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.
SUPPORT 
Search for new and
ongoing trials on the
CTAG PCa web site
Aloha Dr. Arnon,
I know that my prostate cancer will return. (G = 8 & 9; 12 of 12 cores, 4 to 70%; PSA = 8 and 6 months later PSA = 14; started ADT 5/07; EBRT/IMRT 9/07 and 10/07; last shot 4/08; PSA = 0.72 on 01/09; testosterone 1.7.)
My doc says he wants to start ADT again when PSA is 1 to 2. The side effects of ADT were and are still very bad: continuous pain at shot sites, teeth worn down, weak split nails. I do not want ADT again unless there is a clear indication of PCa. Finding the PCa does not seem to be achievable or within the realm of modern medicine. Is this correct?
As I understand it, we cannot detect the returning PCa until it is sufficiently large to be seen on a scan. So there is no location that could be determined for biopsy. So, it is ADT again or wait until the PCa is detectable.
I do not like this position.
Joe
****
Aloha back to you, Joe, and mahalo for writing.
I don’t like the limitations of our technology either. You are quite right that there are limits on what we can know. The PSA is sure sensitive and it does pick up recurrence before a CT, bone scan, or other test can validate it and this is its problem: it does not tell us where the recurrence is and does not tell us about options for localized treatments such as radiation. Which leaves us with generalized approaches, such as the hormone treatments that you do not like.
If you do not go on with the recommendation for ADT, be sure to stay in close contact with your doctor and to stay compliant with protocols for surveillance.
Arnon
Biochemical recurrence after 5 years to 0.56. Doctor 1 recommends waiting for radiation. Doctor 2 says do radiation now. Please give your opinion.What could the side effects be? Thank you.
******
Dear Gerry
I assume you are talking about biochemical recurrence after radical prostatectomy. Not knowing your medical and social status I am somewhat reluctant to give an opinion. There is surely some risk with pelvic radiation, including of urinary urgency, bleeding, pain on defecation, and fatigue. Depending upon your medical situation, age, and such, there may be reasons to monitor and not treat. On the other hand, there may be every reason to treat now, not later. Again, I would have to know your status to render an opinion. Please discuss your situation in light of your overall condition.
Arnon
Hi Arnon,
I’m 60, caucasian, with no family history of prostate cancer. However, in one year, my PSA went from 3.0 to 5.4. I read about PSA velocity of more than 2.0 being an indicator of aggressive cancer, but was confused by the arguments. I asked my urologist if there was any way to determine aggressiveness from PSA scores and he said no. He then told me that a rapid rise in PSA was probably a sign that it was not caused by cancer because cancer-caused PSA velocity is slower. Since this contradicted what I read, I’m even more confused. Any thoughts? Thanks.
**************
Dear Thomas:
1) PSA can rise and fall for many reasons including cancer and infection.
2) The rate of rise is suggestive of cause. Fast rise (and fast fall) is consistent with infection, trauma, cystoscopy.
3) It is not at all clear that the risk of a positive biopsy as assessed from the absolute serum PSA is in any way moderated by calculation of velocity. Here is one entry on the subject.
4) With a PSA of 5.4 ng/ml a man generally has a 25% risk of a positive biopsy (showing unknown amount and grade of cancer). The question is if given everything else in your life (smoking, obesity, diabetes) you want to know if you have prostate cancer. If the answer is yes, then a biopsy is useful.
Hello Dr. Krongrad,
Thank you reviewing my question. Basically my question is regarding what you think is the best treatment choice for my prostate cancer and if I should get a second opinion. I was diagnosed in January of 2009 with one core out of the ten showing 55% cancer. My Gleason score is 3 + 3 and stage is T1c. I will be 60 in July of 2009. My urologist is recommending robotic surgery to have the prostate removed. He will also attempt to spare the nerve bundles. Since I have not had a second opinion except for the meeting with a radiologic oncologist and a consult with my family physician, I am having a hard time making a decision and having a problem communicating my questions with my surgeon. He is somewhat dismissive of my questions and I walk away without clear answers. Please advise on how I should proceed. Any advice would be much appreciated.
David:
Three issues:
1) Which treatment? This has to do with competing risk analysis. Without knowing your health nobody can really advise you on even the simplest question of should you be treated. This recommendation cannot be made by public blog but can be made by private consultation. Which leads to …
2) Communication. You cannot communicate with your surgeon. This is preop. What happens post-op? Would you want to be not communicating with your surgeon post op?
3) Doctor selection. There are many variables in selecting a doctor. If it’s a surgeon, as you are discussing, then here are my thoughts on how to pick one: http://prostatecancerinfolink.net/tips-tools/pick-surgeon/
You keep asking about a second opinion. Is this in itself not a reason to get one? Why would you not?
Dr. Krongrad:
I am wondering if you have had any patients present with pleural mets and a solitary lung lesion who have not had any bone metastases?
I am 12 years post seed implant in Seattle and external beam radiation in Denver. Had Gleason 6, T2c lesion when treated at age 56. Two bone scans are negative but a PET scan found the LLL lesion. Surgeon went in to remove it and found my pleura covered with small mets, all prostate cancer.
Have just started ADT but trying to find if others have seen this presentation since none of my care providers have seen it. My PSAs were all <0.1 for 8 years post-treatment but began a slow rise. Just hit 10 at the time of my lung surgery but doubling time has decreased to 3-4 months now.
Dear Bob,
I am sorry to hear about your situation. It is never fun being the only one of your kind and it appears that this is your situation. No, I have not seen this scenario, though prostate cancer can in fact go anywhere.
How do they know it’s prostate cancer? After all, there is evidence of PSA production in lung tissue. Is it at all possibly a lung cancer?
Arnon
Dear Dr. Krongrad:
I’m 76 years and have just been diagnosed with prostate cancer. I have a 6.7 PSA, 3 + 4 = 7 Gleason score and a stage ll classification cancer. The cancer is localized in the prostate. I’m considering Cyberknife therapy. What is your opinion? Thanks in advance for your response.
Best wishes,
Ron
_____
Dear Ron,
First of all I would really like to know much more about your general health. In other words, the first question is not how to treat but if to treat. If you are in failing health it may be that simple surveillance is a right choice. You get my point: the question should first be answered in a broader context.
Secondly, assuming the choice is to treat, the question next is how to treat. Radiation is one option in early stage prostate cancer. If you are a clinical stage II (I am assuming cT2 or cT1; you can confirm with your urologist), then this might be very reasonable. As to which type of radiation, I would defer to the radiation oncologists. Among the critical considerations is not only which approach but who should treat you. Remember that radiation success is partly dependent on the doctor doing the treating. To this end you may wish to read How to Pick a Radiation Oncologist. You may also find interest in some of the posts relating to cyberknife. Here is one example.
Arnon
Dr. Arnon:
Does the prostate gland ever actually heal itself with time from the impact of the core needle track where the tissue has been removed in a prostate biopsy? From what I have seen on the internet the needle track never appears to heal itself but rather remains as a needle track with varying levels of cell necrosis that never repairs or resolves itself with time. What are the currently known long-term ramifications of this on the organ’s ability to function.
Brady
________
Dear Brady,
Two separate questions.
1) The prostate has blood supply and like all organs when healthy it can heal. So a traumatic injury which naturally causes some cell necrosis is soon overcome with normal scar formation.
2) The prostate’s function is a bit of a mystery in that while we know what it does — it makes part of the semen — we do not know if it is necessary. So two sub-answers: a) we know that biopsy does not interfere with semen production and b) we don’t know that even if it did it would have any clinical meaning.
Arnon
Arnon,
Here is a not-so-obvious case on which your opinion will be appreciated. A healthy and active 60-year-old patient has PSA 6, T1c, Gleason 7. Eight of 12 biopsy cores have cancer. The Partin tables predict about 50% probability that cancer may be in the surrounding tissue but CT and bone scan show no metastasis.
What would be the preferred treatment options and why? If surgery is preferred, can Da Vinci match traditional open surgery to eradicate cancer the first time?
Silvia
****
Dear Silvia,
Thank you for writing. The situation you present is actually very common. Let’s go through some issues:
1) There is absolutely no surprise in the CT and bone scan findings. First of all, the nomograms relate largely to micro extension, which CT and bone scan cannot pick up even if they are there. Secondly, there is a 50% probability that even micro extension is not present. No surprise at all.
2) The treatment preference is largely set by the patient. In other words, we do not have randomized comparisons of such standard treatments as radiation and surgery by which to provide a scientific framework for a decision. The patient really should spend time learning about the treatments, including their standard applications, logistics, and side effects. He should meet doctors who could give them to him at a high level of ability.
3) Da Vinci is but a remote controlled sewing machine. Can it match a directly held scalpel? Sure. In my hands Da Vinci patients do as well as laparoscopy-no-da-vinci patients who do as well as open surgery patients, though with less bleeding and pain. The key question is not tools but the surgeon who’s wielding them. Ask yourself: is it the club or the Tiger Woods that wins the matches? Focus on the surgeon, not on the gizmo. Do not let go of this question: who is the surgeon?
Arnon
Dr Arnon:
If you are scheduled to have a prostate removal or part of it [that contains] cancerous cells, and after the MRI scan they have prolonged the operation, is this because the cancer was found in other areas too?
Dear Nick,
I have no way to know why the operation was postponed based upon what you are presenting. Maybe your surgeon can explain this to you. Ask him.
Arnon
My husband had an elevated PSA at age 49. The urologist recommended Flomax and a biopsy. The biopsy was done in the office without any discomfort. 24 hours later he developed a high fever and was admitted with sepsis and the bug was E. coli. After 5 days of tobramycin, he was discharged with Flomax, Avodart, and 1500 mg Cipro for 10 days. After finishing the Cipro, he was getting his strength back. On day 21 out from the biopsy, he developed a fever again. Back to the urologist and he has a major UTI. Outpatient IV tobramycin for 10 days along with Levaquin 500 mg. Cultures came back with sepsis again and UTI all with the same E. coli bug.
We are early in this process but we are now hearing 90 days of Levaquin followed by 90 days of Cipro. Should we be seeking a second opinion at this stage of his relapse? And by the way, there was no cancer in any of the 12 samples. I’m pretty sure this isn’t a normal recovery from a needle biopsy. What could have happened?
Dear Katidyd,
Thank you for writing.
First of all, the prostate is a dirty organ. It is a repository of bacteria and viruses, for which there is usually no pre-operative evidence (click here).
Secondly, bacteremia and sepsis are known complications of prostate biopsy. For a look at another and rather dramatic case you can click here.
You are surely within your rights to seek a second opinion. However, what you are describing is a situation known to any doctor who does biopsies. It should also be something that has a relatively straightforward solution.
Arnon
Hi. I need to understand the PSA levels. My brother is 65 years old and has been told that he has prostate cancer. His PSA level is 10. What does that mean?
Dear Rose,
I am sorry for the delay.
PSA is prostate-specific antigen, a protein made in the prostate. PSA “leaks” into the blood stream, but more so with some conditions, including cancer. The higher the blood PSA the more likely it is the man has prostate cancer. For a man known to have prostate cancer, the higher the blood PSA level the more advanced the cancer is likely to be.
These are very general rules. No PSA level can specifically say if a man has prostate cancer or if his cancer is at a specific stage. For this, one needs additional tests, including biopsy (it sounds like your brother has already had one) and scans of various sorts.
A PSA of 10 ng/ml cannot be interpreted in a vacuum. To known its meaning to your brother a lot more information is required: his age, his health, the cancer grade, the cancer stage, and more.
Thank you.
Arnon
I am 62 years of age. I had a radical prostatectomy in September 2005. For the last 3 years my PSA has risen. In February of this year it was 0.6. I had it tested again on May 14th. My PSA has gone down to 0.4. Can you explain this?
John,
PSA fluctuations are common. For this reason, we tend to look at patterns in a post-op situation. A steady rise over 3 years suggests one thing, and a temporary quick rise and fall another. You should review your pattern with your surgeon and see where to go next.
Arnon
My husband is 43. He’s had two bouts of prostatitis that have seemed to respond to antibiotics. He had two PSAs done in January. The first was 5.8. They didn’t tell him not to ejaculate within 24 hours before the first draw, so he had a second done a few days later that came back w/ a PSA of 6.1 and a fPSA of 12%. Based on that they did a biopsy that showed 11 clean cores and one core with ASAP cells, labeled ’suspicious’, foci of asap.
We were advised to wait 3 months to have another PSA, and depending on those results another biopsy immediately or in another 3 months. We went ahead and had another PSA drawn at 6 weeks, which came back lower, 4.63 (good news), but the fPSA was also alarmingly lower, 9% (though the PSA/fPSA came down EXACTLY the same percentage). Does this mean the fPSA decline is explained by a change in volume of the prostate rather than an increase in bound PSA — making the decrease in fPSA a statistical artefact rather than a true indicator of increased risk?
Other history, his father was treated for PC at age 65 (and seems fine today at age 76) and his mother, her twin, his first cousin, maternal grandmother & great grandmother all had breast cancer. On the other hand, he’s had four normal DRE’s in the past 3 years.
Here’s my question: Are we moving fast enough to get a diagnosis that would allow a cure? Nothing I’ve read is reassuring that we can be sure that (a) he doesn’t have PC today or (b) that we can dismiss the possibility of it being a high grade, aggressive cancer. What do you think of the PCA3 or PCA3Plus tests as diagnostic tools? Are there other diagnostic tools we should be pursuing?
My worst fear is that his urologist knows that in a guy so young, it’s inevitable that it’s a high grade, lethal cancer and that he’s delaying treatment to give us a little more time before we enter the phase where he’s meaningfully debilitated by treatment on the way to dying before the age of 50. My more reasonable fear is that we’re going to screw around and let the cancer extend beyond the prostate, making the treatment much more invasive, the recovery much less complete, and the possibility that he’ll still die from PC much, much younger than he should much, much higher!
Why would we be advised to go so slow when the risks are so very, very, very high? If 30k men a year die of prostate cancer, clearly the existing protocol isn’t getting everything right.
