Ask Arnon … he’s a prostate cancer surgeon
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.
Dear Dr. Krongrad:
What is the difference between prostate surgery done with and without a robot? Is one better than the other? I am trying to decide what type of surgery to get and where to get it!
Dear Imperativa,
Thank you for writing.
The question comes up all the time. I recently summarized the related issues, which generally relate to minimally invasive prostate surgery. Click on the link and have a look. If you have any questions, please write me back.
AK
Dear Dr Krongrad,
Thanks for doing this!
My situation is unusual, and I want to learn possible theoretical explanations — and the evidence for and against each theory — before deciding on further treatment.
In May 2007, per DRE and biopsy, I was diagnosed with cT2aNxMx, cGS7=4.3. My PSA in late May was 4.56.
In August 2007, I underwent RP. The pathology report restaged and regraded the cancer to pT3aN0Mx, pGS9=5+4. But my PSA was measured at 4.6 (four weeks post-op), then 4.5 (five weeks), then 4.4 (seven weeks), then 3.0 (ten weeks post-op).
Post-op CT, bone scan, and PET scan all showed nothing of interest. ProstaScint was equivocal.
Since then, I’ve been on a clinical trial (Avastin+Tarceva) and my PSA has dropped another 35% — from 3.0 in November before the trial, to 1.9 now in March. Without any theoretical explanation, however, I have no reason to think the PSA changes were the result of treatment vs diet vs simple passage of time.
Question 1: How often does it happen that RP has little or no effect on PSA? (Once in a hundred? Once in ten thousand?)
Question 2: What are the best theoretical explanations of this unusual phenomenon?
Question 3: Is there any reason at all to undergo local radiation? If it has no theoretical underpinning, I see no reason to try it. Nonetheless, it’s been recommended to me on a “just-in-case” basis, based on studies of men whose post-RP PSA dropped considerably and subsequently started to rise. I see no particular similarity between my case and those cohorts - my RP didn’t lower my PSA, and my PSA hasn’t been rising. From where I stand, it can’t possibly help me, and has a very probable impact on QoL.
Question 4: Is there anything to suggest (or rule out) one systemic treatment rather than another — e.g., docetaxel vs hormone therapy vs diet vs clinical trial?
Dear Paul 1956:
Thank you for writing. You are asking question best suited to an oncologist, which I am not. We do not yet have an Ask the Oncologist, so please take this with some caution. With that said …
1) I cannot cite a specific statistic, but yes, this is rare. I have seen it one or two in the last 1000 men I’ve taken care of. As I recall (I am not in the office right now), they had Gleason 9 cancers also, but the PSAs did not stabilize after surgery. They went up. I cannot remember a situation like yours.
2) We can speculate but not know what explains a stable PSA after radical prostatectomy. For example, we might suggest that most of the PSA never did come from the prostate; there are many sources of PSA in the body. Given your Gleason 9 and pT3a (into fat; presumably a large tumor volume), this is hard to accept, especially since all imaging tests were negative. I have no explanation for what you are describing.
3) “Just in case” is not a medical rationale. It’s a phrase possibly meant to mitigate the emotional ill effects of uncertainty, either yours or the doctor’s. You don’t seem to be seeking that given the rational nature of your presentation (correct me if this is a wrong impression, please). No, your case is not like those of other cohorts and so you cannot reasonably extrapolate from them in any event. Sure, radiation (possibly with hormones) can have ill effects on your quality of life. Finally, you are not in a “virgin” situation and the real question is this: what does radiation offer in this (unusual) case after treatment with (experimental) Avastin and Tarceva? Nobody has a scientific answer to this question.
4) Diet is generic. I don’t understand what you mean but I cannot endorse dietary modifications until somebody shows data suited to your desired outcome. Sure, eat well, but there is no basis for using diet to achieve any desired clinical outcome related to what you describe. Clinical trials? Always a consideration but requiring analysis of stated goals, possible side effects, and convenience. Again – too generic to an easy answer but worth a serious discussion with a Principle Investigator. Would you qualify for one after Avastin? As for hormones and docetaxel – worth a consideration under the care of an oncologist who specializes in this.
Question to you: Did you pathology show lymphatic and/or vascular invasion?
Favor to ask: Your situation is atypical. Would you please keep us updated?
Thanks, Dr Krongrad, for your very helpful reply.
I’m happy to keep people updated as events unfold.
With respect to the pathology report:
* Lymph nodes (three L, three R): no evidence of carcinoma
* Neurovascular bundles (right base and right mid):
“No evidence of carcinoma or prostatic glandular tissue”
* “Prostatic adenocarcinoma, Gleason score 5+4=9,
involving the right prostatic lobe and extending
extraprostatically to involve the right posterior
adipose tissue”
* “Resection margins free of carcinoma”
The report also used the phrase “perineural invasion”, but my surgeon reassured me this was normal and didn’t refer to the neurovascular bundles — but I’m still a bit hazy on this. He also indicated that he “shaved the nerve” in an effort to spare erectile function while resecting as much suspicious tissue as possible.
With respect to the four specific questions:
1) Thanks for the validation / reality-check. As a scientifically educated layman, it seems to me that if a phenomenon is very rare, it is more likely (compared to ordinary phenomena) to require a very unusual explanation.
