Ask Arthur … pretty much anything you like

Arthur’s done this all before. Hundreds of people around the world asked Arthur their questions about prostate cancer from 1994 to 1997 on the original Prostate Cancer InfoLink.

Please understand that Arthur is not a physician. He is only a reasonably well educated layman with some experience of prostate cancer and its problems. He cannot provide you with medical advice. You should always talk to your doctor about your clinical condition and how it should be managed.

You may post your question for Arthur 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.

127 Responses

  1. Hi Arthur,

    August 2010, PSA on PE 5.4, asymptomatic. October 2012, PSA on PE 7.5, asymptomatic. Family Hx, my mom had breast cancer.

    Prostate biopsy on 11/12/12, 5 of 6 cores adenocarcinoma, Gleason score 3 + 3 = 6 in all five cores. Prostate size 37 cc. DRE negative. On all of the risk analysis assessments I seem to be between low and intermediate risk. First urologist referred me for a chest x-ray, a bone scan, and an abdominal CT scan. Second urologist recommended surgery. It seems my cancer has possibly spread outside the prostate due to the number of cores with cancer. However, the cells are moderately slow growing. I am 63 years old, work full time, and am going to massage therapy school.

    I am scheduled for robotic prostatectomy on 12/12/12. However, with all of the previous entries about post-prostatectomy complications and having to end up doing radiation and/or hormone therapy, maybe surgery is not the best first choice. I am wondering if you could offer feedback on how to decide between surgery and radiation as treatment.

    Thank you so much,

    Chris

    *****

    Arthur responded as follows:

    Dear Chris:

    Arthur says that you do appear to have a diagnosis that is on the high end of “low risk” or the low end of “intermediate risk” … and there is certainly a significant possibility that your cancer has already extended into or through the capsule of your prostate on at least one lobe. However, …

    It is completely impossible for Arthur (or anyone else) to be able to tell you what form of treatment might be “best” for you. These decisions are enormously personal. Here is what Arthur can tell you:

    – You appear to be an appropriate candidate for at least three relatively standard forms of treatment (surgery, external beam radiation therapy, and “brachytherapy”).

    – Your personal outcome after any treatment is likely to be a great deal more affected by the skill and experience of the treating physician and his/her support staff than it is by the type of treatment, because from an oncologic point of view you ought to respond reasonably well to any one of these three types of standard treatment (if they are carried out well by an appropriately expert physician).

    – Your would be wise to recognize now that there is a high likelihood that you are going to lose good erectile function post-surgery (because of the combination of your age and the likelihood that the nerves that control erectile function will be affected by treatment on at least one side of your prostate).

    Much as Arthur would like to be able to tell you that one type of treatment would be better or worse for you than any other, there are no data to support such advice. There are, however, a lot of data that tell us that outcomes of prostate cancer therapy are better when treatment is carried out by physicians who are really good at the form of treatment they provide.

  2. Dear Arthur,

    Thank you so much for your quick reply. My wife and I just got back from my second visit with the second urologist. He answered her two pages of questions, particularly defining what stage it is (2) and classified as T2c and about the risks associated with RRP. He reports he had experience doing open prostatectomy before learning RRP with the da Vinci machine. He performs the surgery two to three times a month. He is Chief of Staff of the nearby hospital. He and the nurses and receptionist were warm, welcoming, and actively engaged with us every step of the appointment today. The urologist did ultrasound and DRE again. My wife got to watch the ultrasound — no visible abnormalities of bladder and urethra. The only remaining glitches are to follow-up on a referral by my PCP to have a vascular surgeon evaluate carotid bruits she heard on my PE in October. I have an appointment with the vascular surgeon tomorrow. And, that I am cleared by my PCP after my pre-op appt on Friday. After reading the many questions and answers on this beloved site, we realize cancer is unpredictable; however, we feel confident in the urologist’s skills and his caring. The skill and care will help us face whatever arises from this point forward. I remain forever grateful for the service you provide. I look forward to staying connected with you all as we traverse this territory.