*******
Tracy
You have very correctly assessed that there is uncertainty at every step and that our tools are imperfect. What you have also assessed is that your young husband’s family history of prostate and breast cancer along with his PSA and atypical small acinar proliferation (ASAP) have put him at a very real risk of having prostate cancer. That assessment is moderated by two more facts: 1) it is very possible that he does not have prostate cancer and that 2) if he does have prostate cancer it is in an early stage.
In such circumstances as your husband’s I have at times advised my patients to repeat the biopsy. This is a relative recommendation, not absolute. On the one hand is the idea that he has an approximate risk of 50% or so of a positive biopsy in the next year. On the other is that he has an approximate chance of 50% of a negative biopsy in the next year. If he is not only young but also very healthy then the argument for a biopsy sooner rather than later becomes more pronounced. This is something he can discuss with his doctor.
Arnon
Dr Arnon:
I had my cancerous prostate removed in 2005. After the operation my PSA flat-lined at 0.04 and stayed that way for 1 year, and then the PSA climbed to 0.15. I was given 33 radiation treatments and the PSA returned to 0.04 and stayed there for 9 months. At the next 6 month PSA check it had gone back up to 0.07, and 3 months later the PSA was 0.09. I don’t know how long I should go through the “wait and see” phase or at what level the PSA should go to before I get more treatments. I don’t even know what type of treatment I will get, but suspect it will be hormone therapy. I am 72 and have additional heart problems. Thank you for any information you can give me.
Thank you
James Frush
Hi James,
Thank you for writing.
A PSA is a blood test and not a disease. So we really do have to look at the broader perspective you invoke. To make any decision you really have to involve your entire medical team, including your cardiologist, because any decision for active treatment can lead to potentially important side effects. Hormone treatment, as one example, can cause mood dysfunction, lethargy, and bone loss. You’ll want to discuss these with your cardiologist before you risk them.
I would also suggest a diagnostic consideration. For example, a bone scan. This is so if you have hormone treatment (to be sure your’re not risking “flare” in teh presence of a bone metastasis) and if you are not having hormone treatment (to be sure you’re not under-treating a bone metastasis). In any event, something to discuss with your medical team.
Arnon
Every year I have a Vantas implant. After my last blood work was reviewed my PCP mentioned I wouldn’t need to replace the Vantas due to a near zero PSA level. Is this possible without risk?
Tom,
You raise the key question: what is the risk of going off treatment? The answer depends partly on the need for treatment (a reflection of your Gleason score, general health, etc) and the likelihood that you have achieved permanent suppression (which can happen, through usually after more than a year of active treatment). I would encourage you to review these issues with your medical team
Arnon
Dr. Krongrad,
I recently heard the term, “ultra-PSA” in reference to a more refined(?) test than the standard PSA. What is this, please?
Also, please enlighten me on EPCA-2 levels??
My husband had robotic surgery April 14th. His first post-op PSA at 6 weeks, was “below 0.1″ His next PSA is scheduled in 3 months. I can supply all data from the surgical patholpgy report if needed.
Thank you,
Sincerely,
Judy
Hi Judy,
PSA is a protein measured in the blood. There are various assays with which to measure it. Some are more sensitive than others. Do we want maximal sensitivity? I ask because first of all PSA is produced by things other than prostate cancer, eg normal glands of Littre. To measure all PSA is to measure things that are distracting too. I also ask because all tests suffer from some limitations in specificity, such that all begin to pick up “background noise” at super-low levels. I have never really found any good use for ultra-sensitive PSA tests. They do tend to give patients something to obsess about but they really do not alter clinical decisions.
EPCA-2 is a new “marker” proposed to help distinguish malignant from benign prostate tissue. This is not a task your husband faces for the simple reason that he has been already diagnosed and treated for malignancy.
It’s good to hear about your husband’s PSA of <0.1 ng/ml. That is where you'd like to see it after treatment. And yes, it makes good sense to check it periodically with the input of his doctor.
You may want to join the social network, where many of these issues are reviewed on a regular basis.
Thank you.
Arnon
Dr. Krongrad:
My prostate cancer was diagnosed in 1992 and I had external beam radiation. My PSA stayed below 1.5 till around 2000 when it crept above 3.0 ng/ml and I was talked into seed implants. This lasted lasted till about 2005, then the PSA crept up again, and so I started getting Lupron shots and my PSA went to 0.3 and has been that way since. I’ve been off of Lupron for 7 months and the PSA is still OK at 0.3. My question is that I was told by my urologist there’s too much scarring from radiation to have my prostrate removed now! Is this a valid statement now at this time?
Thanks for any answer or comment.
Dear Ron:
You are talking about a salvage prostatectomy, a radical prostatectomy done after another primary treatment has failed.
Salvage operations are at times more difficult than “virgin” operations because the primary treatment — radiation, brachytherapy, cryotherapy — has had an effect on the surrounding tissue. As a consequence, patients are exposed to greater risk of such complications as incontinence and injury to adjacent organs such as the rectum.
There is no way to know precisely how much the primary treatment has effected changes that are problematic. I have done salvage prostatectomy after radiation, seeds, and cryotherapy and every case was different. One was just incredibly difficult.
In the setting of uncertainty regaring the precise effect of primary treatment we throw in the ambiguity of “too much.” When is risk “too much?” And who decides? And when is it not worth taking? Here too there are not black and white boundaries. One can tilt the balance — the patient is 80 y old and in poor health argues against taking surgical risk — but not set the balance. Only a patient fully informed of his overall health, his prostate cancer, and the risks of salvage and the risks of doing nothing can decide if the risk is “too much.”
My opinion.
Arnon
Bob,
Thank you for writing. I will answer your questions below. However, let me first clarify that I am not your son-in-law’s doctor. I am missing considerable specific detail and have not examined him. Accordingly, I will provide more or less generic structure within which perhaps you and he can begin to get answers relevant to his condition.
Arnon
My 45-year-old son-in-law has been diagnosed with T2a prostate cancer: his Gleason score is 6 and his PSA is 5.2. Our research leads him to believe that surgery is the appropriate form of treatment. However, our research leaves us wanting more specific/quantitative information about the prospects for particular side effects.
We are hopeful that someone familiar with available/credible databases can offer quantitative tendencies (e.g., frequencies or probabilities) for patients in his age group and with similar staging conditions. For example:
(1) Relative to sexual function: What is the likelihood for full recovery without drugs such as Cialis? What is the likelihood of full recovery with the aid of drugs such as Cialis?
“Sexual function” is a term covering a broad range of specific functions that include intimacy, libido, erection, ejaculation, fertility, and orgasm, each of which is to some extent separable from the rest. Prostate cancer surgery can affect them to varying degrees. For example, radical prostatectomy causes infertility in all cases but loss of orgasm in few if any cases.
Assuming you are asking most specifically about erectile function, I will further assume that you are asking about the likelihood that he will achieve erection adequate for penetration after surgery and when. To answer this question one really must back away from surgery and examine the broad medical and psychosocial context: age, illness (diabetes), smoking, obesity, depression, stress at work and home. All these color our assessments of expected current and future function.
There is a very specific question about surgery and its individual effect on erections. Here again we must back away for a moment and ask about the cancer. This is because it may or may not be sensible to save the nerves, which can in itself change the likehood of regaining erections. So if there is a lot of this Gleason 6 in this young man it may be risky to save one or both nerves. And conversely, of course, it may be smart to save one or both nerves. This question must then be placed into the general context above as we seek to assess the projections into his future.
(2) Relative to escalating PSA and the need for remedial treatment: What is the likelihood that the remedial treatment will involve radiation therapy? If the follow-up treatment involves radiation, what is the likelihood that such treatment will produce impotence in those who were fully potent before radiation therapy?
It is not clear that he will have escalating PSA. It is not known what the pathologist will find. Without these answers there is no way to assess if he will ever need additional treatment. As a rule, additional treatments may include radiation and hormones, both of which can reduce erectile function.
(3) Relative to incontinence: What is the likelihood of suffering mild-to-moderate incontinence? What is the likelihood of suffering more severe incontinence?
The likelihood of post-prostatectomy incontinence varies inversely with age: young men have less of a problem than old men. His overall risk of long-term incontinence would seem to be relatively low. Like most men he will almost surely have some short-term incontinence.
You have asked a number of excellent questions. Your son-in-law is lucky to have such insight on his team. As you go forward remember also that what you really want for him is a surgeon with a LOT of experience, focus, and sensitivity.
Arnon
Dr. Arnon:
I am a 70-year-old white male. I had my prostate removed 12 years ago, and for about 6 years after that my PSA stayed at <0.001. Since then it has been slowly climbing to 4.7 (from 2.7 six months ago).
I had a Prostascint scan 5 years ago and the results were negative. About 3 years ago I had a "PET" scan and it was also neg. Just last week (June 15 2009) I had another Prostascint scan and the results were: "Negative study for metastatic prostatic carcinoma" No abnormal uptake is noted.
I had an appointment with my urologist yesterday and asked him why the scan did not show anything when the rise in PSA indicates that something is going on? I also asked him what my options are and he said: (1) I could do nothing and just wait another year or so and have another scan, or (2) I could go to a radiation oncologist and receive radiation in the area where my prostate was.
He was concerned that if I did not try the radiation treatment to see if it would stop the rise in my PSA or lower it, then by the time we found out where the problem is with the previous type tests, the cancer may have metastisized to other areas and radiation would not longer be an option?
Please advise (or suggest or whatever you are allowed to do).
Thank you
Bill Stevens
************
Dear Bill,
I apologize for the delayed response.
As a first step I would want to know about your general health. I know you were born 70 years ago but are you overweight, diabetic, smoker, epileptic, fit? I would want to know those to gauge your likely survival time independent of prostate cancer and to gauge your ability to tolerate radiation. If you are quite ill, then the argument against early adjuvant (additional) radiation is fairly strong.
Your PSA is on a slow course up. This argues that the likely site of recurrence is in the pelvis, as implied by your doctor. However, it is remotely possible that it is not. Thus, to move forward with radiation, if you do, is to take on the very small risk that it is a treatment that is mis-targeted. This relates to your question about the tests: They are not infinitely sensitive and cannot compete with the PSA blood test at detecting early recurrence. On this subject, I would consider a bone scan.
There are no absolute rules on when to start (if you start) adjuvant radiation. At 4.7 ng/ml you have hit many doctors’ threshold but I have seen patients go for many years with elevating PSA, no treatment, and no clinical sign fo recurrence. The precondition for observation is that there be observation, which means periodic testing with such tests as bone scan. The last thing you’d want to do if you are observing is miss a new metastasis in the cervical spine. The last thing you’d want to do is ignore a new back pain. etc.
Good luck. And please consider joining us also on the network.
Arnon
Dr. Krongrad:
My husband’s post-op robotic prostatectomy pathology report showed Gleason 4 + 3 = 7; surgical margins: positive, rt. posterior, 1 cm in linear length; extraprostatic extension: positive (rt. posterior, unilateral extensive); seminal vesicles: negative; 4 lymph nodes: negative; TNM pathological stage pT3a. First 6-week post-op PSA was < 0.1.
I understand there is debate as to whether radiotherapy should be instituted at this time. Next PSA due on September 1 (3 months after the initial PSA ). What is your opinion regarding radiotherapy and timing thereof?
Sincerely,
Judy Yoakum
*********
Judy, please see the answer to Bill that I just posted and the discussion on the network (click here).
Dear Dr. Krongrad:
I am 76 years old, in good health and exercise regularly. I have prostate cancer and am currently undergoing IMRT external radiation — 27 days to date. When diagnosed I had a PSA of 6.7 and a Gleason of 3 + 4 = 7, stage II. I am scheduled to have HDR brachytherapy on July 20th after my final external radiation treatment on July 6th. I have concerns about the side effects from brachytherapy vs. external beam radiation — primarily incontinence. Is the risk greater with brachytherapy than if I continued with external radiation which is an option I have?
Thank you for your response.
Ron
*******
Dear Ron,
Sorry for the delayed response.
To the best of my knowledge there are no data to suggest that the risk of incontinence varies as a function of how radiation is delivered. If you find otherwise, I would appreciate you letting me know.
Thank you.
Arnon
Dear Arnon:
Thank you for your response. The web site at http://www.brachytherapy.com addresses the issue of incontinence and radiation therapy.
Ron
Doc Arnon:
I am 47 years old, 5′11″ and 120 lbs (no laughing please). After having a MRI for back problems (arthritis) and while going over the results with my Doc, she started to ask about how I was peeing and such and then did a DRE (something I could have gone years without having) and got sent for a PSA test which came back at 3.9. Now I have been doing a lot of reading since and find that a score from 0.01 to 2 is what I should have. Is a 3.9 score something I should be worried about after reading about many others with a lot lower scores having PC and the side effects!!!?
Dear Stephen,
A PSA of 3.9 ng/ml is associated with a 25% risk of a positive biopsy (a biopsy showing cancer). This is absolutely something you should be discussing with your doctor, along with any possible implication about the DRE findings, family history, and any other related features of your case.
Arnon
Hi Arnon,
Firstly, I want you to know how very much I appreciate The “New” Prostate Cancer Infolink. It is wonderful to have this support. I admit to still trying to find my way around, comfortably!
I found your discussion regarding PSA tests very interesting, esp. the point of possible obsession with the ultrasensitive PSA findings. I could very easily be one of those who would obsess!! Thanks for offering your point of view. We will also definitely keep in mind the suggestion regarding a bone scan if PSA rises. I appreciate your reference to keeping first things first, kind of not jumping into things prematurely, and taking one step at a time.
Thanks again for this great networking site !!!!
Regards, Judy
After “seeding” of the prostate, does the radioactive content of the seeds leech into urine or feces, and is contact with those two things dangerous? thanks
Dear Dean,
The “seeds” are radiactive and will radiate the urine and feces. However, if the “seeds” are properly place into the prostate by a skilled team, they will not be in the urine or feces. As such, and because they are the one and only source of radiation, the urine and feces will not be a source of radiation. As the urine and feces moves away from the prostate they will be subjected to less and less radiation from the “seeds” in the prostate. The only source of potential danger is the “seeds” in the prostate, not the urine or feces.
Arnon
Has abiterone got another name?