None of my doctors thus far have seemed to understand this reasoning; instead, they simply make recommendations on what to try next.
2) Thanks for explicitly saying you have no explanation. Again, I’d much rather have a doctor say, “I don’t know” than to say (as mine have mostly done), “We can’t guarantee success, but here’s what we’ve set up for you to try.”
As a layman, my first instinct in trying to explain the odd PSA results would be to look for some kind of instrumentation problem. I even managed to find two obscure cases of men for whom PSA assays are invalid because their serum cross-reacts to the human anti-mouse antigen (HAMA) reagents used in the assay.
Even more obscurely, I wonder if I might have chimeric prostate cells: My mother was told early in pregnancy that she was bearing twins, but had only a single birth; maybe I prenatally incorporated some of my sib’s cells?
My imagination is limited by a lack of medical education; isn’t one of the main functions of a physician to come up with plausible etiologies based on previous case studies?
I can’t help feeling that with hundreds of thousands of prostate cancer cases out there, there must be at least a few dozen with a history like mine. What else might we as a group have in common?
3) You read me correctly - I sought out the clinical trial because my mainstream oncologists seemed to be stampeding me into mainstream treatment (immediate Lupron followed by adjuvant radiation) without theoretical underpinning for their plan - or at least, without any that they explained to me.
One doctor said, “Look at the Stephenson study.” I replied, “Yes, I brought a printout with me — here, where I’ve highlighted, is how the cohort of men in the study seem to differ from me. If it is your opinion that I’m similar to them anyway, what leads you to that opinion?” He replied, “Well, there have been other studies as well, but Stephenson is one of the best.”
In my world view, asking people to elucidate their premises and reasoning gives them an opportunity to teach, and possibly to find and correct errors. If a person replies, essentially, “X is Y because A says so, and A is good,” then I know that either my request for premises+reasoning hasn’t been heard or else the premises and reasoning are shaky or unknown.
By the way, thanks for raising a good point that radiation might pose a higher hazard ratio now that I’ve done a bit of system monkeying with Avastin and Tarceva. I’ll dive back into the clinical studies of lung/breast/colon cancer patients to see if anyone’s looked at post-Avastin/Tarceva adjuvant radiation, and I’ll be sure to start toting those printouts with me from doctor to doctor as well. :-)
4) I used “diet” as shorthand for “no beef, no pork, no dairy; low animal fat, low sugar; plenty of soy, cold-deepwater fish, cruciferous veggies, green tea, and pomegranate juice; lycopene 35 mg/day, vitamin D3 4000 IU/day, vitamin E 400 IU/day, selenium 200 mcg/day, resveratrol, quercetin, …” — the usual.
Mainly, though, I was /intending/ to ask a generic question: Is there anything to suggest or rule out one systemic treatment over another? I know I could try one or more of these four modalities, and/or possibly others. What I want is some guideline, some theoretical underpinning, that would help me lean more towards one than another.
Basically, as I see it, my situation crystallizes to this:
* I think that anyone who would recommend treatment that carries a fair chance of mild or higher impact on QoL must first answer the question: What reason is there to think I have any prostate cancer to be treated?
For half a year, results from tests and imaging exactly resemble those from someone who is cancer-free. Not only have my PSA levels not risen, they’ve essentially ignored powerful drugs. The simplest assumption is that there is no population of cancer cells that can be measured, even indirectly, by any diagnostic means. With no evidence of disease and no symptoms, treatment is clearly unnecessary.
* But I also think that anyone who would recommend nontreatment must first answer the question: What distinguishes my disease from those of men with GS9 or 10 who generally develop metastasis within three years of a failed RP?
I also worry that my physicians might have a mistaken reaction to the way I present my case, always pressing for explanations. I’m not out to build a malpractice case, but rather to understand my disease’s etiology and extent (possibly now zero). The way I’ve been trained to do that for other physical phenomena is to generate plausible hypotheses and then adversarially challenge the hypotheses with experiments that potentially falsify them. I gather that most physicians adopt some other methodology, but I don’t know what it is.
Can you suggest an approach that might communicate better, without intimidating or alienating?
What I’d like to say to my physician is this: “We are partners; you have vastly more information, I have a vastly higher stake. I don’t presume to know which of us is more intelligent. Please share with me your premises and your reasoning so that I can examine and question them, thus probing their validity and strengthening my understanding and buy-in.”
Dr. K,
In reading your “update” on Selenium, I was a bit surprised with the rather short treatment you gave to the results of your earlier study. I’ve been taking 200mcg since the Clark data was released. Was the new study a “mega-analysis”? and was selenium examined as a discrete element?.
(I was diagnosed in ‘95, PSA 18.2, Gl 3+3, had 15 mos. of CHT, then 24 EBRT and finally 57 palladium 103 seeds. My PSA has been undetectable since,.over 12 years.) My concern now is whether to drop selenium.
Thanks in advance for “take” on all this.
Many surgeons are prescribing Viagra as soon as the catheter is removed for theuraputic purposes so why aren’t prescription drug plans covering this drug?
*** Arnon Answers *****
Dear Bernie,
Thank you for writing.
I suppose the question first is what rationale is there for early initiation of any treatment. The simple reality is that many men recover erectile function without treatment. The questions are:
Does treatment accelerate recovery?
Does it improve the likelihood of recovery?