    Chris

    *****

    Arthur responded as follows:

    Dear Chris:

    The only comment that Arthur would make on your remarks above is that most of the very best prostate cancer surgeons do three to five (or more) radical prostatectomies each week rather than two or three a month. Arthur wishes to be very clear that this does not mean that the surgeon you saw today is insufficiently skilled. However, his annual frequency of doing radical prostatectomies is definitely lower than that of surgeons who are generally considered to be “the best” at this procedure.

  3. Arthur,

    Call me a hypochondriac but I need to ask this. I am 64 years old and have had PSAs in the 2.0s for the past few years. Last year it was 2.8 then a year later 3.4 ng/ml (found out that it is not good to have sex before a PSA blood test). So 2 months later I had another PSA and it was 2.7. I am still a little skittish and the past 4-5 months have had back pain. Have had some minor back issues over the years and I was going to wait until my next physical to have another PSA. Recently read that backaches are a symptom of prostate cancer in advanced stages?

    I will probably see a urologist in the next few weeks just to check and talk about BPH, etc. What do you think?

    *****

    Athur responded as follows:

    Dear JL:

    Well, Arthur agrees that you may well be a hypochondriac … but on the other hand, “Better safe than sorry.”

    The chances that your back problem is in any way related to advanced prostate cancer with a PSA of around 2.5 to 3.0 ng/ml are about as near to zero as it gets. Can this happen? Yes it can. Arthur thinks he can remember coming across two such cases in the past 20-odd years, both in much younger men than you with what appeared to be unusual cases of prostate cancer.

    At 64 years of age, a PSA of 2.5 to 3.0 ng/ml is within the normal range. And a finding of anything other than low- or very low-risk prostate cancer is relatively unusual in any man with a PSA level within that range. However, finding prostate cancer cells in the prostate of a man of your age is quite common … but that doesn’t mean these men have clinically significant disease. It means they have some cancer cells in their prostate. Finding cancer cells if one looks for them hard enough is a normal part of the aging process and needs to be carefully differentiated from the risk of clinically significant cancer.

    Arthur would note that there are, in fact, all sorts of possible reasons why a man of 64 years of age might have a PSA of 2.5 to 3.0 ng/ml. It could just be his “normal” PSA level; he might have a low-grade prostate or urinary tract infection; he might indeed have the beginnings of BPH; etc., etc. Prostate cancer is relatively low on the list of possibilities.

    If Arthur was wearing your shoes, he would forget about this until his next scheduled physical. However, Arthur is not a hypochondriac, so his opinions are less than worthless when it comes to how you think about it. Certainly you could do worse than go get a urologist’s opinion. However, Arthur sincerely hopes the urologist will, indeed, advise you that there is no reason to think that you need a biopsy at this time.

  4. How do I sign up for this site?

    Arthur responded as follows:

    Dear Kevin:

    You can “sign up” as a member of our social network if you click here.

    You can sign up to receive daily e-mails about the news delivered on this web site if you click on “Entries RSS” in the header at the top of the page.

  5. Thanks, Arthur

  6. Dear Arthur:

    I have written to you a couple of times before and I really appreciate your answers. In short, I am 50 years old and I had an RP exactly 1 year ago (Gleason score, 3 + 4; one positive surgical margin and no evidence of spread; pre-surgical PSA, 5.8). My post-surgery PSA levels, taken every 3 months, have all been zero, and with the exception of heavy blood in my urine 6 months ago, all tests (including cystoscopy and scans) were negative.

    My question is how often my PSA must be measured passed this point if it stays at zero? Is there a standard? My urologist suggests every 6 months up to 5 years and annually thereafter and my primary care physician insists on every 3 months for another year and every 4 months after that.

    Best, Abbas

    Arthur responded as follows:

    Dear Abbas:

    Arthur is not aware of any formal standard for the frequency of PSA testing in a man with a zero PSA after radical prostatectomy. However, there are customary recommendations within the urology community, and the recommendation you have received from your urologist certainly conforms to those customs.

    The key question, it seems to Arthur, is exactly why your primary care physician seems to feel the need for a PSA testing frequency that does not conform to any standard or custom that Arthur is aware of. Arthur would suggest that you ask him or her that question. Offhand, Arthur cannot think of any such reason … but then Arthur is not a physician and he hasn’t had the benefit of being able to follow all your medical care.

