I was diagnosed with prostate cancer in October, 2005. My minimally invasive surgery 2 months later was very successful. My PSA since then has remained less than 0.1.

My question, however, is not about me. It’s in regard to a friend of mine who was diagnosed with early stage prostate cancer about 2.5 years ago. I don’t know what his PSA was at the time, nor do I recall his Gleason score or exactly what stage his cancer was, but during his “watch and wait,” period, he has had a few biopsies and several PSAs. The PSA levels have steadily decreased. Because his most recent PSA was down to less than 1.0, his primary care physician told him that he’s now probably cancer-free. Is this possible? Could a biopsy, or repeated biopsies, somehow remove the cancer? Does cancer ever disappear without treatment?

Tom

*****Answer*****

Tom,

Not too likely, even as his overall risk is low (as implied by a low PSA).

Arnon

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Thomas,

Have a look at this discussion thread on the social network.

Arnon

I’m not sure of your husband’s age or general health, but 4 weeks post-op is certainly not long enough to be concerned about an erection.

I had DaVinci prostate removal 2 years ago (nerve sparing and localized cancer contained in the capsule) by an excellent surgeon. It took 2 months for total continence to return, and about the same for some rectal pain to subside. To this day an erection without some sort of mechanical intervention is not possible. Shots will do it with no problem, but I do not tolerate those well. I personally prefer a vacuum pump, which does well. I am now — after 2 years — capable of achieving a slightly firm appendage on my own, but it is not sufficient for intercourse. I am 54 years old and in great health and fit. The point is that everyone is different and the recovery period for each will be different. Be patient and support your husband as much as possible through his recovery. There are many ways of achieving closeness and intimacy without the actual act. If you both are anxious, then ask about the injections, because they do work, but don’t let your husband get discouraged because his recovery doesn’t happen as quickly as you or he think it should.

Greg

His results were fabulous, all organ contained; cancer was very small and found through PSA. Surgeon said he was able to save nerve bundles. He is continent except for a few “stress incontinence events.” He has moderate abdominal bloating and some back/flank type pain which bothers him and I know worries him. His bowel pattern has changed.

He has gone back to work (desk work) but sits a great deal of time at home, complaining of discomfort and swelling. Cialis 5 mg/day but nothing in the erection department. I am very frustrated and not sure if this is to be expected, depression, or being “whiney”. This is our first health crisis. Surgeon follow-up vist in 4 weeks.

My husband has talked with office nurse, but is told all is moving as expected. Thanks for your help!

*****Answer*****

Hi P,

Unless your husband is 30 years old, then the lack of erections at 4 weeks post-op, especially since he has other physical discomforts, is not at all surprising. It also has no particular prognostic significance and you may not want to work into anxiety with it.

Back pain is not uncommon in the first few days if the patient has been lying in bed a lot. This is especially true in men who have chronic back pain, which can be exacerbated by bed rest. On the other hand, flank pain is less common, although it can represent muscle spasm and ache. However, at a month post-op, and especially if flank pain is stationery (doesn’t move about as you would expect if it was from intestinal gas; which raises the question of if he’s constipated) and/or is associated with nausea/vomitimg/loss of appetite and/or is getting worse, then it unusual and would warrant serious attention and, at the absolute least, informing his surgeon.

Arnon

My father is 71 years old; no history of prostate cancer. His PSA 11.6 in November and 17.0 ng/ml in December. The urologist suggested a biopsy for him. He had a heart bypass 8 years ago and he has diabetes and high blood pressure. My question is, are there any side effects of biopsy?

*****Answer*****

Hi Sangita,

Yes, like all invasive procedures, prostate biopsy is associated with a range of risks, including bleeding and infection, which can include sepsis (bacteria getting into the blood stream). Your father can review these risks with his doctor(s) so he can make an informed decision and consent.

Arnon

I am 73 and had an RP in 2003, at biopsy my Gleason score was 3 + 4 and I had 16 core samples (right side sample clean, left side had cancer cells). [After the RP], the surgeon felt that everything looked very good because the cancer was contained within the gland.

After 1 year the PSA reading was 0.1 and from that time forward to November annual PSA, where the PSA read 1.4 ng/ml, the rise seems to be 0.2 per year since 2008. I am concerned about a constantly rising PSA. As I understand it, PSA can be produced by either or normal prostate cells or cancer cells remaining from the RP in 2003, slowly multiplying in the cavity, or around the urethra or bottom of the bladder.