Answers to the questions demand randomized trials of treatment vs placebo, without which bias (co-existing risk factors such as smoking and diabetes; volunteerism wherein men most motivated to have erections are most likely to achieve them and also find Viagra) might overwhelm and fully invalidate any inference regarding what is cause and effect. To the best of my knowledge, such trials have not been done. Have I missed it? Are there such studies?
A personal observation: the oral treatments seem to work only when some spontaneous function has returned. Before that, they sometimes cause side effects (headache), falsely raise expectations, and add expense.
A second observation: many men recover very late (second year, third year, even fourth). This fact is not always shared with patients early in their course, which can cause anxiety. It’s worth noting. In many cases, patience is a virtue.
As to prescription plan decision making — this is over my pay grade. :-)
Dear Chas1934,
Our 1996 study was a “patterns of care” study. This means we gave selenium and/or placebo and watched what happened. We did not impose prostate biopsy. What if selenium merely dropped the PSA and did not prevent cancer? Selenium would have concealed, not prevented, the cancer. I explain this in The Ghost of Larry Clark.
The NCI study was not a meta-analysis. It was observational epidemiology. Yes, selenium was examined as a discrete element. In men who took multivitamins, selenium supplementation was associated with substantially increased risk.
I have had PCa for 13.5 years. Aggressive for 8+. I have been in MANY treatments now limited to clinical trials. I have been to Steven Tucker, Robert Amato and now a new research facility in San Antonio where I live. I’m told I can’t take any more Taxotare treatments. PSA is 211 and rising. What chemo treatments if any can you reccomend?
Also, I recently started having significant bone pain in my upper right leg. Morphine patches and Vicodan don’t provvide much relief. Any suggestions?
Amazingly I’m in good health otherwise. Starting a new trialk next week involving attacking proteins and causing them to fold up.
Any help would be appreciated.
Mike
Dear Mike,
Thank you for writing. I agree that a clinical trial is a good direction provided you’re comfortable with the risks and benefits as explained by your oncologist. Please also be sure to speak with your doctor about the pain you’re describing and review your medication regimen, both for baseline and breakthrough pain.
I am a fellow blogger on Word Press and came to your site becuase you have one their fastest growing blogs.
This is just a suggestion - since you are doing well you don’t need my advice - but please bear in mind that on the internet not everybody is American or lives in the US.
Hi Steven. I’m sure Arnon will “pitch in” to reply to you but as one of the “creators” I couldn’t resist.
You are absolutely correct. You might want to visit The “New” Prostate Cancer InfoLink Social Network (see link in left margin) and have a look at the proposed “Country/region-specific groups” forum that we started literally 20 minutes ago!
We are on a truly global mission here, and thanks for noticing.
Mike
Precisely, Mike. We have been pushing the idea that prostate cancer is NOT an American problem, starting with the supert invited presentation by Peter Boyle, Director of the International Agency for Research on Cancer:
http://www.laprp.com/PCMevent/PCM_Nov152007_Putney_Boyle.wmv
Secondly, as you were Asking Arnon, I was posting this listing of who’s from where on our baby social network. Have a look at the countries represented:
Venezuela, Chile, Australia, South Africa, Israel, Dominican Republic, Cayman Islands, Canada, Turks & Caicos, Puerto Rico
Thanks for stopping in. And please do join the network at http://prostatecancerinfolink.ning.com
Situation:
Here is a case that represents many - ‘low’ PSA (4-5 range) pre-biopsy, Gleason 6, prostate volume 32 cc and DRE is Stage T1c. Based on this info and ‘young’ man in 50’s, surgery is determined as the “gold standard” treatment in this case. NO further imaging or testing is done to determine extent of tumor, even after asking about Endo-rectal MRI, PAP, or CT scanning. The man goes to surgery. The the DRE pre-surgery under anesthesia confirms Stage T1c, tissue is ’soft’, etc Nerves are spared, recovery and rehab begin.
Post-op Pathology report says T3a, Gleason 4+3=7, focal extra-prostatic extension, PNI, tumor 20-30 % volume and clear margins. A second Pathologist review then confirms 4+3=7 Gleason, T3a, but now ‘established’, or non-focal ECE, and a positive margin at the extension.
Very quickly this man has gone from low-risk local cancer, selected treatment based on this information, and now is hi-risk, advanced, possibly needing salvage therapy that can negatively impact the sparred nerves and other functions that remain.
Question(s): Understanding that all pre-surgery information points to hi probability for success, how often do big jumps like this occur? Would further testing pre-surgery, or other local treatment be warranted more routinely?
Dear FairRider:
Thank you for writing.
Let us first examine the notion of “low” PSA. In the general scheme of things, I do not like qualitative PSA reports. For example, “normal” connotes that there is no risk, but “normal” PSA of 3 ng/ml is associated with a 25% risk of a positive biopsy.
What you describe is not common but it is not rare. I see cases like this perhaps fives times a year. All of which illustrates the imprecision of our ability to stage from the standard trio of PSA, DRE, and biopsy report. This imprecision is an argument against observation, one that must be tempered with other counter-arguments. Patients often take assurance in “low” PSA and “only a tiny focus on the biopsy,” but these interpretations are potentially invalidated by exactly the imprecision we are discussing.