Is it being trialed at the Christie?
Thanks
—-
Dear Ms. Ashworth:
Since yours is not a medical question (and Dr. Krongrad might not even know what “the Christie” is), I have take the liberty of responding on his behalf.
Abiraterone acetate is also known as CB7630. Clinical trials with this drug are being conducted in the UK, but our understanding is that ongoing trials are fully enrolled.
Your best option to learn about potential new trials of abiraterone in the UK is to contact the office of Dr. Johann de Bono at the Royal Marsden Hospital in Sutton, Surrey. They should be able to advise you of any new trials scheduled to begin in the UK.
Dr. Arnon:
I have been diagnosed with prostate biopsy on the basis of a DRE, which indicted a slight enlargement/hardening of the right lobe. My PSA is 0.52 which corresponds to the level it has been the past few years. The biopsy indicates cancer having a Gleason score or 9 in the right lateral apex and right lateral base. Does this make sense given the low PSA? Should I request that my doctor obtain a reading from a different laboratory, or have another biopsy performed?
Dear Lloyd,
Thank you for writing. I fully appreciate that you are trying to make sense of a Gleason 9 diagnosis and to double check the findings. I would too.
Please remember that PSA is not a disease. PSA is but a marker of risk of positive biopsy. At a level of 0.52 ng/ml, it marks that the risk of a positive biopsy is low, perhaps on the order of less than 10%. This means that fewer than one in ten men will have a positive biopsy, not that no man will have a positive biopsy. There is nothing nonsensical in a positive biopsy with a low PSA. It happens. In this case, it happened in the setting of another marker of positive biopsy, the DRE. The positive biopsy makes sense.
Yes, at some point, perhaps now, it makes perfect sense to request that the slides, upon which all treatment decisions will be based, be read by an independent laboratory. If there is any doubt, a second opinion is in order.
As for another biopsy, it’s tricky. If there is any suspicion that the slides are not from your prostate, then yes; but why would you think that? If this is not under suspicion, and the biopsy is adequate (click here to see more on adequacy), then I would not see any reason to repeat the biopsy; to repeat is to cause inconvenience, discomfort, delay other potential actions, and potentially cause confusion.
My 13th LRP patient had a Gleason 8 in the setting of a palpable nodule and PSA of 0.5 ng/ml. I remember him as 13th because this is how he refers to himself and his jokes about it are part of the reason I remember his case so well. My 13th was almost 10 years ago. Which is to say that a 52 y old man with Gleason 8, nodule, and PSA of 0.5 ng/ml treated surgically is alive and well and joking with no evidence of disease nearly 10 y on.
Get yourself staged, starting with a “baseline” bone scan. Then put all the information into your context: age, general health, personal situation … and go from there. Find someone smart who you can talk to about all this. And if you need anything at all please feel free to write back.
Arnon
My husband has been taking Propecia 1 mg for some time (decades). We knew nothing about its lessening PSA scores until I researched it after his dx of PC. I have read some interesting articles: both that it may have treatment implications and that there may be a “treatment effect” which make intermediate cancers appear more aggressive. My question now: Husband has had a RP with Dr. Manon in Detroit. Final report:T3a, 1 focal positive margin, Gleason 7, no mets, lymph node or seminal vessel involvement. We are monitoring PSA. How do we know, and account for the issue of Propecia possibly suppressing PSA reading? Thank you, Claire.
Hi Claire,
Thank you for your question.
You can pretty much know that Propecia is suppressing PSA, if there is any around to be suppressed. In other words, you know that you are evaluating postop PSA in a hormonally artificial environment. The question is if this matters. To this I have no answer. Specifically, I cannot recall a study on the question of Propecia and its clinical meaning in the monitoring of a post-op patient. Instinctively, I feel somewhat uncomfortable distorting and potentially concealing important clinical clues in the future. Instinctively, I would want your husband off any and all hormonal treatments so as to get an unadulterated view of his situation.
Arnon
Dr. Arnon:
I am 8 weeks after RRP. I am 56 years old, in good health; Gleason 4 + 3 and tertiary of 5; T3a with a focally positive margin; post-op PSA undetectable. I am inclined to adjuvant RT in light of the worrisome pathology. Radiation oncologists are recommending hormone therapy along with RT. I am not so attracted to the additional treatment. Do you feel that there is a significant advantage to doing the ADT along with the RT?
Dr. Arnon:
I am 62-year-old with recently dx’ed Gleason 8 & 9, PSA 5.32 at time of biopsy, and with perineural invasion and ECE on one side. My surgeon proposes da Vinci surgery and states he will remove entirely both the nerve bundles and the lymph nodes. I am concerned that nerve bundle removal will adversely impact my prospects for post-surgery continence and that lymph node removal might result in lymph fluid build-up in testicles and legs/feet.
I am dx’ed separately with hypogonadism and I experience many side effects associated with low testosterone: depression, insomnia, lassitude, ED, cognitive defect, poor executive function. Accordingly I declined to pursue my doctor’s script for hormonal ablation, e.g., for Lupron and Casodex. As an alternative to da Vinci surgery I’ve separately looked closely at proton beam radiation therapy. The proton doctor stated that if I decline hormonal ablation prior to being treated with protons, l will lower my chance of recovery from 80% to 50% (which he defined as the likelihood of no relapse within 5 years.) Any thoughts?
********
Dear Lynn,
Thank you for writing. Yes, I have a few thoughts.
First of all, the gizmo is not the issue. What matters to you is the surgeon, about whom you have shared nothing. You are dealing with a serious situation and you want a serious surgeon, one who does work primarily in prostate cancer surgery. Which gizmo he uses should be his decision.
The likelihood of a obstructed lymphatic drainage is vanishingly small. That is an issue with other forms of lymph node dissection, but not with prostate cancer related dissection. As for incontinence, that risk varies inversely with age and generally shows poor correlation to nerve preservation or not. Contrasted with incontinence, erectile dysfunction does show a correlation to nerve preservation.
If you are hypogonadal, I wonder how much lower your testosterone could be. This partly depends on where your testosterone is at baseline.
There are some data to show improved survival (not “recovery”) with hormone therapy in advance of radiation. Again: How much lower could yours be given hypogonadism?
To the best of my knowledge, there are no good data to show that hormone therapy matters with surgery.
You’re invited to also join our social network. Your situation best fits into the Primary Issues group, since you are diagnosed but not yet treated. If you like, you can +Start Discussion in that group’s Discussion Forum. Topics can range from which treatment to choose to the effect of hypogonadism on choice of hormone therapy. If you go and get lost, feel free to holler and I’ll help you navigate.
Arnon
I am 62 years old and I was diagnosed in 2006 with prostate cancer. My urologist performed a robotic radical prostatectomy in late June 2006. Gleason score was 2+2.
I still have some incontinence when sneezing or coughing. Erections are not sustained for any length of time.
My surgeon says that research now says it may take up to 4 years for recovery of these functions rather than the 2 years that was the standard at the time of my surgery. Is this true?
What can I do to to help my situation?
******
Hi Roger,
Yes, it can take some time for functions to return. I have heard of return of function at 4 years.
The specifics of what you can do are varied. It’s best to review them with your doctors, including a review of items like diet, fluid intake, rest, medications, and the like.
Arnon
Dr. Arnon:
As a follow-up to a previous post, I am 68 years old and have prostate cancer with a Gleason score of 9 (and a PSA of 0.52). CT, bone scans, and an MRI do not indicate the cancer has spread beyond the prostate. My oncologist (who has extensive experience with prostate cancer patients) has recommended a combination of hormone and daily external radiation as being more effective should the cancer have spread in a manner not detectable by these tests. He says that this is currently considered a more standard treatment than radical prostate surgery for my situation. I would welcome your comments. Thanks.
Lloyd
Dear Lloyd,
Thank you for writing. Several points:
First of all, there are no randomized trials looking at treatments for clinically low stage Gleason 9. So the words “considered” and “standard” really lose scientific and operational meaning in this context.
Secondly, patients with clinically low Gleason 9 can be “cured” with surgery in some cases, without need for any additional (adjuvant) treatment. All surgeons with extensive experience have seen such patients.
Thirdly, to get a better sense of a specific situation, yours included, I’d really like to see the biopsy report. Among the things I’d look for are the adequacy of the sample and nuances that a simplistic “Gleason 9″ does not convey: number of cores involved, number of sides involved, proportion of core involvement, perineural invasion, and the like.
There is another possbility not mentioned, which is chemotherapy followed by surgery. I am NOT advocating this in your case, especially since I have not really learned the details of your case. However, in some high volume, early stage, Gleason 9 cases in young healthy men this is a choice that should be examined.
Arnon
Dr. Arnon,
My dad died of prostate cancer. I am 45 years old. I have had PSA tests for the past 5 years — the first 3 tests were about 1.4 and the most recent two about 1.7. I have some BPH symptoms, though I suppose they are relatively mild (I get up twice every night, and have occassional urgency and frequency — but nothing that interferes with my life). I saw a urologist who said my prostate does not appear to be enlarged based on DRE. He gave me a prescription for finasteride — based a little bit on the BPH symptoms but mostly on a desire to reduce prostate cancer risk — but said it is “up to me” whether to take it. Although it would be nice to reduce my urinary symptoms, I really would not be taking it for that purpose, since the symptoms are mild, but instead to reduce my risk of prostate cancer (which I gather is somewhat high, since my PSA is high for a 45-year-old guy and my dad died of prtostate cancer). Fortunately, the cost of the medication is irrelvevant to me. But, in deciding whether to take the finasteride, I am trying to balance the benefit of reducing my risk of prostate cancer against the possible downsides of (1) side effects, (2) the unknown effect of taking this medication for a very long time (since I suppose I could be on it for 30 years), and (3) whatever adverse impact it could have on my ability to detect prostate cancer in the future (for example, uncertain impact on any future PCA-3 test results, and maybe uncertain impact on psa over many years). (I would have added to this list of potential downsides the prospect of a more aggressive cancer if I get it, but I gather that the most recent research has suggested that finasteride is very unlikely to cause more aggressive cancers, notwithstanding the appearance of that in a prior study).
Can you give me any advice about whether I should take the finasteride or at least how I should analyze the decision? Also, what about finasteride versus dutasteride? My urologist said they are essentially the same, although with different half lives. But some research suggested there may be more difference than that. If I do take it, does it matter which I take? Finally, would it make sense for me to have a baseline DHT level test, or any other tests, before I start the finasteride? Many thanks, Louis
Dear Louis,
Thank you for writing and the thoughtful analysis and exposition. You know a lot. You may be missing the forest for the trees. So let’s take a step back.
You are a young man (I assume generally healthy) whose father died of prostate cancer. You have mild symptoms and a PSA that is 1.7 ng/ml and, if anything, trending up over very slightly over the last few years. Your risk of prostate cancer is approximately 15% – 20%.
My question is this: if you had prostate cancer now, would you want to know? If so, have you discussed a biopsy with your doctor?
Thank you.
Arnon
I had cancer of the prostate diagnosed on October 24th, 2007 and it was removed. Now its August 2009 an I have noticed I am starting to get erections on my own once in a while with my wife. I have tried twice with Viagra; nothing happened but twice it has happened with nothing. It seems it happens more at night when I am asleep. I wake up with an erection. Could this be an indication my erectile dysfunction is reversing. I would like that!
Hi Daryl,
Yes, this is a great sign. It’s not unheard of for erections to return 2 years after surgery and then to progress to improved function.
Arnon
Dr Arnon,
I found your site whilst searching for information on GTx-758 as I may be participating in a 2-week clinical trial for this drug. I became concerned when I read that it’s clinical castration! I want to help out and also earn a little money, but not if it’s going to cost me my sex life, etc. So my question is: Do your testosterone levels return to their normal levels once you’ve stopped taking the drug?
A reply would be most appreciated.
Cheers,
Mike.
******
Hi Mike,
I think I know the answer but, not being involved with the trial, I would defer to the people running it.
Please call Dr. Gary Barnette, Vice President, Clinical Research & Development Strategy, at GTx, Inc. He and I corresponded and he invites you to call him at 901-523-9700 X 138.
Please do me a favor and let us know what you discover.
Thank you. Arnon
Arnon,
Thanks for your prompt reply. I’ve called Dr Gary Barnette several times and each time I receive a message saying he’s not available. To be honest Arnon, I was looking for advice from someone neutral, someone who doesn’t have a vested interest in the drug. Due to his position with the company developing GTx-758 I can’t rely upon his views/advice being impartial. With this in mind, I’ll not be calling again. I’d like to hear your thoughts on the matter though.
Cheers,
Mike.
********
Hi Mike,
Actually, the best way for you to proceed is to get both knowledgeable and neutral inputs. I can be neutral but I do not know the drug and its history, so neutrality has its limits. You might reconsider leaving a message for Dr. Barnette.
For now, this is what he supplied me by email ….
“It is not GTx general policy to give information on an unapproved drug .. [Their] Phase I study is being conducted in London (Richmond Pharmacology) in healthy volunteers. If [you] live in or can get to the London area, I would invite him to go to Richmond and apply for participation in the study. Through the informed consent process, all his questions will be answered under confidential and informed processes.”
This drug is only in Phase I clinical trials. In other words, it is
extremely early in the development process. We don’t know if it works
in man. We don’t know if it will be safe in man. And I don’t know
personally if its effects will be reversible if a patient stops taking
it. Frankly, just about all I know is what it says on the GTx web site
at http://www.gtxinc.com/Pipeline/GTx758.aspx?Sid=5.
Having said that, my guess would be that its effects probably ARE
reversible (at least after a while) if the patient stops taking the
drug, but it is certainly going to have the same effects on libido as
older hormone therapies if it ‘rapidly suppresses secretion of
luteinizing hormone by feedback inhibition on the pituitary, thereby
inhibiting the production of androgens by the testes.’ So, even it if
GTx-758 is shown to have a better safety profile than the older LHRH
agonists or the new LHRH antagonist degarelix, it is reasonable to assume that it will leave most men impotent (at least while they are on drug).
