
Arnon
I was recently surprised with a diagnosis of aggressive prostate cancer based on a biopsy conducted on June 29, 2010 with Gleason 9. I am 66 years old and in outstanding health with no other symptoms of prostate cancer.
My dilemma is my urologist thinks da Vinci surgery is a good choice for me since he believes there is a good chance the prostate cancer has not spread, while my radiation oncologist says there is a good chance the prostate cancer HAS spread beyond the prostate, so I should consider going straight to HT/RT since it is likely the RP will fail and HT/RT will be necessary anyway. Each argument makes sense given their respective premises, but without knowing the likelihood of containment to the prostate they don’t provide me the information needed to make an informed decision.
Partin tables and Sloan-Kettering nomograms indicate fairly good probabilities of organ confinement and favorable RP outcomes despite the high Gleason score, but they do not take into account the contravening indictors of short PSA doubling time, high PSA velocity, and low free PSA that all point toward probability the prostate cancer has escaped the prostate. I have not found any models that do include these factors. So my hope is that someone can help me with probabilities that take all the known factors into account, and also suggest any further tests that might shed more light on the question of confinement of the prostate cancer to the prostate. I do have an endorectal MRI scheduled for August 16, just a week before the surgery. If that test shows likely migration of the cancer to outside the prostate my understanding is that probably means radiation and hormone therapy would be a better choice than surgery.
Here are my details so far:
Date of diagnosis: 29 June, 2010
PSA at diagnosis: 7.3 taken 25 May, 2010, up from 4.1 on 7 December, 2009.
— Doubling time 7.12 months.
— Free PSA 10%.
— PSAV 6.46 ng/ml/yr.
Gleason score at diagnosis: 9
— 12 cores sampled; 10 cores negative, 2 cores positive.
— Right Mid malignant, 3 + 4 involving 20% of specimen
— Right Lat Mid malignant, 4 + 5 plus tertiary involving 50% of specimen, high-grade prostatic intraepithelial neoplasia.
Prior and current treatments: None yet. da Vinci robotic surgery scheduled for 23 August locally.
Current PSA: 7.3, taken 25 May, 2010
Prostate volume is 22.2 cc by transrectal ultrasound. Calculated PSAD is 0.33 ng/ml/cc.
Clinical stage T1c.
Bone and CT scans negative.
Endorectal MRI scheduled for August 16, 2010.
I would greatly appreciate any suggestions to help me make an informed decision between RP and HT/RT. Would a test for PAP levels provide information of value in addition to the endorectal MRI? My primary criterion is survival time. Time to make a decision is short. Appreciate any suggestions for anything I have overlooked.
George Kralovec
*****
Hi George,
It does not appear to me that you overlooked very much. That’s a very systematic and thoughtful presentation and analysis. At the heart of the matter is that we don’t have a clinical trial that would provide the definitive answer you want. So … there is certainly uncertainty in the situation.
Having said that, surgery is not unreasonable. I have lots of patients with high-grade cancer, including Gleason 9 and even Gleason 10, who do very well with surgery only. Presumably they are doing well because their high-grade cancers were low stage cancers and that this is what permitted a salutary effect with but one treatment. It’s the stage of your cancer that we don’t know with precision and this may be the key to knowing the effect of one treatment on your future. So again: Uncertainty.
One thing is encouraging: The cancer is not at the apex. I don’t like apical, high-grade cancers. They tend to be the most problematic. Furthermore, your cancer is apparently not high volume. This also is good. Again, I think surgery is reasonable.
I wish you all the best, George. Please don’t hesitate to write back.
Arnon
My father has been in a prostate cancer-induced coma for almost 4 days now. Pulse ~110 somewhat erratic, BP 100/60, respirations 3/min, some rattling. He’s at home, no IV fluids or O2 being given, various hospice prescribed narcotics given sublingually and rectally. May he go in peace. He was originally diagnosed with prostate cancer in 1996, had a prostatectomy, biochemical failure in 1997, hormone therapy to date since then. Biochemical failure again October 2009, EBT January 2010, Taxotere April – June 2010. Oncologist recommended hospice late June, but he only agreed 5 days ago. He is 77 years old.
Main question: What is the likely mechanism of death?
Second question: How long is he likely to survive (and/or what are any signs that would indicate death is near)?
*****
Dear Dave:
We are sorry to hear from your follow-up message that your father passed away last night (rendering an answer to your second question moot).
Patients with highly advanced forms of metastatic prostate cancer like your father usually pass away as a consequence of multiple organ failure, and it is commonly almost impossible to say which specific critical organ was the one that stopped working first. Given that your father had been in a coma for the past 4 days, he may well have had significant metastasis to the brain that were causing this coma, but there are almost too many possibilities to speculate.
I am sure that if Dr. Krongrad has any additional insights he will add them to this post when he gets the chance, but … under the circumstances … we wanted to offer you some form of response to your question as fast as possible.
We offer our sympathy to you and your family at this time.
Sitemaster
Follow up:
My deceased father (history in previous comment) chose to die with home hospice care. While he was still lucid, he signed and discussed with his doctors a medical directive declining “extraordinary measures” for life extension. He specifically refused IV nutrition, I don’t recall any other interventions being called out.