I do not believe that pre-surgery testing would have changed much. Until a test is developed that has ability to say that cancer is not outside the prostate (a high Negative Predictive Value), we will be left unsure that cancer is inside the prostate.
With all that said, what is still missing is a scientific framework within which to make treatment decisions given pre-surgery data. (Consider that radiation and other treatments never do give us post-surgery data. ) Given a PSA of 4.5, Gleason 6, normal DRE, etc what is the best treatment?
FairRider, I sense some anxiety and maybe second guessing. If so, I do not see a basis for it. I would also point out that many men like the one you describe do well. Please take one day at a time. And as time passes, please write back and let us know what is happening. We will be grateful.
Arnon
Thank you. I read your reply and its refreshing to hear a ‘medical man’ declaring the lack of certainty in science. I know there are many who’ve been ‘upstaged’, but ‘Stage Jumping’ is more of a curiosity.
While I am fully aware that medicine is not an exact science, unfortunately, it appears the ‘business’ of Prostate cancer is having a seat at the Pca management table. As for surgery, the robots are expensive and the practitioner’s results & statistics impact ‘business’. People are ’shopping’ for the lowest surgical margin rates, the quickest recovery, the fewest side effects. That is challenging practitioners to ‘compete’. It’s getting hard for assertive ‘patients’ to walk the path and find ‘do no harm’, when there is so much uncertainty within the claims.
Further, It is easy to fall into a trap of believing one is low-risk because of the numbers. It’s cancer! Who wants think they are the exception? If you are encouraged that you are among the few that have a chance for ‘the cure’ by being in a high probability group for getting all the cancer, the treatment decision gets clouded. Other probabilities need to be aired. Cancer patients are always told to ’stay positive’. But we can’t afford ‘empty positive thinking’.
I AM second guessing myself for not requesting an endorectal MRI or a PAP blood test. From what I read these have value in treatment decisions. We would have most likely chosen surgery anyway, but some type of ‘mapping’, perhaps color-doppler ultrasound may have helped prevent a positive margin. If the first post-op PSA is elevated, hinting at already distant disease, then surgery, and all the loss of functions, may not have been the gold decision. I suspect further studies would have given us a little more information. Cost is given as a reason not to do further testing, and while I agree, there may be others ‘costs’ for not doing a further investigation.
It is further perplexing when 2 respected labs disagree on pathology. I understand there is some subjectiveness in thtis science, but this just points to further study and a need for funding and research.
Sorry to have carried on - perhaps I should be posting in the Advocacy area :)
I am two weeks after surgery.
At this point I just want to comment on a non-medical aspect of this ordeal. More important than the scientific-medical knowledge any one urologist, surgeon, doctor may have is the personality behind the coat. Arnon, is the most human doctor I have ever met. If I had to go through this again, it would only be with him.
Once we are aware of our problem, we are suddenly bombarded with tons of overwhelming information, stressful to say the least for the average non medical person like me. Arnon, cuts to the chase (with an incredible calming sense of humor) and explains in very simple form what is going on.
Dr. Kongrad is “Mentch” therefore he must be a good doctor also. Hope and Ruthy are amazing. If you must to go through this, these is the team to go with DEFINITELY.
Thank you Dr. Kongrad.
Great response!! I wish you well.
I have read a few articles about “needle tracking” involved in prostate biopsies. Is this a valid concern? Is it wrong to assume that its possible to aggrivate and increase the aggressiveness of any cancer found in the prostate with biopsies. Is it true that if you look long enough and hard enough for cancer in the prostate of almost, any man over 50 years of age that you will find it. It just depends on the degree. Thank you for offering a site like this for men who are going through the hell of prostate cancer. I look forward to hearing from you.
Frederick,
On the face of it, I see no reason to believe that needles cause “tracking.” I have head of no cases of prostate cancer implanting in the rectal wall, for example, through which needles traverse. Moreover, tens of thousands of men are diagnosed with needles, are treated, and never have signs of recurrence. This also suggests that needles are exerting no ill effects through “tracking.”
With that said, there is no scientific answer to your question. To validate the concern we would need to diagnose prostate cancer with and without needles, so as to illuminate the contribution of needles to “tracking.” This is impossible because we do not have a means to diagnose prostate cancer without needles.
It is true that if you live long enough, a piano will fall on your head. If this has not happened, you have not lived long enough for it to happen. Get it? The question is teleological. Let’s get back to the bedside …
I hear often that if you live long enough you will have prostate cancer. I don’t know why I hear it. At the bedside, it is not useful. What would be useful would be data that indicates 1) how long an untreated man will live, 2) what an untreated man will die of 3) which treatment, if any, can prolong his life. Our data today are imperfect, to put it mildly.
Thank you for writing.
Dr. Krongrad,
Thank you for your prompt and informative response. I had also questioned if a biopsy could make a cancer more agressive upon penitration of the needle. Thanks again for all your doing. You are truely to the point. I only wish to find a doctor in my area with your dedication and ability to communicate.
Good Afternoon Dr. Kongrad:
I cant seem to find the -mails you have sent me. There is some important information there. How do I find them?
Gil
Hello Dr Kongrad
I had a Da Vinci RP 10 months after a TURP. My surgeon was one of the most famous and experienced in the UK. He said he encountered technical difficulties caused by the previous TURP (loss of landmarks). I had 50 grams removed and am left with nearly 10 grams of prostate tissue which MRI and TRUS seems to show as benign.