You raise an interesting question about reversibility. Certainly GnRH analogue effects are often reversible. However, there is a phenomenon of permanent testicular suppression, especially after prolonged administration. I doubt that anybody knows anything about the magnitude and dynamics of such a phenomenon with the drug we are discussing.
Dr. Barnette is required by law to fully disclose the known side effects of any drug he is developing to patients who wish to participate in a clinical trial. I am sure that he is difficult to get hold of because he is probably spending half his life in meetings. Leave him a voicemail or leave his assistant a number where and when he can return your call.
I’m 67 and in 2003 I was seeded, radiated, and put on hormones. In 2007 my prostate cancer returned and I went to the Netherlands for a Combidex MRI, which showed 12 pelvic tumors. They were radiated 45 times. Then in August 2009 I returned to the Netherlands where 4 old pelvic lymph nodes showed metastatic tumors, plus 8 new nodes in the abdominal area. My PSA had gone up to 6.8 in April and I was put on hormones. In August the PSA came down to 3.4. What treatment would you advise at this point?
Dear Mr. Wilson,
I am sorry to hear about your situation. It sounds like a real roller coaster.
Your PSA has dropped considerably but not fully on hormones. We do not necessarily know at this stage if it will continue to drop. Certainly with the passage of a little more time you will know better. If the PSA drops to undetectable levels and you can tolerate the hormones, it might be reasonable simply to maintain you on this regimen. However, if it does not drop and certainly if it rebounds again, you may very well need additional treatment, including possibly chemotherapy.
I would strongly suggest that you consult with a medical oncologist who specializes in treating prostate cancer. You may also find value in joining our Hormone Suppression group.
Hi Arnon,
Thank you for contacting Dr. Barnette on my behalf. I am a UK resident and the trial is at Richmond Pharmacology London. Unfortunately, his reply sidesteps my question. He’s basically saying “ask them.” After filling out all the questionnaires, etc., I did raise my concerns with them (trials4us.co.uk ). This was several days ago. So far all I’ve received is silence! This may be phase I, but three groups have already been through the process. GTx, Inc must already have some inclination as to whether the production of androgens in the test subjects is restored to their pre-trial baseline levels. Dr Barnette and trials4us seem reluctant to answer my question. This leads me to believe that, at best, your view of (in a nutshell) you’ll probably be ok but we simply don’t know enough yet, is most likely the answer.
With this in mind, I’ve reached the conclusion that it’s just too much for me to risk. The possibility at being rendered impotent because of “permanent testicular suppression” is just too great a risk to take.
Thank you for your time. I think it’s great that people can contact you like this. I hope GTx-758 is a success and can be used to help people such as your patients.
All the best,
Mike
Aaron:
My husband, 53 years old, went for his annual physical (missed a few years). He is healthy, athletic and without any prostate CA history in his family. His PSA level came back at 19 from the physical. We went to the urologist, did a DRE which was negative, and another PSA that was 23 a week after the first. He’s had the ultrasound biopsy and we’re waiting for the results, anxiously. Any suggestions? Or do we really have to wait for the results. The urologist told me after the biopsy that he didn’t see anything that alarmed him but maybe a suspicious area at the apex.
I appreciate your opinion.
Thanks,
Cheryl
Dear Cheryl
Thank you for writing. I fully appreciate the anxiety that can be caused by the uncertainty of the moment. One way to cope is as you are doing: Collection of information. I would strongly suggest you have a look at Diagnosis section, especially “an introduction,” so you can be familiar with the basic jargon, including such terms as grade and stage. You may also want to look at the Biopsy group on the Social Network.
If you like, you may also find value in joining our social network, including the Wives and Partners group.
Please feel free to update us and ask more questions after you get the biopsy results.
Arnon
Dr. Arnon,
This is a follow up to my question of August 24 and your response. You asked whether I have discussed a biopsy. When I saw a urologist (at Hopkins) recently, he said he would not suggest a biopsy unless my psa “spiked up” or eventually got over 2.5 ng/ml. He said my psa is high for a guy my age, but that the slow increase over past 5 years is a good sign. You think I should ask for a biopsy now? See how my next psa (in about a week) looks and then decide? Do you think it makes sense for someone in my position to take finasteride to reduce the risk of p ca? Thanks!
Louis,
You are getting this consistent feedback: Your PSA is higher than expected. I believe that given five men like you (same age and PSA) one would have a positive biopsy (I phrased it before as a 15 to 20% chance of positive biopsy). Add that your father died of prostate cancer, an assumption (which you can validate) that you are healthy, and you have a an even more pressing benefit:risk ratio.
Nobody can make the judgment call for you about your need for biopsy. You have the facts regarding your risk of having cancer now and your relative health. If you are very sick (if you have cystic fibrosis, as an extreme example), then this is moot. If you are perfectly healthy, then this is worthy of attention.
It sounds like you are struggling with the decision. I wish you luck with it.
Arnon
Mapping 50-core biopsy or standard 12-core biopsy?
15 months ago a 5-core biopsy showed about 40% involvement with Gleason 3 + 3 = 6, clinical stage T1c, PSA vascillating between 4.2 and 8.3 with no real pattern, even using regression analysis. Two top midwestern USA robotic surgeons fear that a 50-core biopsy could adversely effect surgery. Both prefer a new 12-core biopsy before doing surgery. Another robotic surgeon, lower volume but still at a top midwestern cancer center, says he’s seen no impact from the saturation biopsy. I hold out some hope that the saturation biopsy could result in a downgrade of my tumor and I could further delay radical treatment. It could even support some sort of partial treatment, although I abhore radiation and won’t do that. Any thoughts? Oh yeah: 54 years old, great health, married, heavy prostate user.
*******
Dear James,
Thank you for writing.
I wince at the sound of “robotic” surgeons. Are they really? Or are they thinking surgeons? For your sake, I hope they are the latter and that they are thinking about you.
The issue at hand is not the gizmo being used to remove the prostate. The issues are: 1) Should you be treated? 2) If yes, then how should you be treated? 3) If surgically, by whom? 4) If surgically, should the nerves be preserved?
I believe there is a very adequate basis already for strongly considering treatment (I don’t know your case but this is my gut feeling based upon the limited input I have received). Since you have ruled out radiation, I believe you are left with surgery, meaning radical prostatectomy. Whether it is done open or laparoscopically (with or without “robots”) is immaterial to the specific issues you raise.
So should you have a repeat biopsy? I think this gets more to the question of nerve preservation than the question of should you be treated, which in my mind is pretty well answered. To answer the nerve preservation question is a little hard for me without seeing the report and examining you, but here are examples of how it a repeat biopsy does (not) affect the issue.
1) If your cancer was scattered in small foci on both sides, then probably not since you are heavily invested in your erections and I sense would want both nerves preserved so as to maximize the likelihood of their return; I sense you would take some risk for this and I don’t see how a repeat biopsy changes the actions upon which you decide.
2) If your cancer was all in one place, for example two cores positive at the right apex involving 90% of each core, then probably not because in the last 15 months you will have incurred a rise in your risk of extraprostatic extension and no biopsy finding — even one that “downgrades” or “downstages” — would dissuade me as your surgeon from very strongly advocating for only contralateral nerver preservation.
You are young and healthy. Your PSA is in a range at which I commonly see extraprostatic cancer. You’ve had cancer for at least 15 months. I have not seen your biopsy report or examined you, but my gut feeling again is that you are taking real risk by delaying. And I have yet to see how any biopsy changes your actions.
Good luck.
Arnon
Dear James,
Yes, I am a FEMALE, but as the wife of a husband who was diagnosed with PC, with subsequent surgical removal, I hope you can see this response with an open mind.
Arnon has said it all. Eloquently and to the point. You have cancer, James, and you have had it for 15 months. All the biopsies in the world, are not going to alter that. It seems to me that you might be putting off treatment as you are primarily concerned with your future erectile life. I can understand that, but by delayiing treatment, you are more apt to suffer greater consequences in that department.
Since you “abhor radiation” I fervently hope that you will choose surgical removal and choose it SOON! It may help you to know that my husband did choose Da Vinci method surgery, in the Mid-West, and has done very well. It is important to choose a surgeon with great experience … know his/her stats, etc.
I wish you the best, James, and hope that you and your wife do the necessary research as we did, and ultimately and quickly, get treated! It is time to accept your diagnosis and get proactive. I feel as Arnon does, that “you are taking a real risk by delaying”. The time to act, is NOW.
Warm Regards,
Judy
Follow up to: Mapping 50-core biopsy or standard 12-core biopsy?
Note that in my first post both surgeons I’m consulting with want a more recent biopsy before surgery, so unless they are wrong, whether or not to biopsy again is not the question. The question is should I have a saturation biopsy or a traditional 12 core biopsy? They don’t like the saturation biopsy idea but I wan’t to make sure that it doesn’t have some value before making a final decision.
Ps thank you so much for the lighting quick reply. I do want to decide this very soon. AND, sorry about the “robotic surgeon” remark. I meant the type of surgery not the type of surgeon (I’m flying without a spellchecker here so sorry for less precise terms).
***********
I understand but I am still a step back from how many needles. I am searching for the rationale for any needles. I’d be interested to know how the results from any needles will change any clinical decision given what is already known about your specifics. Any example will do.
Yep, that was my initial thought. All I can say is that I’m now relying on expert testimony: Mani Menon at Henry Ford requires another biopsy if more than 6 months has transpired since the last. It’s pretty standard policy for him. His staff will tell you that even before your initial appointment. Why? He says it helps him determine how aggressive he should be during surgery. Kevn Zorn out of the University of Chicago says another biopsy would help too.
Dr. Arnon,
My PSA from a routine (retirement) physical at age 62 was 4.7 and a biopsy was recommended. I had a history of nightly trips to the bathroom and some problems urinating. However, before a biopsy could be done I got a severe prostate infection. A trip to the emergency room, an injection of antibiotics, and a 3-week course of ciprofloxacin put me back to normal. My urologist put me on Flomax and took another PSA and it was very high, but he put this down to the infection and scheduled another PSA and probable biopsy 3 months later. At that time my PSA had dropped significantly, but we went ahead with the biopsy, which was negative. However, I experienced a severe prostate infection — E. coli – from the biopsy and was in the hospital on antibiotics for a week. A PSA taken a few weeks later was again very high and another was scheduled for 3 months later. By that time the PSA had dropped to 8 but the doctor wanted to give it a little more time and do one more check before we tried another biopsy. At this time I moved from Switzerland to the U.S. and I did not get another PSA until 6 months later. It was 8.3 and my new urologist put me on a 3-week series of ciprofloxacin. After that another PSA showed 9.6 and he is suggesting either another PSA in 4 months or a biopsy.
I am naturally very concerned about the risk of another infection if I have another biopsy. I have some symptoms that the Flomax has helped but otherwise my risk factor seems to be low — no history of prostate cancer in the family — and it would seem to me the high PSA could all be laid to prostatitis or BPH. Using the calculator from the UTHSCSA site it looks like slightly under 50% chance of a positive biopsy but as high as a 20% chance of high-grade disease. However, I could not factor in my infection history so I think those numbers may be too high.
My questions:
– Is my reasoning above sound?
– Is there greater risk of another infection from a biopsy for those with a history of prostatitis and/or an infection from a previous biopsy?
Dear Loren,
I understand your dilemma. There is risk either way: 1) risk of infection with biopsy and 2) risk of missing cancer without a biopsy. Without knowing more it is surely hard for me to guide you specifically and would encourage you to be open with your urologist.
I would point out that the biopsy did not “cause” an infection. The prostate is a dirty organ in any event and it sounds like in your case you had more than your “fair share” of bacteria; these would have been released into the blood stream by the mechanics of biopsy. It is something that might happen again, but not necessarily.
THank you. Arnon
I am 69 years old and was Dx’d in August 2006 with a PSA of 5.5, a negative DRE, three positive cores out of 12, clinical stage T1c, and Gleason 4 + 5 = 9 by Kaiser. Subsequently, upon exiting Kaiser, I sent slides to Bostwick where they graded them at 4 + 3 = 7.
I’ve had no treatment, PSA had climbed to 10 a couple of months after Dx, subsequently fallen to 6.5 and as of December 2008 was again at 10+.
I’ve refused treatment or follow-up biopsy as I am of mind (after very extensive research) that therapy for the most part is ineffective and morbidities are certain and horrific. I like the odds of likely 80% that I will not die a prostate cancer-specific death in the forthcoming 10 to 15 years, whether I submit to therapy or not. As of now, I suffer no effects exceptcystitis at Kaiser after I requested procedure to test for it.
I’ve had all the prerequisite color dopplers, bone scans, CT scans, and MRSIs at UCSF. All scans and procedures were OK 10 months ago. I have also visited Loma Linda to examine proton beam radiation, and Stanford. Again I have determined that all treatments are not anything I wish to undergo. I do not wish to appear that I am totally ignoring this disease, just want no further biopsy procedures because of consequences of same that can occur, and the likelihood that another finding would not change my chosen path.
My question goes like this and after extensive research I’ve found not the answer, even having asked this question of experts in the field.
“Does/can the mere act of being diagnosed with PCa, cause a man’s testosterone level to plummet to excessively low levels (about 200 or a Free T of 3.1)?”
The background on this question is as follows:
1. About 2000 I went on a regimen of statin drugs to control a high cholesterol of 250. Zocor was the chosen drug. Cholesterol fell to about 180 and I felt fine.
2. A couple of years later, in 2002, my libido had fallen dramatically and the ability to maintain an erection was poor. I ceased Zocor and all was well. I then over the years tried Lipitor, Vytorin, Mevacor, etc., all with same result. While on statin all was poor, when off all was well. I remained off statins as QOL was improved.
3. 2006 as noted, I was diagnosed with PCa. Libido and erections were fine. I again tried statins (also tried Zetia and Napasain) to control LDL and hopefully PCa. I observed same result, low libido and moderate ED.
4. I then begin to have testosterone testing. I found when on statins, my T would be about 200. No statins I would be about 450. This was consistent. My cardiologist has no explanation and has never heard of such a thing.