  7. Hello, I am 58 years old and live in England. Yesterday my urologist conirmed prostate cancer. My PSA is 6 and, out of 12 cores, only one had a Gleason score of 4 + 5. He used the term “unlucky”! He thinks the cancer is localised. He suggested either surgery or CyberKnife. Would you give me some advice? What are the chances of me beating it?

    ***** RESPONSE FROM THE SITEMASTER*****

    John:

    If you join our social network, it is set up specifically to help you think through your various options and come to good decisions. We may even be able to give you specific guidance as to your “chances of beating it”.

  8. Dear Arthur:

    I’ve written you before about my circumstances. I received the diagnosis of metatasized prostate cancer over 17 years ago and have been treated successfully with hormone therapy ever since, having had undetectable PSAs all that time. In a response to a question of mine, you replied that surgery in cases of metastasized prostate cancer is generally not indicated as the horse is out of the barn already, so to speak. But you added that in some cases of locally advanced disease, surgery may increase survival. My cancer was confined to the lymph nodes and a bone scan was negative and I think that qualifies as locally advanced.

    Because of this, I consulted with both an oncologist and a surgeon at Sloan-Kettering. They said some things you may find interesting and which I hope you will be so kind as to comment on.

    First, they said that it is possible that a prostatectomy in some cases of locally advanced disease can be curative if the lymph nodes are removed as well. There is no guarantee of cure because cancer cells could have escaped the lymph nodes. But they seemed to say that it is becoming common practice to remove the lymph nodes during a prostatectomy. And with robotic surgery, it is possible to remove more of the lymph nodes than with conventional surgery. Second, the surgeon (the co-director of robotic surgery) told me that he would not want to recommend a prostatectomy immediately for the following reason: He said that in a very small percentage of cases, hormone treatment seems to “cure” prostate cancer and because such a long time has elapsed in my course of treatment it is possible that I may be one of those cases. He therefore would not want to perform unnecessary surgery. He suggested that I consider going off hormone treatment to see what happens. Naturally, my PSA would rise as I still have a prostate but if it does not rise too high, surgery would be unnecessary. He also stated that it is possible that after such an extended time on hormone therapy, I might no longer be able to produce testosterone, so that hormone treatment at this point might be irrelevant. He did acknowledge that it is an imponderable whether there is any risk in discontinuing hormone therapy, but stated that there appears to be no difference in survival rate among those patients treated continuously with hormone therapy and those treated intermittently. Therefore, he suggested that it would be reasonable to consider discontinuing hormone therapy with the idea that I would be closely monitored and that if my PSA rose to a certain level, a prostatectomy could be considered. If the prostatectomy was ultimately unsuccessful, hormone treatment could be reinstituted.

    I am inclined to follow the surgeon’s suggestions. On the one hand, I am reluctant to discontinue a treatment that has been so successful for so many years. On the other hand, I know hormone treatment is not a cure and that I can become hormone resistant. It seems to me that I have nothing to lose by following the surgeon’s suggestions. But I would be most interested in your comments.

    Charlie

    *****

    Arthur responded as follows:
    Dear Charlie:

    First and foremost, Arthur would point out that, stictly speaking, you never ever seem to have actually had “metastatic” disease (if you only had cancer that had spead to the lymph nodes). The clinical presence of metastatic disease requires visible evidence of metastasis to the bones or other distant organ site. At worst it would appear that you were suspected of having positive lymph nodes and micrometastatic disease (clinical stage TxN1M0).

    Some physicians have long believed that one could treat positive lymph nodes surgically (with or without a course of follow-up androgen deprivation therapy or ADT) with curative intent. It is also very certainly the case that the surgeons at Memorial Sloan-Kettering have been doing so more aggressively in recent years, but surgeons at the Mayo Clinic in Rochester started doing this some 20 years ago, and have published extensively on this option. People used to think that this was unwise and that the Mayo Clinic was some sort of outlier.