I am now back on active surveillance and will have a multi sequence MRI and TRUS plus PSA in late June, plus a biopsy if any suspcion. Current PSA is 0.76 (PSA density 0.08) Post op path showed 0.3cc disease volume.
I regained continence after 4 months and really want to avoid new morbidities with additional treatment. But my surgeon says that if prostate remant has disease we should radiate. A second opinion says HIFU would be better.
My questions are :
(a) have you heard of cases where this amount of tissue has been left behind?
(b) does loss of landmarks sound reasonable after a thorough TURP?
(c) Do you have an opinion (as a surgeon) of HIFU as against radiation for salvage?
Given no SV involvement, no lymph node involvement, 0.3 cc of Gleason 3+3, clear margins I am hoping to be able to stay on active surveillance.
Ted from England
Dear Ted from England:
a) Yes. I have heard of this and about 15 years ago I watched a very experienced surgeon leave prostate behind on a very bloody perineal radical prostatectomy.
b) Absolutely. TURP can distort anatomy. I have done a number of LRPs after TURP and generally it’s a non-issue. However, I will never forget one in which the TURP must surely have been complicated (I had not done it), because the entire pelvic anatomy was scarred and distorted. A most extreme but nicely illustrative case.
c) I would need to know substantially more about your situation before advising about HIFU, radiation, or any other treatment or non-treatment. In any event, I will not be able to make a recommendation in this forum, which is intended for review of generic and broadly applicable points, not for taking care of individuals. I would say that if you are unsure of what to do, as with all other patients you should consider a second opinion. Not with me in this forum, but with another doctor you can sit with and really review.
Thank you, Ted. And please keep us informed (you can do this in the Surgery group on the network; it will be nice to have you sign up over there).
Arnon
I have read that ultra-sensitive PSA levels of < or = 0.01 ng ml-1 are considered “undetectable.” On the other hand, some doctors claim to be using ultra-sensitive PSA tests but use the figure < or = 0.03 as being is undetectable (and do not reference < 0.01). On the other hand, my URO uses convential PSA testing and cites the figure of <0.02 as being undetectable. How might the differences be explained for the ultra-sensitive test results? Thank you.
Hi Harvey,
The word “undetectable” is used clinically to connote that there is no reason to worry or change course. What you are describing is varying thresholds as applied by different clinicians. The differences in thresholds as used by different clinicians is not explains by the availability of ultra-sensitive assays but by the choices of the clinicians.
Incidentally, I think you may be adding extra zeros. In most cases, we refer to <0.1 ng/ml as “undetectable.”
Arnon, do you have any experience with or knowledge of using TDE to relieve hot flashes?
I was diagnosed with PCa 10/05; RP, 12/05; Gleason 4+4/8 (Upped by MD Anderson to 4+5/9), T2C N0Mx; Salvage radiation, 2/07; I have hypogonadism; T <30 ng/dl; on Casodex 50 mg 10/07 to 1/08; DHT, 4ng/dl. I will go on TRT no sooner than 8/09 and maybe not even then. So I’ll continue to be subject to hot flashes for a long time – they are severe from May to Nov.
Phil
Philip,
Thank you for writing. I do not do any hormone suppression in my practice so no experience. Would you please clarify TDE and TRT? Thank you.
Arnon: I suspect TDE = transdermal estrogen and TRT = testosterone replacement therapy.
My husband has been trying to find an injectible that will give him an erection without pain. The straight alprostadil and the tri-mix were both painful to him. Last night he tried bi-mix and was pleased to have a pain free erection. However his penis and testicles were cold. I have heard of this using a VED, but did not know this was a problem with the shots. However, his color was normal-not bluish at all. Is this normal? Unusual-but heard of? Or really something weird?
Thanks for any info you can provide on this.
PS
I have an update which poses a further question. My husband has informed me that his urine was bloody this morning after his shot last night. Is this normal, unusual, a need for concern?
Mati
You are describing signs with which I am not familiar. Cold penis and testicles? Not welcome signs. Blood in the urine? Not welcome either.
Please hold off any more injections until your husband can get very specific and direct consultation with the urologist who prescribed this treatment. I would strongly advise that your husband tell the urologist everything that you have described here.
In addition … would you please keep us posted on the social network? We can discuss side effects of these treatments in the ED group. I think it’s important and that others should be exposed to what you are learning and teaching here. Please consider.
Arnon, thank you for replying. TDE is trans-dermal estrogen. TRT is testosterone replacement therapy.
Philip
I have read about prostate replacement. Now I can’t find the sources. What can you tell me about it. I’m curious and wonder if it would work for my husband. We had a wonderful sex life and his surgeon never consulted with me before or after the surgery.
*** Arnon Answers ***
Sharon, I am not familiar with prostate replacement and cannot think of a reason to replace the prostate. If you find the reference, we can review. As for sex life, there are many forms of sex. I assume you are referring to loss of erections specifically. If so, this is something that can be discussed further.
My husband is a 41 years old and recently saw our family Dr. for a physical. The Dr. insited on doing a DRE and PSA test. The DRE indicated an enlarged prostate but he was told not to worry about it. 2 days later the Dr. called and told him that his PSA was high (4.6) and that he would be referring him to a Urologist for biopsy.
