You might recall me.

I am 49 years old. I had a robotic RP 6 months ago. Pathology report was as follows: Gleason 3 + 4; cancer volume, 6%; prostate weight, 38 grams; pathological stage, pT2c; no extraprostatic extension; one unifocal positive margin; perineural invasion present.

My pre-op PSA was wobbly between 2.9 and 5.8! And my bone scan and body scan were clear.

My post RP PSA 3 months ago was zero. I am scheduled for another PSA test in 1 month. I feel pretty healthy, with minor side effects.

However, over the past 2 weeks I have developed blood in my urine that at times is quite noticeable. It is accompanied with some major discomforts like urgency, pain, and some sensations. Urinalysis confirmed blood in urine but with no white blood cells or bacteria present.

I am very concerned. Could this be a sign of recurrence of the cancer in my urinary tract? Could this be because of usual side effects of RP and injuries to the urinary tract? How normal or abnormal is this 6 months after RP?

What is the next step (as my surgeon is not communicating well)?

Thank you in advance,

Abbas

***** Answer*****

Hi Abbas,

Not terribly uncommon, though usually associated with urine infection in the first year post-op. Your surgeon will be better able to address, so keep trying to communicate with him.

Arnon

Doctor feels robotic surgery would be best treatment option but chance of cancer returning could be 50% within 5 to 10 years. Do you agree with the doctor and what are my chances of survival?

Thanks for your reply.

Worried

*****Answer*****

Dear worried,

Surgery could well be the best choice, depending upon various factors: height, weight, previous surgery, overall health, and the like. I am not sure I understand what you are asking in regards to survival. If you are asking what are your chances of dying of something other than prostate cancer (assuming you have surgery), then, depending upon your other medical conditions, the chances are good. Again, I’m not sure how to operationalize your question.

Arnon

*****Answer*****

Dear Mr. Weber:

On behalf of Dr. Krongrad, there are a series of relatively simple answers to your questions above, as follows:

(1) The PSA test measures the levels of a protein called prostate-specific antigen in the blood. You can find a basic introduction on the Wikipedia web site. There are several categories of PSA level (total PSA, free PSA, and serum-bound PSA). The standard PSA test measures the total PSA level in serum. You will also find links to several articles on the relevance of PSA testing in the section of this web site that deals with Diagnosis.

(2) PSA levels in individuals can be very difficult to interpret, which is why their value in the assessment of risk for specific prostate disorders is controversial. Some men simply demonstrate elevated levels of PSA in serum (in response to things like prostate inflammation, benign enlargement of the prostate, urinary tract infections, and prostate cancer) more easily than others. We really don’t know why this occurs. The PSA test can not be used on its own to diagnose any prostate disorder. It merely suggests risk for a number of disorders. Subsequent diagnosis of specific disorders then require further tests.

(3) Yes, in some individuals, the prostate can become enlarged without any really significant or demonstrable and consistent increase in PSA levels. However, generally, an enlargement of the prostate over time is associated with a gradual increase in serum PSA levels.

(4) Yes, the PSA level can most certainly increase without any enlargement of the prostate (most commonly because of an infection or inflammation, but also because of the presence of cancer).

(5) In fact, the Department of Health and Human Services has clearly stated that, at least for the present, Medicare will continue to cover the costs of PSA tests. It is the U.S. Preventive Services Task Force (an independent, government-funded advisory group), not Medicare, that has stated that it can no longer recommend that healthy men get regular PSA tests to screen for prostate cancer.

(6) If you were to find that you had a PSA level that was constant at, say, < 1.0 ng/ml over an extended time period and then suddenly rose signifciantly, this would likely be indicative of some sort of prostate or prostate-related urological disorder. (It would be most unusual for a man with a functional prostate to have a PSA level as low as 0.1 ng/ml.)

Your personal need for regular PSA tests is a matter that you you need to discuss with your primary care or other physicians (as recommended by many sets of guidelines).

The Sitemaster

My husband’s PSA results have come back elevated. Physical examination did not show anything present in the way of a lump, swelling, et cet. There is a history of prostate cancer in the family.

My husband is on Plavix due to a prior stroke. In order to do a biopsy, his urologist has said he has to be off the Plavix for 10 days prior to biopsy, and then 3 more days after. He was told there is a 95% chance that he will stroke again being off this long. It has been suggested that a color Doppler ultrasound at this point would be better than the biopsy considering the circumstances. Do you think this would be beneficial?

Thanks, Sherry

*****Answer*****

Sherry,

Given the vascular risk, the first question really is what is the relative risk of doing something (biopsy, treatment if needed) vs. doing nothing. This question is probably best answered by his internist in consultation with his urologist.

Arnon

My husband just had a radical prostatectomy 3 weeks ago. All borders are clean; they took two lymph nodes as well and they are also clear … but … he has seminal vesicle invasion, and has to have a urine sample and PSA test this week. I have read that with SVI after a radical prostatactomy, the results are poor. His PSA prior to surgery was 6.5 with a Gleason score of 4 + 3.