Hospice provided oxygen, but we didn’t end up administering it. On the first day of his final coma, he did try putting on a canula, but he pushed it off. Although we didn’t try oxygen any later on, I suspect that he wouldn’t have noticed the mask the following days. We occasionally swabbed his mouth to provide moisture, but didn’t otherwise provide any hydration. Pain medication was provided by suppository, and orally (sublingual).
Not that it matters now, or that there could be any definitive answer, but I wonder if oxygen or IV hydration might have eased his last hours? Of course if they would have significantly prolonged his life in coma, he wouldn’t have wanted those interventions. Thoughts?
BTW, there is an interested article, “Letting Go, what should medicine do when it can’t save your life “ in last week’s New Yorker discussing the problematic nature end of life care.
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Dave,
Thank you for the thoughtful, poignant post. It sounds as if your father could not have asked for better support.
I can only imagine that hydration would ease discomfort, in that dehydration and thirst are very annoying. Ditto on oxygen. I say this based simply on observing non-hospice patients, not based upon systematic study of the issues. If you find more on this, please advise us.
Sincerely,
Arnon
My dad was diagnosed with stage 4 prostate cancer about 10 years ago. He has been on chemo, hormone therapy drugs, and has had 5 surgeries. I have since found out that the 3 tumors in his abdomen are blocking his kidneys and although he has been on radiation for 3 weeks its not improving. His PSA has gone up to 187 and the doctors said they couldn’t do another surgery or switch his drugs again. … Does anyone know exactly what this means? I have a hard time getting a straight answer?
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Dear Natalie,
It’s a bit hard to guess as to what’s going on based upon your report. If the problem is that you are not getting straight answers, why not get a second opinion?
Arnon
Dear Dr. Krongrad:
My PSA result in July 2009 was 0.2 and now in August 2010 it is at 0.4. I underwent a radical prostatectomy in July 2004, having had a Gleason 5. My PSA went from < 0.01 to 0.1 the first 2 years and from then on stayed at 0.2 for 3 years. I have no idea how long it has been at 0.4 and I never knew when it was at 0.3 (if it ever was). I cannot see my urologist before another month. How should I interpret this increase? Thank you in advance for your reply.
*****
Dear Joseph,
Given that this increase has happened over the course of 6 years for what was a low-grade cancer (I assume you mean 3 + 2 = 5, not 5 + 5 = 10), it’s not very likely that the next month would make a major clinical difference. Accordingly, we may not want to interpret or assume very much. My only real advice is to bring this up with your surgeon.
Arnon
Hi Arnon.
Bruce had RALP in March 2009, with extraprostatic extension, +ve margin (lower right). Due to the pathology report post-op, and with the surgeon’s opinion, we anticipated possible recurrence in time.
Bruce’s PSA remained < 0.05 until May 24, 2010 when it read 0.104, then 0.12 on June 25th. He is essentially continent (perhaps nocturnal enuresis x1 every 2 weeks) and has total ED. He is now 68 yrs old, in very good health, and asymptomatic.
We are in process of considering probable further treatment for recurrence. Presently, it appears to me, from researching Comprehensive Cancer Centers and other reliable sources, that there is debate within the medical community regarding the usefulness of a ProstaScint scan. We have received only one positive opinion regarding this procedure as our next step. Others offer bone scan and endorectal MRI as a precursor to radiotherapy/hormone treatment.
You are always my "go to" source when I am searching for opinions. Therefore I am asking for just that. Your "take" on the reliability of the ProstaScint scan in investigating recurrence.
Of course Bruce’s life is the issue of utmost importance here, but money is also an issue. The ProstaScint scan is $5,000 plus, and our insurance coverage for this procedure is very debatable.
Once again, thank you for your input and for all you do.
Warm regards,
Judy
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Hi Judy,
Since I’m not Bruce’s doctor please take this as very general commentary. Under such circumstances it is not clear to me how clinical decision making would be affected. For one, it’s not clear that the scan is precise. And another, it’s not clear how the results should affect the next step. You may want to discuss all this with his surgeon.
Arnon
My father, who is 96 years old, has prostate cancer. His doctor said he is too old for treatment but has been taking hormone shots every 3 months to slow it down. He has been taking these shots for a few years now. This year he has had 2 procedures to help him urinate; he now has a catheter in. His urine has recently been very bloody, almost black at times he says. He has gone to his doctor about this but they do not seem very concerned. We cannot find any information about what to expect when prostate cancer is not treated. Is he too old for treatment and if he is too old for treatment what can he expect, how does the cancer progress? Is there any treatment that will help at his age? He has always been in good health and active until this prostate cancer, I don’t like seeing him go downhill.
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Dear Betty,
Thank you for writing. I certainly can understand you not wanting to see your father go downhill.