My question is given my husbands age, no family history of PC should we be alarmed? I have read that age specific PSA should be less than 2.5. He is not having any prostate symptoms that might suggest Prostitis. What are the chances that he has Prostate Cancer?
Tori, the chances of prostate cancer as shown by a positive biopsy are approximately 25%. Should you be alarmed? No. You should be informed. When you see the urologist, ask him to verify the information you got from your family doctor and discuss with him the likelihood of a positive biopsy. Ask him to explain in the context of your husband’s overall health what this would mean IF the biopsy shows prostate cancer.
I would hope that with the newly forming scientific board that one or more of the following Medical Oncologists who specialize in prostate cancer research and treatment will be asked to participate: Stephen B. Strum, Charles E. “Snuffy” Myers, Bob Liebowitz, Mark Scholz, Richard Lam, Steven Tucker, Glenn Tisman, Tanya B. Dorff, Celestia S. Higano, Bassam Mattar, Beth Hellerstedt, Oliver Sartor, Robert Amato, Chris Logethetis, and others Israel Barken, Mark S. Soloway, Michael Dattoli, Martha K. Terris, to name a few.
I am surprised that you refer to cryotherapy as an investigational technique. Although I do work for a cryotherapy company, there are two recent events that point to the fact that is is becoming a mainstream treatment option.
1. 10-year data. The long-term rates of biochemical control for primary prostate cryotherapy are comparable to external beam radiotherapy or prostate brachytherapy. This data is actually with previous generation cryotherapy systems.
2. American Urological Association (AUA) recently presented new best practice statements for prostate cryotherapy. The guidelines state that cryoablation is a treatment option for men with clinically confined prostate cancer of any grade and that salvage cryoablation is a treatment option in men who have failed radiation therapy.
In addition, all current systems for prostate cryotherapy use Argon gas, not liquid nitrogen or liquid argon.
I wish you the best of luck with the website.
Regards,
Pam
Dear Pam:
On behalf of the content editors for the site, our exact wording states, “many still consider [cryotherapy] to be an investigational technique at this time.” The “New” Prostate Cancer InfoLink is very careful to take a neutral position on any specific therapuetic option until we have been able to carry out our own assessment of the available data.
With repect to the use of argon gas, you are correct, and the current content will be adjusted accordingly. Thank you for your comments. Dr. Krongrad may also wish to comment on your post.
Hi Pam. Thank you for disclosing your conflicted interest.
You imply an interesting question: can a thing that is mainstream be investigational? Consider tomatoes, which are arguably very mainstream. At the same time, their putative salutary effect is unproven, i.e. they are at best investigational. Tomatos are at once mainstream and investigational. Cryotherapy can theoretically fit the same rubric.
Dear Dr Krongrad:
I am a healthy male in my twenties who is happily living a self-chosen completely celibate life (no ejaculation at all, either with others or on my own). I exercise reguarly (2-3 times a day) and consume a low fat diet with lots of fruit and veg.
Recently a friend pointed out to me that celibacy can increase one’s risk of prostate cancer (based on report PMID 12887469) which troubled me somewhat since I am personally very happy with being completely celibate - I focus all my time on my work which I really enjoy.
Could you tell me what you think of this report? Is it in your view good evidence or has it been discredited? In short, I’d love to know whether it’s likely that by living a completely celibate life I’m increasing my risk of prostate cancer later in life?
Thanks so much for your reply - you’re very kind helping me (and others) in such a generous way! Best regards,
Yazan
Dear Yazan,
I am not familiar with PMID 12887469. Can you post a link to it? Better yet, if you have a pdf we can post it on the social network also for input by the many smart people who inhabit it (http://prostatecancerinfolink.ning.com).
I am aware of no other report that would substantiate, let alone quantify, a modified risk of prostate cancer with celibacy. Let’s start with careful scrutiny of this report and go from there.
AK
Arnon: Yazan is referring to the abstract at http://www.ncbi.nlm.nih.gov/pubmed/12887469
Dear Arnon,
What’s your opinion on PCA3 gene-based test?
Thanks
Peter
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No practical experience. In the one patient in which I ordered it there was no value. What I’d like to see is a study that quantifies the additional informative value of the test. In other words, if I already know the PSA, DRE, and possibly a biopsy report, what more am I really learning? Have I missed such a study? If so, please shoot me a note at ak@laprp.com
I don’t know why you asked. In any event, you’re invited to explain more and get more feedback on the Social Network.
Dear Krongrad,
Thank you so much your kind reply! There a PDF or HTML of the report at the bottom of the page of this link:
http://www.blackwell-synergy.com/links/doi/10.1046%2Fj.1464-410X.2003.04319.x
(click at bottom of page on ‘full text HTML or PDF link - it’s free access. For some reason it won’t let me link directly- sorry!)
Also, there’s a later article by the new scientist here:
http://www.newscientist.com/article/dn4861-frequent-ejaculation-may-protect-against-cancer.html
(And thanks Mr Scott for pointing out the ncbi link!)
I’m hoping that the following line of reasoning are sound:
1). These are only initial studies - we have as yet no real evidence to back up any claim that strict celibacy is bad for the prostate?