    In Arthur’s opinion, it is certainly possible that, if you stopped your ADT, you might have a very small rise in your PSA level which would then stabilize, and you would require no further treatment. Even if your PSA did continue to rise, it would probably do so slowly, and you could always go back on the ADT if you needed to.

    Like the doctor you spoke to, Arthur doesn’t think surgery now is a particularly viable idea. You would be at risk for all sort of side effects of the surgery and few real benefits by comparison with just trying stopping the ADT. Indeed, Arthur thinks having surgery at any time in the future for someone like you is a questionable idea. Radical prostatectomy for someone who has been taking ADT for 17 years may come with a whole bunch of additional complications that we know little about, and you don’t want to end up with unpredictable side effects of such surgery.

    If you want to stop the ADT and see what happens, Arthur thinks that may not be a bad idea at all — so long as you are being carefully monitored, with PSAs taken every 3 months for at least the first year. Maybe you will simply never need any further treatment at all.

  9. Dear Arthur,

    Thanks very much for your comments. I sincerely appreciate the helpfulness of your replies.

    I wonder if you could briefly expand on a couple of things. First, I understand that any surgery has inherent risks. But you mention that an RP for someone on ADT for 17 years may result in unpredictable side effects and other complications. What kind of side effects or complications are possible? Or does the fact that they are unpredictable make it impossible to comment on them?

    Secondly, can prolonged ADT really result in a “cure” of prostate cancer in a very small number of cases as my doctor suggested or was this just another way of stating that recurrence of prostate cancer has not been observed in a small number of cases where ADT has been discontinued — which, as I am writing this, sounds like two ways of saying the same thing. Is there any understanding why this occurs?

    I should mention as possibly relevant facts that I am 68 years old, am enjoying life very much, and, like most people, would like to live as long as I can. I should also mention that I have suffered no intolerable effects of ADT and would not be disappointed if I had to continue it. On the other hand, the idea of a cure sure seems nice even if I had to take the risk of an RP.

    Once again, I am most grateful for the polite and supportive manner of your helpful replies.

    Charlie

    *****

    Arthur responded as follows:

    Dear Charlie:

    First, Arthur doesn’t like the work “cure” when it comes to forms of prostate cancer that are known to have escaped the prostate capsule and the seminal vesicles at any time during the patient’s disease. He prefers to think in terms of remissions, with the full acknowledgement that those remissions can be short-term or they may be so long-term that they come to the same thing as being “curative” to all intents and purposes.

    Having said that, let’s look first at the issue of side effects of surgery as a whole in men of your age. These are potentially significant, even though Arthur recognizes that you probably have no surviving concerns about any risk for loss of sexual function since that probably hasn’t already been dealt with after 17 years of ADT. What Arthur is much more concerned about in a man of your age is loss of good continence. A recent study has shown that, among men of your age, about 30% of patients receiving surgery will have a significant degree of incontinence at 12 months post-surgery (and potentially for a lot longer), quite apart from all of the other standard risks of surgery at 68 years of age. in Arthur’s humble opinion, surgery of any type for 68-year-olds is something to be avoided if possible, simply because we don’t recover from it as well as we would have done when we were in our 30s and 40s. If it is essential, that’s one thing, but if it isn’t really likely to be significantly beneficial … Just going under anesthesia at all comes with significant risks for men of 65 and older!

    This brings us to the risks of radical prostatectomy in men who have been on ADT for 17 years. The one thing that we know about surgery in men who have even short-term ADT is that it makes radical prostatectomy technically more difficult. The effect of the ADT can be to increase adhesions between tissues, making it harder to tease apart the tissues and efficiently remove the prostate … and we learned this from men who were on ADT for just a few months prior to surgery in the days (long ago now) when we thought that ADT before surgery might actually improve long-term outcomes. (It didn’t.)

    So … Arthur’s gut sense is that 17 years of ADT may make the surgical removal of the prostate a lot more testing than your surgeon is really aware of. Just how many prostates has he removed from men who have been on ADT for 5 years or longer? Does this actually increase the risk of long-term incontinence? Does it come with any other risks to quality of life? These are serious questions that Arthur would want serious answers to before he underwent surgery if he had been on ADT for 17 years.