My primary care doctor scheduled a consultation for me with a specialist who flatly said I had cancer again. How can he determine whether or not these remaining cells are cancerous, seeing that the cancer was totally within the prostate prior to the RP, without any tests?

He did order a bone scan, which I have just received, and a CT scan which will be performed this Tuesday, as a “base-line.” I also have a consultation with a radiologist this coming Friday — presumably to discuss what and if radiation is recommended at this time with a PSA at 1.4 and apparently low risk.

I was also told that with low-risk cancer/slow growth, as in my case, after an RP and 10 years later a PSA at only 1.4, they would not start aggressive treatment until the PSA reached 20 ng/ml.

What does the historical data show in cases such as mine, for the PSA increasing more rapidly at some point, as more cells multiply, healthy or cancerous or both?

Do you recommend radiation therapy for me at this time, or wait until the PSA rises to a trigger level? I know that radiation can have unsought consequences of it’s own.

Thank you in advance, Dr. Arnon.

*****Answer*****

Dear Richard,

The bone scan is a good idea. It will probably be negative, but a baseline is useful in the future. And it is possible that the bone scan will be positive, even if low likelihood and in which case you definitely do want to know because it will potentially alter management.

Yes, with time, if this is cancer, there is a chance that the PSA rise will accelerate. But so far it’s risen slowly, so all bets are off. Only time will tell.

Yes, radiation has risk, as you noted. So any decision to have it has to take that into account (and only after the bone scan results are available).

Arnon

I am 61 and had an RP in 2003, followed by radiation and hormone therapy later that year when I had an immediate recurrence. My PSA before surgery was 14 and my Gleason score was 9.

My PSA has stayed at 0 since the radiation/hormone treatment, but I still struggle with anemia. It was extreme back then — a 3 red count. Not so bad now, but below normal. Any thoughts?

Also, does small cell carcinoma with no elevated PSA ever occur in patients who once had higher numbers.

My concerns, obviously, have to do with wondering when/if the other shoe will drop, given my high Gleason score.

Thanks so much.

*****Answer*****

Dear John,

I understand your anxiety but have no crystal ball. At this point, regardless of any theoretical construct, e.g. small cell carcinoma possiblity or not, there will continue to be an element of uncertainty.

Anemia is a nonspecific finding and can be caused by lots and lots of things. If it persists and/or is problematic, then the best way to sort those out is to consult a hematologist.

Arnon

I just got my most recent PSA result, which went down from 6.2 to 1.9 ng/ml. I’m elated, but concerned that the test was inaccurate. I had a biopsy in the fall of 2011 that indicated a 1% positive biopsy core in one of 16 samples, Gleason score of 3 + 4 = 7. I have been on Avodart since then. Could the medication have so drastically reduced my PSA number?

*****Answer*****

Jack,

Yes, along with other things, e.g. resolution of unrecognized prostatitis, dutasteride can lower PSA.

Arnon

My last exam confirmed my prostate was slightly enlarged … Given my age, I’m not suprised. Im more concerned by the extremely high PSA level and the possibility that the biopsy was incorrect.

Should I get another biopsy?

Appreciate any thoughts …

Steve

*****Answer*****

Dear Steve,

In theory, sure, anything is possible. So it’s possible that a biopsy was wrong. Overall, yes, there is a chance of a second biopsy being positive when the first was negative. So this is something you can discuss with your doctor.

There are many explanations for high PSA. Cancer is just one of them.

Arnon

My PSA has risen from 4.7 in June 2011 to 8.2 in November 2011 to 10.9 in December 2011! A prostate biopsy, performed 01/13/2012, has shown that I am positive for prostate cancer in three (3) of the twelve (12) areas biopsied; all positive areas in the same half of the prostate.

My own research leads me to believe these “high-risk” PSA velocity numbers are indicative of extremely aggressive prostate cancer growth, yet my urologist recommends “watchful waiting.”

Added pertinent information is as follows:

(1) I am a 55-year-old white male and have lived all my life in Chicago. (2) My father had prostate cancer, but he died of a heart attack at age 73. (3) Results from my prostate biopsy include a Gleason score of seven (7)… 3 + 3; clinical stage has been determined to be IIA or T1cNXMX; prostate size 43 cc.