It seems to me that a good bit of detail is missing, which his doctor(s) can supply. To make the best decisions, among the details one really needs most are the stage of his cancer (is this metastatic? localized?), the grade of his cancer, and the role of his cancer in the urinary retention, which might have to do with plain old benign enlargement and not the cancer. One should also really try to understand the expectations from the hormone shots, in that they are not curative of prostate cancer, although they can help with specific manifestations, such as bone pain and/or urinary retention (for which there are other treatments). To understand the expectations from the shots is critical given the potentially serious side effects they can post: bone loss, muscle weakness, memory loss, mood changes …
My best advice is to go to his doctors with these questions. The answers will guide you.
Arnon
Hi Dr. thank you for what you do. I am 66 and have had the following changes to my PSA:
06/01/09 — 3.9 (my PSA has always hovered around this level)
11/27/09 — 4.53
03/12/10 — 4.36
06/18/10 — 4.96
07/19/10 — 6.0
On the last test I also had a free PSA level of 08
I also was very under the weather for about 3 weeks in July and at one time I thought I had Lyme disease. I had lots of fatigue and lack of energy. I did not think it could effect my tests on 07/19/10; however, after some research I am not sure. I had a chest X-ray which was OK.
I visited my doctor and he suggested a biopsy since I have had a slow rise since last November. Do you concur and could my illness have effected my PSA and Free PSA that much?? Should I do another PSA and free PSA?
Thank you so much.
Sonny
Hi Sonny,
I am aware of no association of Lyme disease and PSA elevation. Not that one couldn’t exist. That said, your PSA has been solidly in the 25% risk category since before your feeling lousy. So overall, what’s the argument that you should not have a biopsy? And if it exists, does the “Lyme” episode really change it?
Arnon
Hi Dr. Krongrad,
I’m 66 and went in for my occasional prostate check recently. After the DRE the doctor said my prostate was soft and he felt no lumps. My PSA reading came back at 243. The doctor said, “That’s very, very high. Let’s do a biopsy.” I agreed and it’s scheduled for next week. But he didn’t offer an opinion about the PSA of 243.
In looking at the wealth of reports on the internet of men who are struggling with various prostate problems, I have never seen a PSA number that high. My questions is, does such a high number mean anything special other than I should have a biopsy? Thanks for your advice.
Ted
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Dear Ted:
Dr. Krongrad is currently traveling and may not be able to look at your question for a while. What we can tell you in his absence is that a PSA of 200+ is often associated with a significant risk of prostate cancer that has escaped from the prostate into other parts of the body. We suggest that when you go back to see your doctor, you ask him whether he thinks it would be a good idea to get a bone scan (a test to see if there is any sign of prostate cancer that has moved to your hips or your spine or other bones) in addition to the biopsy.
You could also get more information from other experienced patients if you joined the social network associated with this web site.
Sitemaster (on behalf of Dr. Krongrad)
Dear Dr. Arnon:
My husband has just been diagnosed with prostate cancer. He is 59 years old. The left lobe biopsy showed 6 out of 6 positive cores at 60% total tissue, Gleason 4 + 3 = 7 with perineural invasion; and the right lobe biopsy showed 4 of 6 positive cores at 15% total tissue with no sign of perineural invasion. The Gleason score was 3 + 3 = 6. Clinical stage T1c.
His PSA levels have been 4.80 on 9/30/09; 5.66 on 2/5/10; 5.72 on 4/16/10; and 6.56 on 7/23/10.
A bone scan on 8/18/10 showed no demonstrable evidence of metastatic bone disease; a CT scan on showed that 8/10 the prostate gland demonstrates somewhat heterogenous density. No definite abnormally enlarged lymph nodes by size criteria in the pelvis.
The oncologist has suggest radical prostatectomy. He believes the nerve bundle is involved on the left side of the prostate and that he can not have clear margins without removal of the nerves. The right side is less of a known, therefore unsure of the ability to achieve clear margin unless the nerves are removed.
Any suggestions?
My husband is very healthy otherwise. Sex is very important to both of us. However, we do not want to take a gamble on trying to preserve the nerves at the expense of his life.
I have read that external radiation, radical prostatectomy, and brachytherapy have about the same cure rates but we were told that if we choose radiation first then surgery is no longer an option.
We need your insight on this.
Thank you
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Mary,
First the obvious: You can have surgery after radiation. This is called a salvage operation and it’s done for radiation failure. There is more risk of incontinence and injury to adjacent organs.
Now the less obvious. There is no certainly about pathological stage. So the caution you’re hearing makes sense given the tumor burden described by the pathologist. At issue, of course, is the balance between objective (getting rid of the cancer) and side effect (erectile dysfunction). My instinct is right on track with what you’ve cited: be careful. With this level of burden and perineural invasion, the probability of tumor outside the prostate is moderate. Not absolute, but it’s real.
Sex is important to you. Good. And as with the Solomonic baby decision, you’ve bet on the obvious priority: not gambling with life. With this in mind, I’ll state what is surely obvious to you: sex is about more than erections. This is not to say that no matter what he chooses he won’t have erections. Rather, it is to re-assert the obvious, which may need re-asserting at a time like this. Surely your husband has some level of turmoil about all this and your reassurance regarding love, commitment, and intimacy is profoundly valuable to him. Tell him what you’re thinking. Tell him what’s important.
Arnon