2). Even if there IS a link, anyone who prefers a completely celibate lifestyle more than a noncelibate lifestyle could still keep their risk of prostate cancer low by following other prevention strategies - such as eating sesame seeds, tomatoes, regular excerise, avoid smoking/drugs etc,.
As an expert in prostate cancer, do you think these lines of reasoning are sound? Or are those of us enjoying a celibate lifestyle putting ourselves at considerable risk of developing prostate cancer later in life?
I thank you so much for your time and help - this issue has caused me considerable concern. Very best wishes,
Yazan
Yazan
We are talking about an epidemiological study that shows inverse correlation between ejaculation and prostate cancer. This study design cannot validate causal relationship. Is it possible that an unidentied factor, perhaps genetic or congenital, causes both prostate cancer and lack of desire to ejaculate? Sure.
To show that low ejaculatory rates cause prostate cancer one would have to randomize young men to either lots of ejaculation or lack of ejaculation; followup would have to be in decades. Presumably they would have to volunteer, since one cannot ethically force such randomization. Volunteers bring bias: hyper educated, more likely to complain etc. So you’d have a study that is poorly generalizable, likely to hit barriers to recruitment goals, and would suffer from data censoring from off-protocol subgroup crossover (most likely from the celibates to the non-celibates, although one never knows).
I put no value in any suggestion of cause and effect.
Hi Dr. Krongrad,
The site is impressive. Easy to navigate. Various topics covered. I was unable to sign in with this pc. Will try from home.
Thanks!
Dear Dr Krongrad,
My heartfelt thanks for your learned opinion and putting my mind at ease - it is very much appreciated! Thank you so much for your kind service to me and many others! Very best wishes, Yazan.
Dr. Krongrad,
I had an RT a week ago and got my pathology report back yesterday. It wasn’t good.
Pre-op, I had 2/12 biopsy sample positive at 3+4 and 4+3. My PSA was 8.5. I’m 45.
The pathology says I’m now a Gleason 8 with positive margins, no seminal vesicle involvement and “lymphatic invasion present” — which is a disturbing term but one the urologist didn’t bring up despite being asked about lymph nodes.
I’m not sure what to do at this point although my first order of business is to have the pathology slides sent to Jonathan Epstein at Hopkins.
Beyond that, I’m trying to figure out whether I’m a good candidate for adjuvant or salvage radiation therapy.
Any words of advice would be very much appreciated.
Thanks,
Jim
Dear Jim,
I assume you had an RP (radical prostatectomy).
As a first order, I am asking myself questions about your pathology report. For example, what did the pathologist mean by “positive margins?” Were they extensive? focal? cauterized? These are potentially important distinctions. Ditto on the “lymphatic.” I am a little confused by your description and wonder: did the pathologist find cancer in the intra-prostatic lymph or vascular channels? Were these involved outside the prostate? Or was he really talking about lymph nodes? None of this is clear from your report and all of it has potentially important implications.
For example, I have had patients with very high grade cancer (including a 45 y old with Gleason 9 and PSA 17) and a tiny amount of intra-prostatitic lymphatic invasion who have had no evidence of recurrence with no further treatment and on long followup. On the other hand, Messing’s work shows improved survival for men who have androgen deprivation who have lymph node involvement. You need some clarity first.
A second pathology opinion is reasonable but not a substitute for a clear discussion and explanation of your situation by your doctor.
Advice: consider joining the social network, joining the Surgery group, and starting a discussion (+Start Discussion) on “Lymphatic Invasion” using your story as a point of departure. You’re sure to get some thoughtful input.
Dr. Krongrad,
Thanks so much for responding and for pointing out the vagaries in my post. Yes, I had an RP.
I have since spoken on the phone with my surgeon and he explained that the “Lymphatic Invastion Present” didn’t add anything negative to the report — or at least more negative than what was already there. Then again, I’ve found my urologists have been persistently sunny when it comes to prognosis. Anyway, it was definitely not lymph nodes as he didn’t take any. A radiation oncologist I spoke with said he thinks they should always take a few.
In terms of the positive margins, the phrases “Positive Margins” and “Extra Capsular Extension” appeared on the pathology report.
I’ve been swayed by some recent articles on adjuvant radiation therapy, I must say.
I’m meeting with my surgeon tomorrow. If you have any good questions I should ask, I’d very much appreciate it.
Thanks again.
-Jim
********
Jim,
I have had patients with lymphatic/vascular invasion on RP pathology who have done just fine with no additional treatment. That said, this is an issue that I would like to explore in greater detail. I’ll start a discussion on “lymphatic invasion” on the social network. You’re welcome to watch it unfold. You are also invited to join in and keep us updated. I’m sorry I missed your email and would like to know what you learned at today’s consultation.
Dr. Krongrad,
I’ve just joined and thank you for your welcome. I do not follow the football much but I am a social member of the Adelaide Club the ” Crows”. I have a question which you may be able to help with : you would have seen the treatment I have had from my introduction. Would you have any idea if my love life would eventually return to normal. I have stopped Zoladex for nearly 2 years but still waiting.
Regards Brian
******
Brian,
I have seen your post on the social network. You ask a great question with no simple answer. I have started a discussion on the ED group. You can help make it more and more relevant to you by joining in and providing additional information.