    And then, last but not least, is surgery actually going to have any benefit at all? We do know that some men who are on very long-term ADT have come off the ADT and stayed in long-term remission. Is this common? No it isn’t. But it may not be common for the simple reason that not a lot of men have ever tried doing this, and we certainly don’t have a good database of men who have tried it to know how successful it may be anyway.

    Arthur’s greatest concern would be that you came off the ADT, had surgery 3-6 months later while your PSA appeared to be low and stable (even 65 years of age with low-risk prostate cancer today. After 17 years of successful ADT, your cancer appears to be at low risk. One of the things you could certainly talk to your doctors about is coming off the ADT but taking a drug like dutasteride (Avodart) to try to minimize any risk of recurrence. If your PSA was still low and stable after a year, you could then try coming off the Avodart too, and seeing if your PSA stayed low and stable. Arthur really doesn’t think he would want to try surgery if he was wearing your shoes at all — but that’s just one man’s opinion.

  10. Dear Arthur:

    Thanks once again for all your helpful comments. You know, the reason I became concerned about all this to begin with is that I noticed a letter in your column from a gentleman who had been on hormone therapy for 15 years and who had become hormone resistant and whose PSA had begun to rise. I figured that if it could happen to him, it could happen to me.

    I hope you have the patience for one final question as I have to make a decision as to whether to discontinue hormone treatment. What are the potential benefits of such discontinuation? I suppose some of them are increased libido, less risk of osteoporosis, and less tendency to put on weight. Are there others? I think I mentioned that I have not found any of the side effects intolerable, am very healthy otherwise, am active, have more than sufficient energy and feel very good. This may not be a fair question but what would you do in my situation?

    Charlie

    *****

    Arthur responded as follows:

    Charlie:

    Arthur thinks that if you were to stop the hormone therapy, in addition to the “increased libido, less risk of osteoporosis, and less tendency to put on weight,” given that you appear to be otherwise in pretty good shape, you would find that you were in even better shape (more vigor).

    Frankly, Arthur can’t see any real downside to stopping the hormone therapy and monitoring your PSA carefully for a while. You are clearly still hormone sentitive, and so if your PSA started to rise again, you could just go back on the hormones. Arthur would certainly be willing to try this if he was wearing your shoes.

  11. Dear Arthur:

    I was notified of prostate cancer after a biopsy on 12/2/10 when two cores (both on the left) out of 12 were found to be cancerous. My Gleason score was 3 + 3 = 6. My PSA has been stable since then, and the last reading on 19/7/12 was 5.74.

    I had a template biopsy on 27/12/12 and four out of 15 cores on the right were cancerous but 0 out 16 on the left. My Gleason score was still 3 + 3 = 6.

    My surgeon stated that all options are open and I have opted to stay on active surveillance, but I have a couple of nagging questions. How accurate is the Gleason score? Is there statistical evidence showing added risk, if any, between remaining on active surveillance as opposed to opting for treatment?

    I am otherwise healthy with no other medical problems, eat a good diet and exercise regularly. On my paternal side prostate problems have affected most males but none have yet died of prostate cancer.

    *****

    Arthur responded as follows:

    Yusuf:

    Arthur doesn’t know you age, but this is definitely a significant factor that needs to be taken into account.

    If you are about 70 or more years old, then Arthur thinks there is every good reason to stay on active surveillance. Although your cancer is potentially progressing, it seems to be doing so extremely slowly, and some form of treatment can still be carried out in the future should it prove to be necessary.

    Contrariwise, if you are 50 years old or less than that, then treatment would seem like a good idea because your cancer is progressing (albeit very slowly), and recovery from treatment will be better when you are younger.

    Of course the chances are that you are somewhere between 50 and 70 years of age, and for men in that age range the appropriateness of treatment compared to active surveillance is extremely difficult to determine for a man with your clinical characteristics.

    If your biopsy slides were “read” by a specialized prostate cancer pathologist, then the Gleason scores from the two different biopsies are probably very accurate. If the slides weren’t read by a specialist, you could always ask for them to be read by such an expert (a second pathological opinion).