5. Now here is my home-grown theory: I suspect that initially when first on statins and before PCa was diagnosed (but I probably had it for years, but to a lesser extent than when first diagnosed), that my T, if I had had it measured, may have been say at 600 plus. Taking statins perhaps may have lowered it to (say) 450, which was still OK for sexual performance. However as PCa advanced T perhaps lowered to 400 or so with no statins. Then to take statins it knocks T down to the 200 level that I now experience with statins, but now I am seeing it at low 200s without statins.
6. I recently went back on Zocor as cholesterol was back at 250, which does not bother me, but does bother my cardiologist. (I have no other cardiovascular risks to speak of except age and very minor calcium build up on CT scan.) I wish to take statins in conjunction with aspirin (Cox 2 inhibition, yes I know that Celebrex is perhaps better, but far more expensive) to perhaps slow progression of PCa. I have yet to have another T test after resuming Zocor.
I would love to hear your comments, Dr. Arnon, but also anyone else that could or may have a theory that may explain my granted anecdotal phenomenon observation.
As noted before, I’ve asked the question of many, even presenting physicians at a recent PCRI conference in LA. This is apparently an area that has not been well investigated (like ulcers being caused by a bacteria for which a pair of Aussie Doctors won a Nobel prize in 2005 for their 1980 discovery). Perhaps someone can shed some light on this topic for me.
One other thought that I will save for another question on another day. Would it be dangerous to undergo T therapy to increase my T to counteract the effects of statins to bring my T back to normal levels. It would seem to me that if a man has a normal level of T of say 500, and his PCa does not progress any faster than a man with a normal level of T of say 200, then bringing it back up should have little consequence. T is T correct, rather natural or artificial? Of course I am aware of the value for PCa patients when driven down to extremely low levels, but is there any difference between say 200 and 600 in progression. My suspicion is that it does not.
Anyone with thoughts on this missive, please feel free to chime in with their thoughts/opinions
Sorry for the lengthy question. I could not make it much shorter and have a full description. Please excuse any grammar or spelling errors.
Roger
********
Roger
I know of no mechanism by which mere diagnosis can cause hypogonadism. We can speculate about mood changes and depression and their effects on libido and such, but this would be very loose speculation, not evidence.
Thank you.
Arnon
Dear Dr. Krongard,
A quick question regarding a medical dilemma I am facing …
The results of two 12-core prostate biopsies have determined that I have HG-PIN and one area of atypia.
My well-qualified urologist recommends a saturation biopsy that ideally would already have taken place were I not taking Coumadin through May 2010 as a result of a procedure to cure atrial fibrillation.
My question — Are you aware of any imaging tools (or any other diagnostic tools), that are as effective at detecting prostate cancer as a saturation biopsy, but would not require me to come off Coumadin?
Thank you in anticipation of your reply.
Michael Ogilvie
Dear Michael,
If such tests existed we would simply never biopsy. After all, we diagnose many diseases, e.g. kidney cancer, with imaging and no biopsy. So unfortunaly, no, I am not aware of such a test.
Thank you.
Arnon
I have a friend who is scheduled to have a PCA-3 test done for his prostate. He does not have access to a computer and asked me to relay this question. Is there a set price for this test and if so could you give him and estimated cost. He has recently become unemployed and is concerned about cost at this time. He is trying to prepare to save up the money in order to afford to have the test.
Thanks
Crystal,
I really have no information on diagnostic test pricing. You might go on our Social Network and post a discussion on the Biopsy and Other Tests group. Good luck.
Arnon
What is biochemical recurrence or biochemical failure and how does it differ from plain old recurrence?
******
Ninel,
Biochemical failure denotes that PSA has risen and/or is rising. This is to be contrasted with plain old recurrence in which there are anatomical signs of recurrent disease, including for example an imaging study that shows cancer.
Arnon
Aloha Dr. K,
Do you know of any cases or causes where problems with the urethra show up 2 years after EBRT/IMRT? The problems are cloudy urine, minor pain, rawness when discharging. Stinging feelings in urethra between releases.
A pee in cup analysis was yellow, cloudy, no growth after 2 days. Prior to this analysis, I used a plastic cup at home, it was very dark red, and very cloudy.
Thank you, Joe
*******
Dear Joe
It sounds like you’re describing inflammation, which can be caused by many things, including bacteria, foreign bodies, radiation … The specific cause in your case really has to be investigated by a urologist who can do the right tests, examine you, and get you the answer.
Arnon
Elevated PSA, 21.5
My PSA was 21.5, I had a bone scan, CT scan, and 3 weeks ago had a prostate biopsy (14 cores); all tests came back negative for cancer. The doctor prescribed Levaquin 500 mg tabs. After 1 month of Levaquin treatment, if my PSA is still elevated, another biopsy will be taken.
I am a handyman by trade. 3 months ago, while at work, I injured my knee and back. I have been getting physical therapy. My knee swells up if I don’t use a knee brace and I am on my feet most of the time, and my back aches most of the time.
Considering the side effects, I don’t feel comfortable using Levaquin, is there another med?
I appreciate your opinion. Thank you for your time.
Marc
******
Marc,
There are many antibiotics. Please note that all medications carry risks of various kinds. Please review this decision with your urologist.
Arnon
Hi,
I had brachytherapy (seed implantation) on the 22nd of this month. What is the “true” risk to people in my household. Is the radiation emitted from my implants so strong?
Are there any cases of injuries to others from stray radiation? Every one is sort of “freaked out.”
Thanks,
Steve
**********
Steve
The risk depends on what you had done and the isotopes used. Your radiation oncologist should be able to provide you with specific guidance.
Arnon
My PSA rose 10 points in 3 months. I have had 2 biopsies in the past — both negative. I also have an enlarged prostate.
I am a little concerned about the rise in the PSA score. I have to wait a month for another PSA test. Your answer would be helpful. Thanks Dr. Arnon
*********
Dave
Without knowing your PSA values, the rise, the time since your last biopsies, the findings in the last biopsies, your family history, your age, your general health, and other things, it is impossible to provide you with specific guidance. Your urologist should be able to provide it.
Arnon
Dr. Arnon,
My PSA rose from a 6.4 to 16.9 in 3 months. My last biopsies were 3 years and then 2 years ago; both negative. They took 16 samples on my last biopsy. My 2 brothers both have prostate cancer. I am 68 years old, and I am in excellent health. I have run 16 marathons, including the Boston marathon 3 times. Such a sudden rise in the PSA test seems strange. I have to wait 1 month for another psa test. I need some positive news.
Thank you, Dave
************
Dave,
I can certainly appreciate the anxiety given your risk profile: PSA at 17 ng/ml and a strong family history. Take one step at a time. After all, you’ve had two negative biopsies. Does the running take your mind off things? Does it help you to cope with the uncertainty?
AK
Dr. Arnon,
Yes, the running helps. I just talked to my doctor and he says such a sudden rise is usually caused by infection not cancer. The biopsy will give us more information. What do you think.
Thank you very much, Dave
PS: Are you a runner?
*******
Yes. I ran the Boston Marathon twice, but today I confine myself to more “reasonable” running. Yes, sudden rise is often from infection, not cancer. So you’re stuck with some uncertainly for now, which is why I asked how you are coping.
Dear Arnon,
My husband is 63, healthy, an avid swimmer, and a vegetarian (the latter since his prostate cancer). He had an RP 3 years ago: T3a, no positive margins, no seminal vesicle invasion, Gleason 4 + 5. His PSA was 0.1 for several months after surgery, then slowly rose to 0.3. He had salvage radiation and it never really changed. The PSA has continued to rise slowly, showing more escalation in year 3, reaching 1.7 ng/ml 3 months ago, and now 3.0 ng/ml 3 months later. He is very averse to ADT. Previous bone scans are normal (not surprising). If we do another bone scan and it is clear, can we continue to wait? Are there any alternatives to ADT that would minimize side effects.
Claire
****
Claire,
I understand your husband’s reluctance, given the potential side effects of ADT. There are various ways to give ADT and some ways to counteract some of the side effects, but I am not aware of any ADT that is not associated with the risk of unwanted effects. If he does choose to not have ADT, then he really does have to work closely with his doctor to stay under regular surveillance, which surely at a minimum should include periodic PSAs and perhaps other blood tests and bone scans.
Arnon
My husband is 76 and very fit but, he has hypertension (medicated), hemochromatosis (phlebotomy now every 6 months), arthritis (medicated), and recently (in 2007) mild type II diabetes 2 (medicated).
After 5 years of watching his PSA go slowly up, to 6.85 ng/ml, my husband was diagnosed on 4/08:
– GRE- Negative,
– Right 1: involving 1 of 3 cores, less than 5% of tissue.
– Right 2: involving 2 of 3 cores involving 5% of tissue.
– Gleason (3 + 3) 6, Stage T2a
We decided on active surveillance.
– On 6/09 his PSA was up to 6.79 and he went on to Avodart 5 mg once a day
– On 7/09 PSA, even while on Avodart, the PSA was 5.95, testosterone was 489.
On 9/09 he had another biopsy: 12 cores, Gland Volume 14 cc,
– Right 1: now benign (where did the cancer go?)
– Right 2: cancer in 2 of 3 cores of tissue; tumor involves about 15% of tissue.
– Gleason (4 + 3) 7
– I believe staging is T2A.
Urologist believes the cancer is confined to the right side. We agree that some intervention is needed, but how to figure out what is over-treatment, and what is being too casual?
Question A: Is this now considered aggressive cancer, based on Gleason score and 15% of tissue involved?
Urologist recommends focal treatment with cryotherapy, or he would do seed implantation. Radiation oncologist believes 25 EBT followed by seed implants would be best way to eliminate the cancer.
Question B: Is it crazy to think of doing seed implantation first, and then if in time PSA rises do a full course of EBR?
Question C: We will go for a consultation to another radiation oncologist, but what questions should we ask based on the recommendations we were given so far?
This is so difficult. From all we read, since each man’’s body and health situation is so different, and the technology is constantly improving, there is no definitive answer as to which treatment is best for whom.
Thanks for any suggestions or ideas you might have,
Ninel
**********
Hi Ninel
Yes, it is very difficult and there are no absolutes, as you have discovered.
A Gleason 4+3 is a biologically active cancer. Is it “aggressive?” That is in the eye of the beholder and not an operationally useful characterization, so I will put it aside for now. What matters is the relative risk of harm from the prostate cancer and everything else. Given that he is “very fit,” the prostate cancer takes on more meaning than if he was “in poor shape overall.” So while I do not know his specifics and have not examined him, it does seem reasonable to consider moving forward with treatment.
If he considers treatment, I would argue the most important thing is to find a “treater” who knows what he’s doing. I would not micromanage the brachy-radiation sequence if that is the direction. I would take a step back and also consider surgery. Again, I don’t have enough detail to even begin to make a recommendation, but from what I can pick up from what you wrote, all options should be on the table for discussion.
Sincerely,
Arnon
Dr. Arnon,
Could taking blood specimens for a PSA test when you are sick with flu-like symptoms cause your PSA results to be wrong?
Thanks, Dave
******
Interesting question. I have never heard that it does or that it does not. If you hear, please let us know.
Arnon
Hello Dr. Arnon,
I appreciate your question and answer page.
I’m taking Levaquin now and will be for 3 more weeks.
I have been taking Flomax. I don’t really have to take it, but it helps the flow. Do you think it would be more effective to take the Flomax ast the same time during Levaquin therapy. I don’t like Flomax’s side effects, but if treatment is more effective, so be it.
Thank you, Marc
*****
Marc, I don’t think Levaquin in any way affects how Flomax works. Not knowing why you are taking Levaquin in the first place, I cannot really advise on whether or not Flomax should be taken or held off.
Arnon
Hi:
My father has a PSA 150, Gleason 7. He is 76 and in poor health. He is hormone [refractory?], has just failed chemotherapy (Taxotere), has been having lots of blood clots come out, and has had his second TURP (the first was a year ago). Yesterday the doctor did a cystoscopy and saw that the bladder was blocked by tissue. He has been urinating through 2 kidney bags. He has cancer in his bladder and inguinal lymph nodes but as far as we know the cancer has not touched the bones or any major organs. He is considering removing the prostate and bladder. Is this a good option at this late stage? How long could he live if he does just symptom managment? Thank you.
Dear Ray,
You are presenting a very complicated situation. In this you are asking about what we call a palliative prostatectomy: An operation to improve comfort and function. However, given the history and “poor health,” the operation itself may be unusually risky. I simply do not have enough information to even begin to advise you about a situation like this and would strongly encourage you to ask these very good questions of his urologist.
Arnon
I had conventional surgery last August for T1c, Gleason 6 prostate cancer. Post-surgery pathology stated organ confined, no lymph node or seminal vessel involvement or anything, and post-surgical pathology was Gleason 6, but with a tertiary Gleason of 4. Recently I read that any tertiary score is a big flag for recurrence. My surgeon tells me no, that everything was removed and he has never had a recurrence with my numbers. My uro guy that follows me locally tells me the same thing. However, what I read has me concerned, very concerned, because it said the chance of recurrence with a tertiary score is 37%. Now I don’t even want to get my first annual post-surgery PSA. Hopefully I read the report incorrectly. Do that many guys have tertiary pattern scores, and do they all lead to recurrence, or just a fraction combined with other factors?
Thanks is advance for you help.
*****
Joe
I assume you had Gleason 3+3=6 and some pattern 4. My first question would then be why is this not a Gleason 3+4=7? In either event, a small amount (which is by definition of a tertiary pattern it is) of Gleason pattern 4 should not meaningfully impact prognosis. I would agree that given teh other features of your report the likelihood of recurrence is low.
All tertiary patterns are not the same. Many are Gleason 5 pattern and I would not lump them into one basket.
I have not see your report or slides but based upon what you report my gut feeling is that you’ve got a great prognosis.
Arnon
Dear Doctor:
My husband was diagnosed with prostate cancer in 1998, and had radiation, seed implant. When his PSA started rising after 2 years, he started hormone therapy. When it started rising again he was started also on Casodex. In 2002 he also had a positive lymph node in the left kidney with aortic involvement.
Last January (2009), his PSA started rising for a third time, and he had a whole-body bone scan that showed he had metastases to L3. He had 5 weeks of radiation that ended April 12. In May he started passing blood in the urine, and he went to a urologist who said was caused by his past radiation treatment. He recommended a new oncologist to do chemothrapy.