How concerned should I be about having an overly aggressive cancer that may kill me within seven (7) years?

I am scared and need other opinions.

What course of action would be recommended for an individual presenting these results?

Thank you for any thoughts you may be able to provide concerning my situation!

Respectfully,

Frank

*****Answer*****

Frank,

There are major internal inconsistencies in your report. First of all, 3+3 does not equal 7. So the first thing to do is to get clarification on your Gleason score. Secondly, I’d get clarification of the stage, too. And then, while your age is useful, I’d ask to put all this into the context of your overall health: diabetes, smoking, obesity, anxiety, social situation …. lots to pull into the discussion. And if this is not enough, then a second opinion is in order.

Arnon

Just got results; age 50; active physically and sexually; non-smoker; no symptoms; PSA 2.4; Gleason 3 + 3 = 6.

What do you advise? Cyberknife, seeds, or Da Vinci?

*****Answer*****

On behalf of Dr. Krongrad, I can tell you that there is no good answer to this question because it depends on your opinions and who you select to treat you. If you join our social network, then you can benefit from the experiences of other men who have needed to make similar decisions over the past few years.

Sitemaster

My husband, aged 55, underwent LRP 2 weeks ago. Catheter removed at day 7 postop. Had reasonable stream, some dribbling, stress incontinence upon rising, etc., …

This morning, 3 days after catheter was removed, he experienced severe pain, 11/10, bladder spasms that took him to his knees, urgency and “dribbling.” We went back to our hospital and a urologist (fellow) carried out a bladder scan, found he was retaining urine and replaced the catheter. He immediately drained about 300 cc of clear, yellow urine.

My husband is devastated. … What does this mean? Will he struggle with incontinence? This is a man who is very active.

Thank you

*****Answer*****

Dear p,

Urinary retention happens in maybe 1% of cases. Probably from a clot or some swelling at the anastomosis. The treatment is a catheter. And … there are no apparent long-term implications for anything. This is typically a very limited event.

Arnon

I had radiation therapy 6 years ago and my PSA went from a 7.4 to an 0.8 after therapy. Now it is up to a 2.2. The 2.2 has been the same for a year. My doctor is recommending cryotherapy but I am not convinced that I need anything else at this time. Isn’t the fact that the PSA stayed at a 2.2 for a year a good sign for me?

Is the doubling time the time from first being diagnosed or from the lowest PSA? I would love to hear your opinion.

*****Answer*****

Leland,

Cryo is only one option. And sure, it is absolutely an option to keep on observing. However, the decision to move forward depends on many things including your tolerance of the risks of any proposed treatments and the wisdom of treating in the context of your overall health. These are subtle considerations and best handled in concert with the doctor who best understands your circumstances.

Arnon

*****Additional comment from Sitemaster*****

Leland:

Your PSA doubling time is measured from the time (and value) of your lowest (nadir) PSA level after radiation therapy to the present time. Ideally, all PSA values used in the calculation should have been generated by the same PSA testing service (to ensure that one is comparing apples to apples). There is an automated PSA doubling time calulator on the Memorial Sloan-Kettering Cancer Center web site that will help you to calulate your personal PSA doubling time with accuracy.

My father, a 63-year-old in great health, was diagnosed with prostate cancer. His test that they collect the multiple samples showed that one piece came back cancerous. He has multiple choices to choose from to get rid of the cancer. Surgery, radiation seeds, etc. My question for you is, what is the safest most reasonable choice to go with if there is one. I’m going with him to his appointment in a couple of weeks when his doctor told him to bring questions with him. Could you let me know what questions I could be helping him with and/or provide us with some resources to help with the questions. Thank you for your advice and help

Sincerely,

Paul I.

*****Answer*****

Hi Paul,

It’s great that you’re getting ready and that you are going. That will really help him.

There is no one right answer for everyone. Each treatment is associated with risks, and you should ask his doctor to explain these to you. In addition, the decision to treat should be placed in the context of his overall health. So for a very healthy, thin, non-smoking 63 y old who has lots of support the recommendation might be different from that of a diabetic, obese, smoker who lives alone.

Arnon

***** Added comment from Sitemaster *****

Paul:

It might help you to look at the list of questions suggested by the National Comprehensive Cancer Center on page 93 of the NCCN patient guidelines about prostate cancer and its management.