I haven’t told him I have researched this, I don’t want to upset him.

Thank you for your time,

Regards, Holly

*****Answer*****

Hi Holly

SVI is not a uniform predictor of what the future holds. A lot depends upon how much involvement there is and also on unknown factors. Take one day at a time. Get the followup PSAs and let his surgeon help you interpret what this all means.

Arnon

My husband is 41 and just diagnosed with early stage prostate cancer. His father is 67 and has prostate and colon cancer. My question is what treatment is most likely to achieve a 100% cure?

I am hoping he decides to select a treatment that will provide the best possible cure outcome. I’m not at all confident in the watch and wait idea. Saving his life and giving him the best possible chance of a cure is the most crucial priority.

Of course we want to continue our sex life so what ED treatments can he begin to use as soon as possible? We have a very active sex life and he does not have any problems achieving an erection. Also what potential incontinence problems will he face if he undertakes your recommended treatment?

As I get more specific result details I will post again. I understand without specific results my post is rather vague.

*****Answer*****

Dear Melanie,

Thank you for writing. The likelihood of cure varies by PSA, grade, stage, and technical factors relating to treatment, e.g. nerve preservation. It will help you to review these details with his doctor(s), who will then be best able to help you navigate the course between maximizing potentials for cure and functional preservation.

Arnon

I was diagnosed with metastatic prostate cancer 2 months ago. My PSA was 7.7 ng/ml; initial examination of the prostate demonstrated normal contours; the prostate volume was 22.9 ml; there were no hypoechoic areas seen and the contour was regular; the seminal vesicles were “unremarkable.”

A total of eight biopsy cores were taken from the peripheral zone of the prostate — four from each side. A further two cores were taken from the transition zone. The cancer was staged as T1cN0M1 based on the results of a bone biopsy from one rib, which was positive for cancer. The Gleason grade was 3 + 4 = 7.

I am currently taking Zoladex injections (10.8 mg) once every 3 months. My PSA level after 6 weeks of treatment was 1.8

I have been amending my diet as much as possible so that I try to control the cancer as much as I possibly can. I read some research on leucine and how this may be detrimental to my condition. To be honest, I am reading so much conflicting information on diet and food that I am finding it hard to know what to do. Do you know of a really good/reliable web site I could access?

Thanks, Philip

*****Answer*****

Hi Philip,

You may want to check out the Diet group on the social network, where you can also post your own discussion threads (click on the bottom of the discussion forum, where it says “+Add a Discussion”).

Arnon

I have been diagnosed with mild prostamegally and have been under medication for the last month, with any improvement I am taking Norflox now I had stopped.

During my investigation I had high pus cells — it was 100 — and I had difficulties in passing urine. I am treating with ms surgeon. He is a specialist urologist. I am following up still but no cure. Do advise me by return which are the tests to be done. During my test my CBC was 14,000.

Regards

Wilson

*****Answer*****

Hi Wilson,

It sounds like you are describing prostatitis, urethritis, and/or cystitis, possibly with urine infection and/or stone [i.e., probably not prostate cancer]. I would need more details to sort this out. Perhaps the best next step is to visit the urologist again.

Arnon

I am a 67-year-old male. My dad had prostate cancer in his 70s and was told it was slow growing and not a threat.

My PSA has been steadily going up for 7 years. I have had three biopsies — 2 x 12-core and a third state of the art 20 core using MRI imaging at UCLA — which were all negative. I have also had three PCA3 tests which were all low scores.

My question is … now that the PCA3 test has been accepted by the FDA, are you giving it more weight than the PSA test, which has many weaknesses, and if my PCA3 test scores remain low, should I ignore my rising PSA levels?

*****Answer*****

Dear Ron,

The FDA is a body meant principally for first of all to make sure that drugs, devices, and tests do not pose undue and undisclosed toxic effects. The fact that a urine test is approved by the FDA does not in itself mean that it is more precise in its purpose than any other test.

PSA has few weaknesses. The way people common apply it is full of weaknesses. Ditto all other tests.

Ignoring tests is usually not a good idea. Putting them into perspective is usually a good idea. Most importantly, in your case, the 3 negative biopsies (44 negative cores) is a very useful bit of information that can help to guide all further actions and decisions, e.g., should there be a 4th biopsy. On this, your urologist can guide you.

Arnon

I am 56 years old. Sometimes I get an extreme urge to urinate but it is a different-feeling urge, seeming even more urgent than a normal urgency. I need to get to the bathroom right away, because if I don’t, I start to leak semen. And when I urinate the urine is preceded by a small amount of semen. Recently while I was running down the street (I don’t normally run) I found that I was leaking semen with each footfall! What is this very annoying and inconvenient condition?

BTW I have had an enlarged prostate for about 25 years.