The whole-body bone scan was again done. The cancer had metastasized to Thoracic and Lumbar from T1 to S1, some ribs, both hips, left tybia and knee, right shoulder. He was started on chemotherapy every 3 weeks, but his PSA kept going up slowly; after 4 chemo infusions an MRI was done, which showed new spots on his hips and no improvement to the prior lesiosn.
His most recent PSA (this month) has doubled — from 21 to 43.8. We have an appointment with his oncologist next Friday.
We would like to know your opinion. Because his PSA has doubled in a 1-month period, does it mean that the chemotherapy is not working and the cancer possibly has spread to another location?
Thank you for your opinion.
Dear Vera,
Thank you for writing. Unfortunately I am so far removed from this kind of scenario that I hesitate. The last thing I want to do is “shoot from the hip” and potentially mislead you. I do think that your question has merit and would encourage you to ask your husband’s oncologist.
If you want consider joining the Social Network. There are some people on there, including Sergio, who might be helpful to you.
Arnon
Thank so much for your reply. Since my original question I was able to obtain more info from my pathology report. Post-surgery pathology showed two tumors and originally I was given a Gleason 7 (3 + 4 = 7); however, upon further review yesterday they said the other tumor was the 3 + 3 = 6 with the tertiary 4. I understand that upon removal and pathological review most prostates show more than one tumor (please comment here) and I understood that the primary was the straight 3 + 4 = 7. However, I understand that both Gleason scores mean about the same (7 and 6.5 respectively 0. My hope is that since they are seperate tumors we are still dealing with 7 and 6.5 and not anything closer to an 8. My surgeon does not feel it is anywhere near an 8 and my question is not to qualify that but just to reinforce it for the sake of putting my anxiety to rest because I am actually debating whether or not to get my 1-year PSA. Thank you in advance for you help. Being able to ask questions like is very helpful.
Joe,
You are parsing the scores to a level that I have not previously seen. First of all, there is no Gleason 6.5. Secondly, I do not see a value in doing this. What I sense from your obsessive attention to detail is a deep seated anxiety, one that may interfere with function. The mere fact that you are debating if to do post-op PSA surveillance is further support for my gut feeling and it is troubling to me. What possible clinical rationale can there be for not doing an easy blood test, no matter the unlikelihood of recurrence? None. So again, the decision making appears to be driven by emotion, not reason. And to this I doubt that any new amount of Gleason score parsing will be useful. Rather, I think you need to think about your emotional state, your ability cope with your recent experience, and how you will function best. Among the things you might consider is professional help (e.g., a psychiatrist), usual adaptive coping strategies (e.g., social interaction, prayer), and/or joining our social network at http://prostatecancerinfolink.ning.com.
I think you’re going to do well oncologically speaking and I sense that your surgeon has given you great feedback. Now let’s get you to feel better about it all.
Arnon
Dr. Arnon,
Do you think the medical evidence is strong enough to justify someone who has a family history of prostate cancer to take statin drugs for the purpose of decreasing the risk of prostate cancer (or at least decreasing the risk of dying of prostate cancer)?
The studies I have read suggest there may be a material reduction in the risk of developing prostate cancer (or at least dying of prostate cancer) if one has taken a statin drug for at least three years. But then the articles say “more study is needed before we could recommend this.”
I guess they can always do more study. But then some people will die while they are studying….
So what do you make of the evidence that now exists? Is it sufficient to justify taking the statin drug (assuming that: the price of the drug does not matter, and it is not otherwise medically contrandictated).
Thanks,
Hi Geoff,
To the best of my knowledge all such studies are retrospective and epidemiological. This is not a basis for a clinical recommendation. It’s scientifically unsound and it’s potentially risky. Please let me know if I have missed a clinical trial of statins in this context.
Thanks.
Arnon
I have been given Zoladex 10.8 mg to suppress the cancer for a period of 3 mos, while postpone beginning my IMRT treatment. Will you verify this to be correct? If you need my numbers, they are: psa 6.2; Gleason 7 (4-3); stage T2a; biopsy 4 out 12 cores; tumor in uper right side of prostate.
Thanks
Del
Del,
I have not reviewed your records or examined you. Thus, I have no basis for evaluating the appropriateness of your treatment.
As a general rule, yes, there can be a rational basis for neo-adjuvant hormone treatment (hormones before radiation).
Arnon
Many thanks for your response. I am not really qualified to do medical research, but I came across this which interested me:
http://jnci.oxfordjournals.org/cgi/content/full/98/24/1819
(“use of statin drugs was not associated with risk of prostate cancer overall but was associated with a reduced risk of advanced (especially metastatic or fatal) prostate cancer”
And this, which suggests a link between statins and development of prostate cancer (but says more work would be needed before men are recommended to take statins for urological reasons):
http://www.mayoclinic.org/news2009-rst/5252.html
What is the “risk” you refer to? I assume it is not the side effects of statins (which seem, as best I can tell, pretty modest when compared to the potential benefits). Is it instead the possibility that taking statins could reduce psa levels and thereby “mask” prostate cancer? That does seem like a real concern.
I was thinking of taking statins anyway because it seems there’s evidence that just about any man over age 40 (even one with acceptable cholesterol levels and no particular corronary risk factors) might benefit from statins, to reduce heart attack and stroke risk — with any prostate cancer risk reduction being a secondary, incidental benefit. But maybe I am wrong?
Thanks for your advice.
Geoff,
I cannot comment on the use of statins for heart attack and stroke. However, I can comment on their use for prostate cancer prevention and treatment: There is no basis for using them. The article you linked is one based on post hoc analyses of observational data, which is not a basis for any clinical action. Risk is all around. You can get very sick from taking too much of something, including statins. So if you want to take statins you really should ask your cardiologist about it. As for the prostate, we’ve been down this road before and what an observational data set suggests may be interesting turns out to be totally useless and potentially risky.
Arnon
Dear Arnon, You have heard from me before. I am now five months after robotic surgery, and four-month PSA was undetectable. I have at least two problems. The major one is ED. The second one is that my surgeon has mysteriously disappeared — I have literally not seen him since the surgery, and the latest I hear is that he “is no longer affiliated…”, whereas he is young and had recently been made department chair of urology, and I have not yet found another urologist I can trust. Today I got an injection of .6 cc Bimix with essentially no effect. That was double the amount of the first injection five weeks ago which had also no effect. Viagra has been having some but not nearly enough effect for the last few months. Before the surgery, Viagra used to work for me. How can I find out what the rational approach to my condition would be?
—–
Allan
When it comes to erections, it’s different strokes for different folks. The best way to design a rational strategy is to work with a sex therapist and/or doctor who will individualize your care.
You might consider starting a discussion on the forum you’ve already joined here. Go to Discussion Forum, where you just commented, find +Start Discussion below the discussions, click, and type. You never know what you’ll get back. Also there are some sex therapists on the site, including Anne Katz and Rhonda Fine. You might query them through their pages.
Arnon
Dr Arnon:
I understand your answer, however, I was not looking for any type of evaluation of a specific case, including mine. My particular data was included as it was my understanding to reference it when making even general inquiries. The problem was my wording of the question. Based on your general medical knowledge …
In general, does Zoladex 10.8 mg have the ability to suppress cancer? To suppress would refer to preventing the cancer from growing or spreading, during an approximate 90-day period beginning at the time of injection?
Thanks
Del
GnRH analogs, of which Zoladex is one example, can delay the appearance of clinical disease, e.g. bone metastasis. The decision to apply GnRH analogs must include analysis of the risk of the appearance of clinical disease, the potential meaning of such disease in the specific individual case, and the risks and side effects of treatment in an asymptomatic man with no evidence of disease. This is a complicated decision that must be held directly with the treating physician.
Arnon
Thank you for your reply. It did get me to wake up and think that I may somehow be making something out of nothing. The Gleason 6.5 was mentioned in a study by Johns Hopkins with a recommendation to modify Gleason scores based upon tertiary findings and indeed my surgeon mentiioned a Gleason 6.5 in my particular case. I will question this no further, but would like to know, in your opinion, what is the average number of individual tumors found by plathologists after the tumor is removed and I believe that it is usually more than one. With regard to emotional status, I guess just as Dr. Walsh’s book states many men have this PSA anxiety, I don’t know if that means enough to seek professional help or if it is just something that comes along with anxiety for the annual PSA after a layman attempts to interpret a study on tertiary findings. In any case thanks for the advice and what is your take on the number average number of tumors found in the prostate after it is removed. I appreciate your candid comments and welcome any input you may have doctor.
Joe
Joe,
I do not know the average number of tumors in a given prostatectomy specimen and am not sure what I would do with that number if I had it.
Anxiety becomes clinically actionable when it interferes with professional, social, and cognitive function.
Arnon
Dr. Arnon:
I am 56 years old and in good health, working last week as self-employed Contractor. I am recovering from a radical prostatectomy on 10/16/09 after finding my PSA 6.2 from a physical then repeated 6 weeks later PSA 5.7 and %PSA was low (don’t know actual number). Biopsy was performed with 1.5 hits out of 11 needles and given T1c grade. After the surgery on 10/16 my pathology from the prostate gland says: “Gleason 7 (3 + 4). Tumor involves bilateral lobes of the prostate, extraprostatic extension ID’d at the R base, perineural invasion identified, margins = neg, seminal vesicles, no tumor present, and no tumors present in either lymph nodes right or left pelvic.” Dr says I am now PT3aN0. My question is, can the cancer cells spread in the nerves as easily as the lymph nodes in my body? What does the extraprostatic extension mean in regards to my prognosis?
Thanks Dave
Dear Dave,
I don’t really know how to answer your question because I am not sure I understand the operational definition of “spread as easily.”
pT3a is a higher stage than pT2c and lower than pT4. So it’s more serious than pT2c but less than T4. With that said, stage is but one of variables informing as to prognosis. So it has to be looked at in a broad perspective. I will say that I have seen many patients with Gleason 7, pT3a, negative margins who do really well with surgery alone.
Arnon
Good evening Dr. Arnon,
My Dad was recently diagnosed with low [risk] prostate cancer. He is 77 years old, African American, and in pretty good health. I am going with him to doctor on Wednesday to find out what treatment if any his doctor is suggesting. He told me his doctor wants to treat him with radiation. I am not sure that is good for him at his age that is why I am going with him to his appointment. What questions should I ask his doctor? Thank you!
Hi Patricia,
Thank you for this.
The decision to treat really must first carefully define the objective of treatment. Depending upon competing risks (he is 77 but “in pretty good health”, implying relatively few competing risks), you may want to treat. However, this analysis really cannot be done without first knowing about his cancer (PSA, DRE, biopsy Gleason score, number of cores involved, proportion of each core involved) and his health (obesity, smoking history, family history, illnesses such as hypertension and diabetes, and the like). These are the things you want to get at during the first consultation.
If a decision is made to treat, it must be made in the context of other factors. For example, if your father has a very large prostate and has been in urinary retention, then brachytherapy radiation (seeding) is a poor choice for technical reasons and because the risk of recurrent retention is high. In such an example, surgery can work well and “kill two birds with one stone” but must also take into account possible risks, such as urinary incontinence. If surgery, then minimally invasive and by a surgeon who is very experienced.
Start with this batch of considerations. And please consider joining our Primary Issues group if you want to share with others as you move forward toward a primary treatment (or not) decision.
Arnon
Have you had any experience using toremifene for reducing side effects of hormone therapy? Do you have any comments about Rexin-G for treating advanced prostate cancer?
Thank you for your time.
Dear John,
I have had no experience with toremifene. I had not heard of Rexin-G until your query.
Thank you.
Arnon
combine gleason score7 ,with isolated foci of 8
extent of invasion [tmn}73bnxmx
lymph examined n/a
margin 1 mm from ottermost bladder neck inked margin posiitive margin, 1 mm from posterior black inked margin ,positive seminial vexicle sorttissue margins blue ink
extraprostatic extension :yes
seminal vesicle invasion: yes
8o % involved on the right
60% involved on left
there is also pobable lymphovascular invasion section
8 out of 12 cores cancer
psa was 17.6 da vince removal of prostate 4 weeks post psa 1.2 7 weeks latter 2.3 then 36 treatmeant of radiation now waite for next psa see doc july 31 on friday and monday before do psa . worried that ill have to do hormone im tired most of the time and hard to keep mind on my job, four weeks after radiation went from 2.3 to 1.5 .. wait till oct. 30 for another psa test ,oct. 26 psa went from 1.5 to 0.07 see urologist fri. what will be next wait and see if it lowers in another 90 days or have treatment
Ron,
I understand that you had a prostatectomy and they found a T3b Gleason 7/8 tumor with probable lymphovascular invasion, followed by radiation and a PSA that has gone recently to 0.07 ng/ml. I understand that you are tired, but I have no ability to know if this is from radiation, depression, or other causes. My best advice, given the complexity of your case, that you discuss your concerns — including your fatigue — with your doctor(s). And be absolutely sure to discuss whatever you mean by “treatment” and its possible side effects.
I would invite you to also join our Social Network, where you will surely find support and understanding.
Arnon
My husband just had a radical prostatectomy. His Gleason score was upgraded to 8. He had perineural invasion; the cancer was outside of the left side of the prostate but with surgery and removal of the nerves they were able to achieve a negative margin. On the right side, they preserved the nerves but had a 1 mm positive margin. We were told that some of the literature considered this a negative margin.
He had negative nodes and the seminal vesicles were also negative. His bone scan was negative and his presurgery PSA was 3.4. He is 55 and in excellent health.
He is home recuperating with his catheter for 20 days, at which time we will return to have it removed. My questions are:
– What are our next steps and recommendations for treatment?
– If radiation is recommended, how do they even know where to radiate?
– What are the side effects (short- and long-term) for this type of radiation?
– If he has radiation, what is his life expectancy?
– What questions should we be asking when we return to have the catheter removed?
– Are there other treatments we should be considering?
Hi Evelyn,
Thank you for writing. For clarify, this is a pT3a Gleason 8 tumor with a 1 mm positive margin. I do agree that 1 mm positive margins are generally meaningless from a prognostic point of view.