AK
Great site.
excelent information
I was diagnosed with prostate cancer 2/15/08 PSA 63, left seminal vesicle involvment, large tumor, MRI 2 pelvic nodes enlarged, and CT shows a retroperitoneal node enlarged.
Bone scan negative.
I have had an indwelling foley catheter before scans were taken and have had a few bladder infections from same.
Question: Should I have a biopsy of that retroperitoneal node? If it is enlarged because of ongoing bladder infection or perhaps something else, I believe I would then be able to get radiation to the pelvis and the prostate which could mean a great deal in terms of survival
Thanking you in advance
Elliott
Hi Dr. K,
I would like to know if you have any information on upcoming clinical trials for the new PSCA vaccine for asymptomatic prostate cancer….OR comments on what you think of the approach.
Thanks, Sam Cox, member
Hi Sam,
I am not familiar with PSCA vaccine. It might make sense to post this on the social network. I can help if you need.
AK
Dr. K,
I had 38 days of radiation to treat my Prostate Cancer 4 years ago. Everything OK until last month when I could not pee and pushing it was so excruciatingly painful. Blood trickled out instead and no urine. Worst pain I experienced for hours I decided to go to ER. Catheter relieved it. Now this “can’t pee episode” happens every so often it is so punishing. My urologist says my prostate varicose veins are dilated. I hate going back and forth to ER for the catheter every two weeks and using Depends everyday. What are my options? Can this be corrected surgically or by meds?
It sounds like either BPH (benign prostate hyperplasia) or radiation cystitis. In either event, one might consider surgical treatments (such as transurethral fulguration) or medical treatments (perhaps a trial of finasteride, which has been associated with reduction of bleeding and retention). The best person to guide this is the diagnosing urologist.
what is the current status of the use of HIFU(high intensity frequency ultrasound) in the tx. of prostate cancer. I understand that it has long time use in europe and canada.is there a proven sucess record? complications?
HIFU has not been approved in the US. The technology changes. Sure, there can be complications.
I am aware of no randomized trials. That is a general problem with prostate cancer treatments. The best we have today are population-based single-arm data showing that early detection combined with treatment is associated with reductions of mortality. In no case have such data reflected the application of HIFU. In the Tyrol studies, for example, we are talking about reductions of mortality with PSA testing and prostatectomy. So when you ask about success, if we accept that reduction of mortality is the aim of prostate cancer treatment and when achieved a definision of success, then no, there is no such record with HIFU.
You can get more information if you enter “HIFU” in the search box in the upper right.
Actually there is an ongoing trial of HIFU vs. cryotherapy in the USA and Canada. For more information interested patients should go to http://www.pcaresearch.com/
Hi, Dr. K,
The National Cancer Institute’s Cancer Risk Calculator says i have a 65% chance of having prostate cancer. How predictive is this calculator, do you think? It seems fairly simplistic.
Hi Martin. If I understand right the calculator you used is the one developed for the Prostate Cancer Prevention Trial data posted on the NCI site. I plugged in the numbers you posted on the Social Network and got 43%. Not sure why we were off.
Anyway … a technical point. Prediction is a yes/no proposition. Probability is an estimation of risk. That calculator makes no predictions. It estimates your risk as based upon the data of men in that study. How valid are those estimates in other populations, including you? Not clear because it’s not been validated that way as far as I know.
Overall, my sense is that your risk given 1) no family history, 2) white race, 3) normal prostate exam, 4) PSA 6 ng/ml, 5) no signs of trauma or infection or prostatitis, 6) age 55 is around 30%.
There is another immediate question: should you have a biopsy? The variables entered into this question have to do with your health. If you are a severe diabetic with multiple sclerosis and are bedbound you may not want to have a prostate biopsy. I am intentionally using an extreme example so as to illustrate to our reading audience that the decision is about more than risk assessment as above. It has to be made in the broader context of things.
I do not know your circumstances and have never met you or examined your prostate. I cannot and am not making a recommendation to you. I am simply laying out a conceptual framework within which your doctor and you can help you to reach an informed decision. This framework is generic and applies to most men, including those who just read this post.
See you on the Social Network. Let us know how you go.
Dr. Krongrad,
Sorry I’ve been out of touch for about month now. In the mean time I’ve gotten a second opinion from Jonathan Epstein at JHU on my pathology. He described it thusly:
“Tumor is present at the inked margin in an area of focal capsular incision.”
Does “incision” mean the surgeon cut through the cancer?
Anyway, I’ve decided that since I’m a Gleason 8 with ECE that I’m going to do adjuvant radiation with hormone therapy.
I’ve already consulted with radiation oncologist Richard Stock at Mt. Sinai and have an appointment to see a local radiation oncologist in a week.
Here’s another odd thing: Recently when I had an orgasm some sticky fluid emerged from my penis. I thought sperm, semen and everything else short of urine wasn’t supposed to come through after a robotic RP!
Thanks again.
-jim
Jim,
There are urethral glands of Morgagni, Littre, Cowper. They make the fluid you describe. With radiation that may cease.
It would be good to have you on the Social Network if you’re up to it. It will be instructive for others to follow your decisions and actions. Link is on left column.
AK
Thanks Dr. Krongrad. I’ll look into it.
-Jim
is there a shot and a pill that you can take that puts prostate cancer that has reached the bones into remission?