Mike

*****Answer*****

Hi Mike,

This is new to me. I’ve not heard of something like this one. Is it semen? Is it lymph (chyluria)? No idea. You may want to see a urologist. And if you get it sorted out, please let us know what this is.

Thank you.

Arnon

My husband had robotic prostectomy 2 weeks ago. He had a biopsy in February with only two of the 12 cores positive (Gleason score 4 + 3). He is 68 years old. DREs by three different doctors appeared to show a smooth prostate. His PSA level had risen from 3.6 to 5.1 in a year and a half. Everyone thought this was going to be a good result. Pathology shows a meaty multi-nodulated prostate with positive surgical margins on the right and left lobes; 50% of prostate involved; Gleason score now 3 + 4.

We have to wait a few more weeks for a first post-surgical PSA, but we are very worried. Do we have reason to be overly concerned? Can he live another 10 years with this?

*****Answer*****

Dear Edie,

I appreciate your concern and understand the anxiety that comes from not being sure and having to wait for PSAs. That said, the term “meaty, multi-nodulated” has no prognostic significance, so please put that out of your mind. As for margins, there are margins and there are margins. In other words, if, for example, these are microscopic (<1 millimeter), cauterized margins, then they are probably of no real significance. Furthermore, a great many patients live just fine for years and years after a finding of positive margins. So you can try to get more detail about the exact extent and nature of the margins, but either way, there is no way to get around waiting for PSAs.

Arnon

Thank you,

Stacie

*****Answer*****

Stacie,

Yes, false positives are possible, which may be why he’s being retested. The likelihood of a real, true positive relates to his original diagnosis: PSA, grade, and stage. You may want to review those features with him and/or his doctor(s), because this will give you a better assessment of what is going on.

Arnon

I read a lot of your thoughts and feelings from the book you wrote. I have recently been found to have early stages of prostate cancer. From a biopsy done by Dr. Aaron Geswaldo in Albuquerque, where I was living, the result of a biopsy was a Gleason score of 3+4. (I had a PSA of 7.7 ng/ml.) The biopsy was done about a month and a half ago. I had been working at a hospital there for a year as a respiratory therapist and plan to go back to school to become a physician assistant this Fall. Aaron suggested I have my prostate removed. He said 4 to 6 months would be fine, but not to wait one year.

I will be 65 years old in June. I am in excellent health and feel like I am in my 40s. I was an athlete both in high school and college. I am now living in Vandalia, OH, which is a suburb of Dayton.

I asked Dr. Geswaldo if it was okay for me to run and work out. He said “no problem.” Do you feel that would be okay as well?

My brother and I have a friend with whom we went to school. He is a cardiologist in Little Rock, AR. He had his prostate removed at Vanderbilt, where I worked for 4 years as a trauma therapist. He said the best and most sure thing to do is to have your prostate removed. He also stated that I should find a surgeon that has done at least 300 a year, one that I feel confident with and have talked to at length.

From looking at the top ten urology clinics and hospitals in the US, a good choice is the Cleveland Clinic which is about maybe 6 hours from here. What do you think? I plan to go there next week and talk to a urologist / surgeon.

A couple questions I wanted to ask you is “how to pick prostate cancer surgeon. What are your thoughts?

You mentioned “Minimally Invasive Surgery”. Could you tell me a little about it and how does it compare to prostate removal?

Dr. Arnon, I look forward to hearing from you.

Respectfully,

Bob Neely

*****Answer*****

Dear Bob Neely,

Lots of questions. Lots of tangents. I’ll try to hit a few:

(1) Prostate cancer is not in itself a contraindication to exercise.

(2) Clinics don’t do surgery. Surgeons do surgery. Forget the clinic. Remember the surgeon.

(3) Minimally invasive surgery is prostate removal but without the big incision. There are benefits.

You may want to do some more reading. There are some useful Q&A’s on http://laprp.com

Arnon

Hopefully you live fine with good health. My name is Rizwan and I am medical student going to submit my final year thesis report. I want to copy simplified drawing of five Gleason grades for prostate cancer; actually my project work is on prostate cancer and I am a student at St. Olav’s Hospital, Norwegian University of Science and Technology. Can you please allowed me to include this diagram in my thesis report. I will be really thankful to you.

Looking forward to hear from you.

Kind regards

Rizwan

*****Answer*****

Hi Rizwan,

I don’t have a version of the Gleason diagram that I can give you.

Arnon

Re: a relatively healthy 67-year-old man recently diagnosed with a serious form of leukemia, who’s had two sessions of chemotherapy and who has been free of any carcinoma for one week, what could a possible prognosis be for such an individual — particularly his longevity given such a limited amount of info?

*****

Dear Mr. Berkowitz:

Dr. Krongrad is a specialist in prostate cancer, not leukemia. He could not give you any meaningful guidance in relation to this question.

Sitemaster