Your questions are:
– What are our next steps and recommendations for treatment? Please discuss this with his surgeon.
– If radiation is recommended, how do they even know where to radiate? They don’t have a specific idea and thus radiation would probably be generalized to the pelvis. This is something you can verify with a radiation oncologist.
– What are the side effects (short- and long-term) for this type of radiation? See above.
– If he has radiation, what is his life expectancy? Life expectancy is a function of MANY variables, of which radiation is but one. To answer this, you’d have to look at all the other relevant variables: illness, obesity, depression, family history …
– What questions should we be asking when we return to have the catheter removed? I would focus on which foods and drink to avoid so as not to exacerbate incontinence, when to check the PSA, and when he can resume desired activity: sport, work, sex.
– Are there other treatments we should be considering? None that I can think of.
Arnon,
I am currently on intermittent hormone therapy and just starting back on Lupron after a 2.5-year “off cycle.” While on Lupron in the past my cholesterol has risen from 160 to 240. Is there currently enough evidence to justify use of statins and/or supplements such as red rice yeast to reduce cholesterol in patients on Lupron?
Thank you for your time.
Good question. I suppose that justification would have to be in the form of data to illustrate that in patients in Lupron lowering cholesterol is associated with a desired salutary effect. I am aware of no such data. At teh same time, I wonder if as a subgroup men on Lupron would hypothetically be any different from men not on Lupron when it comes to this question. In other words, why would being on Lupron exempt a man from the same consideration about statins that are faced by men not on Lupron?
Arnon
Hello Arnon,
After having a prostate biopsy, if PSA deems necessary, how long would it take for prostate to heal and be in shape to do a repeat biopsy? Is there a rule of thumb?
Thanks, Marc
Not really, Marc, but as a practical matter there is rarely a need to urgently redo the biopsy. Usually there are a few weeks anyway in which the prostate can “heal” long enough to have yet another needle introduced into it.
AK
Hello, Dr Arnon,
Male: Age 64.5 years
In the past note, I gave no prostate history, see below brief description
Tests Performed, outcomes
07/30/2009 PSA = 19.5
08/21/2009 Nuclear Bone Scan: Kidneys and bladder appear normal.
Impression: Negative study for osseous metastatic disease.
09/01/2009 Full Body CT Scan:
Impression: Enlarged prostate gland, with area of enhancement and
nodularity centrally within the prostate extending into the
posterior bladder, consistent with the history of prostate carcinoma.
Direct bladder invasion cannot be ruled out.
09/04/2009 Prostate Biopsy, 14 cores, Pathology diagnoses: No malignancy identified
Clinical History: 39 gm sizing; BPH
Dr. said I was diagnosed w/acute prostatitis, prescribed antibiotic, Levaquin to take 30 days, I took levaquin only 14 days as I acquired a pain in my left ankle (a known possible side effect) I called clinic, reported to nurse, I had quit taking levaquin, due to pain in my Achilles tendon and asked if she would please tell Dr to call me, to advise if treatment should be continued with a different antibiotic. Dr never called, I went to clinic next day, Dr was in surgery, spoke to nurse, assured me she would give my handwritten note to Dr, he never contacted me. I kept follow up appointment 11/06/2009, PSA now at 30.0. Dr wanted to do another biopsy right then. I said no, I must recover from last biopsy. Assisting clinic Dr said you must come back, make appointment for no more than a week away. I made appointment for 11/12/2009. I called and cancelled this appt. Confused, if I should do biopsy now, or wait until my prostate has healed from biopsy, taken less than 2 mos ago. Note: took about 3 weeks for blood to get out of my urine from biopsy.
My symptoms: slight full feeling in pelvis, get up 4 times at night to urinate, weak stream (stream stronger in daytime, less frequent), lower back pain, under job stress, need expertise.
Note: I don’t have Insurance or money to choose Drs.
I’m a 64.5 year old and will be eligible for Medicare in April 2010.
Would it be wise for me to wait ?
I would greatly appreciate your expertise and any suggestions that could possibly help?
Thank you, for your time
A bit complicated so be careful with my answer, since I have not seen you. You did have one 14-core biopsy that was negative and your doctor did say you have acute prostatitis, which is also consistent with your symptoms and the relatively rapidly rising PSA. I’d ask about medications (alpha blockers) to perhaps relieve some of the symptoms and ask your doctor very directly what you asked me about a medical approach to management. I am not opposed to a biopsy but I’d really like his opinion about acute prostatitis and whether or not you need a course of antibiotics again before a biopsy.
AK
Dr. felt a lump on my prostate March 2009. PSA 1.6 March 2009. Biopsy negative April 2009, but indicated inflammation. Vasectomy May 2009. PSA 1.9 November 2009. I am 47. My father has and my grandfather (mom’s side) had prostate cancer, both over 70 years old. I am healthy with no other issues. Dr. prescribed Cipro 500 mg for 21 days and another PSA in 6 months. Your thoughts?
My thoughts: I’d want to know the adequacy of the biopsy. Number of cores, how many targeted to the “lump,” pathologist confidence and ability. The family history and “lump” would make me stay very vigilant and keep me wondering if to repeat the biopsy at any sign of technical insufficiency.
AK
12 samples were taken.
How would I get answers to your other questions?
Review the report with your urologist. AK
What about the inflammation? Cipro? Waiting 6 months for the next PSA?
Histological inflammation is very common and very nonspecific.
‘
Cipro is a treatment for bacterial infection, of which you have reported no sign or symptom.
And thanks so much for your prompt responses. I really didn’t expect to receive responses so quickly. I also like the content and format of your website.
Dr. Arnon
Appreciate a doctor who practices taking the time to answer prostate cancer questions. I was dx with t1c pc 46 cores done 45 were clear and one involving <5% ca. Gleason score of 6. Density was .067 and the cells were described as moderately differentiated. My PSA score had elevated from 1.84 in 2007 to 3.4 in 2008 and 5.09 in Oct. 2009. I had this done locally on Oct.6, 2009. My local doctor said if I were 10 years older he would tell me to wait. I then went to a newly designated NCI center in a large city in the southeast. I saw a medical oncologist and 3 weeks later a urologist.
My wife is being treated for breast cancer at this same facility and we think she is getting world class treatment.
I am 59 years old, work every day in a pulp mill, and am 65 inches tall, weigh 232 lbs. I do a lot of physical activity when the system is in upset condition. Other than that I have not been very active. My wife was treated in 2000 with breast cancer aggressively under clinical trial and neither one of us has been as active as before her cancer. Her present cancer is not recurrent by the way; completely new. I was told by the urologist to lose 30-50 lbs and come back to see him in the spring. His specialty is retropubic surgery. I also stated to him my insurance deductible goes from $600 a year to $7500 in 2010. He said I have a very low risk disease and losing weight would help with post-op complications and I need to consider this as opposed to rushing things up because of my deductible situation. I agree, but I have a terrible history of cancer in my family; only 1 that was prostate though, an uncle. I have been schooled in the fact that the earlier diagnosis the better. He stated he has patients with bladder cancer and have a 3-month window in which they need treatment and he is in the operating room more days than he should be. Sounds like they need to hire more help.This is a teaching university.
I have changed my diet since and am walking about 30 min a day, either on a treadmill or walking 10 stories up a tower at work. I have an appointment at Mayo Clinic in Jacksonville, Fla. on 11/19/2009. I have high blood pressure, some heart disease, and diabetes. I have these under control. I was also told through my journey by a nurse at another group that [after biopsy] they like the prostate to heal before surgery for about 8 weeks.
My questions are do treating physicians often recommend this or what happens in a case when the patient has a higher risk cancer and treatment is deemed sooner than later and the patient is obese? I have considered active surveilance, radiation, and seeds. According to my medical reports my prostate is too large for seeds: 84 cc. I really want it out and as soon as possible so I can recover and continue to take my wife to her treatments (surgery and radiation). Can robotic surgery be performed on fat guys like me? If the patient chooses surgery and he has it removed why do you need it to heal up? I know it would help to see me physically but that isn't possible before my next appointment.
Thanks for your time!
Sincerely
David Oliver
************
You raise many interesting questions.
First of all, we face the question of IF to treat. Your cardiovascular risk factors are real and compete with the prostate cancer for dominance. So in this context how urgent is it to treat the low stage prostate cancer? This is a question for your internist and/or cardiologist.
Secondly, it sure seems VERY important to deal with your wellness. Does your employer have a program? Can your internist guide you?
Finally, there is the technical issue that you raise. Sure, it is possible to remove prostates from obese patients. My personal preference, especially in obese patients, is to approach this laparoscopically, not “robotically.” This is an issue best addressed by the surgeon you’re consulting and, as you’ve suggested, is best addressed with a physical examination.
Good luck!
Arnon
Hello Dr. Arnon,
I’m 63, a healthy and fit business owner whose RP pathology report describes a “mostly on the right, intermediate volume, bilateral tumor, 4 + 3 Gleason, with focal posterolateral extraprostatic extension in the right posterolateral region and extension to the inked intraprostatic surgical margin along a 2 mm length in the right posterolateral prostate. There is no evidence of seminal vesicle invasion or lymph node carcinoma ….”
The report concluded with “…the minimum pathologic stage is pT3a NO”
During our first post-op visit, my surgeon discussed the elements of this report and the implications of disease progression with a positive surgical margin. He listed three choices to consider: RT, ADT, or wait and see. I chose wait and see, primarily to avoid the immediate consequences and the uncertainty of my need for those therapies. 45 months later my PSA level is undetectable.
That’s a Good Thing — but a concern lingers about ‘PSM’ and the sensitivity of the PSA test. Presuming some cells remain, based on the pathologist’s report, why isn’t there a measurable PSA? Is a threshold number or “critical mass” of cells required before a PSA can be measured? Is cell growth correlated to carcinoma grade or classification? Do an individual’s hormone levels influence cell growth rates? Will “the other shoe drop?” Is the disease in remission or has enough time passed to declare victory?
Dr Arnon, your thoughts and suggestions would be much appreciated.?
Thanks very much!
Jim
**********
Why isn’t there a measurable PSA? “Measurable” is a relative term. There is probably always some PSA, of prostatic or extra-prostatic origins. And there are assays of variable sensitivity.
Is a threshold number or “critical mass” of cells required before a PSA can be measured? Presumably.
Is cell growth correlated to carcinoma grade or classification? Grade is a classification. Is growth correlated? Not sure what you mean by “cell growth” but clinical progression is surely correlated to grade.
Do an individual’s hormone levels influence cell growth rates? Yes, theoretically so.
Will “the other shoe drop?” Not necessarily.
Is the disease in remission or has enough time passed to declare victory? The disease may be in remission or gone. We don’t know yet. Declarations of victory are perhaps psychologically soothing but they are not clinicall useful. Work with your surgeon and follow his instructions for ongoing surveillance. PSA is a basic element of this.
Dr Arnon, your thoughts and suggestions would be much appreciated.? Take one step at a time. There are things you cannot know today and your course will require patience. This maybe be frustrating but I cannot think of a way around it. Work with your surgeon and follow his instructions for ongoing surveillance. PSA is a basic element of this.
Arnon
I (age 61) initially went to a urologist when my PSA was 8.2. A biopsy revealed I did have prostate cancer and I was told my Gleason score was 6. Three weeks later I had a radical prostatectomy using robotic surgery. There was no evidence of the cancer in the lymph nodes and the surgeon told me there was no cancer on the margins. I bounced back quite well following surgery.
However, there was a little snag when the pathology report came back and said there was seminal vesicle involvement in one vesicle.
The surgeon was surprised, considering my PSA, Gleason score, etc.
He did say there was a possibility that since the cancer was still contained in parts that were removed at surgery that it might not be as ominous a situation as often predicted.
I will have my first post-surgery PSA test next week.
Although I am 61 I am in relatively good health — weight 175 (6′1″). I walk 3 miles a day, do not consume much sugar/carbs.
Obviously I was disturbed to learn that I was not out of the woods, but wonder is there reason for optimism?
Dear Vince,
Yes, there is reason for optimism. This is not to say that you should throw caution to the wind and not do the PSA followup you suggest. However, your surgeon correctly implies that pathological stage is but one crude measure of prognosis. While we generally see SV involvement as unwanted, not all SV involvement is the same. In your case, it is grouped with moderate grade, which is unusual but which must be factored in (in a positive way). And with negative nodes and negative margins. So while yours is a mixed message (yes, SV involvement but no, not that much, really), there is certainly room for cautious optimism.
Arnon
I had a relatively successful prostatectomy in 1997 — and since then have been trying to follow closely the “PSA screening” debate. I have been wondering — these massive studies begin with PSA tests and end with outcomes, and the positive outcomes are less than expected in some/many/most epidemological studies. However there are obviously many steps in between initial PSA evaluation and final outcome, and it’s been my belief that not taking the optimum course after the initial evaluation could substantially reduce the potential benefits of PSA screening. Consequently aren’t results of many of the mass statistical studies reflections of procedures following screening, as much or more than the PSA test itself. This view seems to me to be supported by the recent Journal of Urology study suggesting that many surgeon’s in North America probably shouldn’t be chosen for one’s prostatectomy because of lack of experience on their part. It seems to me that inadequate surgery can reduce substantially the benefits to be obtained from PSA screening. What do you think?
According to an article on Medscape on November 25, 2009, the majority of surgeons performing radical prostatectomy in the United States have extremely low annual caseloads, which can result in an increased risk for surgical complications and cancer recurrence, according to a new analysis published in the December issue of the Journal of Urology.
Dear Lee,
There are many theoretical deficiencies in interpreting observations regarding associations of screenind and diagnostic actions with clinical outcomes, such as survival. The studies that most recently were publicized certainly suffered from a number of deficiencies. For example, the North American study suffered from sample contamination, in which supposedly non-screened patients actually were partly screened.
Variations in the quality of treatment can surely partly obscure any possible associations of screening action and outcome, such as survival. So until such quality is standardized — surgeon case-load is one possible characteristic of quality — we may well be interfering with our ability to understand how screening affects survival. I agree with your analysis.
Arnon
Hello Dr. Arnon.
My father was diagnosed with prostate cancer in November 1992 and was treated with external beam radiation.
After the prostate [cancer treatment], he had string of health-related problems: bladder cancer, quadruple bypass, defribilator implant, and a carcenoid tumor removed from his large intestine.
In the past 2 years his PSA has risen substantially. The last reading was 27.0 ng/ml prior to hormone therapy. He is being treated with Lupron and has responded well; his PSA is 0.57. Now for the problem. It seems that his blood pressure has risen, his ankles are slightly swollen, he is also having mood swings, and seems to have a hard time concentrating.
Is there another hormone or [comparable] treatment that can be given to him that would help to improve his quality of life? I am not sure if it’s the Lupron, but this seems to have happened since treatment began.
Sorry for the long letter. Thanks for taking the time to read this.
——-
Dear Louis,
Thank you for writing.
The symptoms you describe are consistent with the effects of Lupron, so the timing may well be cause and effect. As for substitutes, yes. The conventional surgical castration, while perhaps emotionally displeasing, is generally associated with fewer side effects. So while I have seen some very dramatic hypertensive reactions to Lupron, I cannot recall a single such case with castration (orchiectomy). There are other side effects shared by the two approaches: bone loss, fatigue — but some will be easier with surgery.
He’s lucky to have your support.
Arnon
Dr. Arnon:
My husband had prostate cancer and chose the HIFU treatment. He is 59 years old and had a PSA of 9.5 and a Gleason score of 6 of 3 + 3. He is now 3 months post HIFU and his 1 month PSA was 3.6 and we just recieved his 3 month PSA which had risen to 4.7. My question to you is, should his PSA still be this high?. His current doctor does not seem too concerned about it. I am very concerned because the doctor estimated that it took about 7 years to reach 9.5 and now it is jumping over a point in a couple of months.
Dear Kim:
Thank you for writing.
Please let me point you to a post from earlier this year that illustrates where PSA typically nadirs after HIFU. Click Here. Your husband’s situation seems at clear odds with this typical pattern. I have not heard of such a pattern before and am at a loss to explain it. Please keep in mind that I have practical experience with surgery, not HIFU, so maybe I am missing something. You may wish to review your husband’s case in light of the post I have shared with you.
You may also wish to join our social network, which has an active HIFU group, where you may also find some useful knowledge. If you want feedback about the situation, go into the Discussion Forum within that group, find the +Start Discussion button, and post whatever’s on your mind. You will probably get some reactions.
Good luck.
Arnon
Recently I asked about some optimism considering after prostate surgery when the patholgy report showed semina vesicle invasion (in one vesicle). My Gleason was 6 (3+3) and pre surgery PSA was 8.
My first PSA post surgery was less than 0.1 (five weeks after surgery).
Dr. was pleased with results and indicated that he was surprised by the pathology report, but after first PSA he believes that the prostate cancer was more than likely located near the seminal vesicle.
He now doubts that it was systemic.
He is optimistic because he said said he left nothing behind.
I’m feeling more optimistic. Should I be?
Vince,
Thanks for the followup.
I am not sure I fully understand your question. A few comments:
Optimism is a personality trait that governs emotional coping strategies. I am not sure that optimism as a personality trait varies very much. In fact, I remember hearing from one psychiatrist I know that it’s a rather durable trait. Given your apparent anxiety I suspect that you are not fully coping with the diagnosis and followup, so as a purely remote gut feeling I suspect that you are not by nature an optimist. If so, and if you are struggling with coping, then this is a separate matter and can be dealt with by a variety of mechanisms. I will table that discussion for now.
More to the point, I think you’re asking about the likelihood that you will have recurrence of prostate cancer in a way that clinically and meaningfully affects your life. For this assesssment, I really do need more information than I have at the moment. However, it sure is a good thing that the PSA was “undetectable.” Much better than a measurable PSA. Does this mean you’re off the hook with no risk of recurrence? No, it does not mean that. So there is an element of uncertainty about the likelihood of recurrence that, given the specifics of your case and the things I do not know about your case, is hard for me to quantify.
Which kinda brings me back to the optimism-coping-anxiety issue: How does Vince cope with uncertainty? How does he mitigate the potential ill effects of anxiety?
I’m not sure if I’ve answered your question but these are my clinical reactions and questions.
Arnon
Doc,
Six years ago I was diagnosed with prostate cancer and had EBR which didn’t get all of the cancer. My urologist has me on Lupron. I am 71 year old Caucasian in good health. Are there any other options besides Lupron? Cyberknife, cryosurgery, re-radiation, etc?
Thanks,
Neil
Hi Neil
There are a variety of potential options that depend upon the nature of what I understand is a recurrence, including its stage, and that include more radiation, hormone treatments, salvage surgery … To make this assessment would also require full knowledge of your health. So I am afraid that I am not in a good position to guide you specifically other than to suggest you revisit the question specifically with your doctor.
Arnon
IGRT Question:
In researching IGRT, I found that the Cleveland Clinic uses the following protocol for IGRT and prostate cancer. A cone beam CT to help identify the bladder and rectum, Clarity by Resonant to obtain an ultrasound snapshot of the prostate, and the Calypso system to detect real time motion of the prostate. (I believe that markers are inserted into the prostate.) Reportedly this system provides very precise targeting and lessens the possible side effects of radiation. At this time only one hospital in the MD area — Baltimore Washington Medical Center — offers this protocol for low volume prostate cancer. I am currently in the active surveillance program at Johns Hopkins. I have decided that if I need to move to active treatment that I would opt for IGRT. I have contacted radiation oncology at JHH to see how they deliver IGRT but have not yet received a reply. My question — is the Calypso system substantially better than traditional IGRT?
Thanks for your input.
Hi Glen,
Thank you for the question. I sometimes have a hard time following all the latest commercial names and acronyms associated with prostate irradiation. To know if one new device or strategy is better than another requires the right kind of data. I have not seen any scientific data to prove that Calypso is better or worse than any other modality in terms of survival benefit and/or risk.
Here is a post on Calypso from this site.
Here is a video about prostate irradiation in which you may find value.
Arnon
I recently had my prostate removed. At 4 weeks my initial PSA reading was 0.102. From what I have read that is higher than it should be as it should be below 0.05. Do you feel that taking it 4 weeks was a little early and that taking it again at 8 weeks we will get a better reading or should I prepare myself for further treatment?
*******
Dear David,
In some cases, PSA can take its sweet time dropping after radical prostatectomy. It’s hard to say how fast it will act in a specific case. At 4 weeks you are not necessarily looking at the nadir PSA, so to repeat it in a couple of months is a reasonable approach.
The prognostic assessment at this stage depends also on the pathology report. Indeed, the assessment of what is happening with the PSA and if it makes any sense depends largely on that report.
Arnon
Dear Dr. Krongrad:
In June 2006 my PSA level was 5.0. I was given antibiotics and it went down to 4.0. In February of 2009 my PSA was 10.0 on three different PSA tests. I was biopsied in April 2009 and they could not find cancer. I took another PSA test a couple of weeks ago, and from July 31 to my most recent test, my PSA increased from 10.0 to 12.74. I am guessing they will want to perform another biopsy. My question is this: Is it possible to have BPH with PSA levels increasing at this rate?
—–
Dear Michael,
PSA can rise and fall for many reasons and at different rates. So sure, it’s possible to have a fluctuation due to BPH, lab variation, assay variation, inflammation, urinary infection, urethral trauma, prostatitis, cancer, and surely more.
The question on my mind is this: Do you have prostate cancer? A single biopsy does not absolutely negate this possibility. To assess the answer requires detail (age, family history, DRE results, prostate size, adequacy of the previous biopsy, results of the previous biopsy wherein atypia is different from fibromuscular hyperplasia). Depending upon this assessment, if I was your doctor, and I am not, I might recommend a repeated biopsy of similar or different technique.
Arnon
What would be the appropriate way in which to properly compare the results of a 12-core biopsy with one taken later with 15 cores? If, as in my case, 2 of the 12-core results were positive (4% and 22%), what criteria would apply 18 months later following a 15-core sample? I suspect the “extra” cores were taken from the two sectors that had previously positive cores, plus an extra from an area previously labled “suspicious.” Bottom line: What type of result would indicate a level of progression warranting serious consideration of active treatment?
Dear Don,
We just wrapped an exchange about two men with small amounts of Gleason 6 prostate cancer on their prostate biopsy (click here to see it), one of whom first chose watchful waiting. One of the issues was whether or not we have the staging technology to safely follow such cases and to notify in a timely manner before prognosis becomes irretrievably bad (which assumes we know when that would be).
I argued that we do not. This is because no set of clinical data (PSA, DRE, biopsy) can precisely stage a cancer. Assuming that stage is perfectly correlated to prognosis, which is admittedly simplistic, the argument is that no set of clinical data can precisely guage progsnosis. Accordingly, no set of sequential re-assessments can precisely guage variations (improvement, deterioration) of prognosis.
Sure, you can draw inferences, but you can easily be wrong when each of your data points is imprecise. What if the cancer was actually getting worse, the first biopsy over-estimated the cancer, you embraced active surveillance, and the second biopsy under-estimated, perhaps totally missed, the cancer? You’d think you were getting better, when the opposite was true.
To compare two 12-core biopsies involves two sets of uncertainty. To compare a 12-core to a 15-core biopsy involves three sets of uncertainty: the first biopsy, the second biopsy, the variations in sampling.
Arnon
Dear Dr. Krongrad,
I am 7 months out from a RP with Gleason 6, four very small areas of involvement on pathology, involving about 1% of examined tissue, stage pT2cN0Mx, margins “clear but very close.” My 4-month PSA was reported to me as undetectable (the form actually says ‘<0.1', now that I look at it), but the nurse just called with the 7-month PSA of 0.1, which she says is normal. The two blood samples were drawn in the same place, presumably analyzed in the same lab. The nurse, however, is a new employee. I looked on the discussion group about post-op persistent PSA, and I suppose there is a discussion of this sort of situation somewhere, but I did not see it.
Obviously, I understand that if the first level was not a true 0.0, but merely something or other less than 0.1, whereas this one was actually 0.1, then there is no real difference between the two. However, I had been given to understand that the level by 6 months (if not by 3 months) would be a true 0 if the surgery removed all the prostate and all the prostate cancer. So, what does it mean?
—–
Allan
I see you joined the PSA Persists group. That seems like a great place to post this, especially since you can later update everyone.
I think it’s too early to tell anything. Don’t over-read. Wait for the next test. And there is no true zero, even though some labs round down to 0.
Get copies of your PSA lab reports and look at them yourself. The phone verbals can often miss such details as “<" signs.
Arnon
Dr.:
I am a very healthy 65-year-old who over the past 6 years has had 7 biopsies — all negative. This December I had a TURP to see if the cancer was hidden and it showed — adenocarcinoma of prostate, Gleason’s predominant pattern 4, secondary pattern 3; score 7/10, involving 56 of 97 chips and approximately 40% of tissue.
I have a reccomended treatment of hormone therapy + external beam radiation, and another recommendation by a prominent surgeon to remove the prostate. The external beam recommendation was given because of the increased risk of incontinence because of the TURP. My questions are: (1) does a TURP in fact present an increased risk of incontinence, and (2) does hormone treatment complicate a decision to go the surgery route?
—–
Dear Peter,
You’re surely in the minority category, so many negative biopsies yet there was cancer. What interests me in this observation is the tumor volume and the biopsy’s inability to detect it. There’s a mismatch. So my antennas are up for lots more detail: Pre-TURP PSA, Pre-TURP prostate volume, family history, and more. Something about this tells me there is substantial volume remaining and I would not be surprised if there was cancer into the peri-prostatic fat. I am not saying I know this. I am saying that it’s a subtle gut feeling and I wish I knew more.
TURP does not seem to increase incontinence after RP. And hormones are a non-issue.
If you’re in the mood for it, you can post this also on Primary Issues group (see Discussion Forum and look for +Start Discussion). You’re an unusual presentation and I think the members, as well as you, might gain from the interaction and eventual followup.
Arnon
Dr. Krongrad,
Is it possible that the needles used to perform a biopsy can scar the prostate? And is it possible that the scarring can be mistaken for a tumor in a subsequest DRE? Prior to my biopsy, the DRE did not reveal any abnormalities. My doctor said that he “felt something” during a DRE performed 3 months after my biopsy. The PSA level was unchanged, but he said he felt “something”. Please advise and thank you in advance,.
—–
Dear Michael:
Yes, we know that trauma, including trauma from biopsy, can cause bleeding and scarring. And yes, the DRE is non-specific and cannot precisely distinguish scar and tumor.
Arnon
17.6 prostate removed da-vice .3 months after 1.2 …. 2 months latter 2.3 just finshed radiation,, 36 treatments…go see urologist july 31 on friday monday before get psa test gleason score 7 some parts 8 stage t3c im 55 ill put in pathology report latter
combine gleason score7 ,with isolated foci of 8
extent of invasion [tmn}73bnxmx
lymph examined n/a
margin 1 mm from ottermost bladder neck inked margin posiitive margin, 1 mm from posterior black inked margin ,positive seminial vexicle sorttissue margins blue ink
extraprostatic extension :yes
seminal vesicle invasion: yes
8o % involved on the right
60% involved on left
there is also pobable lymphovascular invasion section
8 out of 12 cores vancer
worried that ill have to do hormone prostate renoved nov. 19 no erection yet started having control of bladder then radiation caused me to lose some control. 2 or 3 pads at work. i guess im trying to get all this out of mind for a few hours. i have emotional break down i guess this is nomal .a year latter down to one pad and a psa of ..05 next psa will be jan 31 2010. im having pain in legs and hips ,like muscle pain or bone pain could this be from working or advance cancer.
—
Dear Ron: We apologize. We have tried very hard to understand your question, but it is not clear to us exactly “where you are” in your treatment. When did you have your surgery? When did you have the radiation? Can you give precise dates for these and for your PSA levels? It is not possible to offer you any advice without some additional input from you. Have you considered joining the social network and asking your questions there?
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
—
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
I have a question about the vantus implant
—
Dear Tom: What is your question?
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