    Arthur thinks that, based on the data available at present, there does not appear to be any significant increase in risk for metastatic disease or prostate cancer-specific mortality between active surveillance and active treatment for someone with your clinical characteristics, but Arthur is not a doctor, and that is really a question you need to address to him or her.

  12. I would like to know if prostate cancer that has metastasized would in any way affect the spleen. My husband has been treated with surgery, hormones, and chemotherapy. His PSA was steady for about a year. However, his spleen is enlarged and his PSA has started to rise very slightly over the past 3 months. I have not heard of the spleen being affected. I would appreciate any info you could give me.

    Ellen

    *****

    Arthur responded as follows:

    Dear Ellen:

    Arthur recognizes that there is not much information suggesting that prostate cancer regularly involves the spleen. However, there are data suggesting that this can and does sometimes happen … most recently from a paper by Afshar-Oromieh et al. that examined uptake of a labeled tracer by various different organs in men with metastatic disease.

    Now Arthur obviously cannot tell you whether your husband’s cancer has metastasized to his spleen (or not). There may be several other possible reasons for the enlargement of the spleen in your husband’s case. However, it does appear to be at least a possibility.

  13. Dear Arthur:

    I am a white, 57-year-old male. Mother had cancer in her uterus; fFather no known cancer.

    Two years ago my PSA was 1.2. I went for a physical in December; my PSA was 8.46. Ten days later I had a follow-up test at the urologist’s: PSA was 9.1. No infection found on urine test. Normal prostate size with no lumps found during DRE. Had a 12-section biopsy with no cancer found. Urologist suggested follow-up PSA test in 6 months. Should I consider another biopsy now or wait the 6 months and see where the PSA is?

    *****

    Arthur responded as follows:

    Dear Bill:

    If Arthur was wearing your shoes he would come to a “deal” with the urologist to do the repeat PSA after 3 months rather than 6 months. Arthur would also ask him to do a %free PSA test at that time as well. Then you can decide what to do next.

    Arthur would point out that there are all sorts of things that can cause a man of your age to have an elevated PSA level. Prostate cancer is just one of them, and by no means the most common.

  14. Dear Arthur

    Thank you for your response dated 17th January. I apologize for forgetting to tell you my age, which is nearly 58. I am happy to stay on active surveillance as my cancer seems to be progressing very slowly and I am hopeful that my cancer will never progress into anything clinically significant but obviously if anything changed all treatment options are open to me.

    It has taken 5 weeks to recover from my template biopsy and I was catheterized for the first 3 weeks. The only drawback I can see from active surveillance is the need for a biopsy every 3-5 years for the rest of my life. Are there any alternatives to a future of invasive biopsies to ascertain whether my cancer has progressed, especially given that the PSA test is not a very good tool.

    Thanks

    Yusuf

    *****

    Arthur responded as follows:

    Yusuf:

    Arthur says that some people already believe that certain types of specialized MRI test can already replace biopsies for men on active surveillance. Arthur would like to see more data before he could endorse such a belief. However, Arthur does think that within the next decade it may become possible to drastically reduce the need for a lifetime of biopsies for men on active surveillance. He also does not think that you should have to have repeated mapping biopsies of the type you had before. A simple 12-core biopsy — or perhaps an MRI-guided biopsy of 4-6 cores — ought to be good enough in the future.

  15. PSA — 4.01 to 3.7; biopsy — six samples in one vial, six samples in second vial, therefore no listing of 1-12; Gleason score of 7.

    Is this “new way for treatment” acceptable ?

    No family history; White; 62 years of age.

    Local Uro / docs do not “believe” in fPSA or other preliminary testing.

    *****

    Arthur responded as follows:

    Dear Richard:

    Arthur says that, based on the information you have provided above, he has more questions than he has answers, as follows:

    – Was your Gleason score 3 + 4 = 7 or 4 + 3 = 7? It makes a difference.
    – What is your clinical stage (e.g., T1c, T2a, T2b, etc.)?
    – Of the 12 cores that were taken by your urologist, how many of those cores (and ideally how much of each core) were actually positive for cancer?

    It is not clear to Arthur what you mean when you ask, “Is this ‘new way for treatment’ acceptable?” If you are asking about the quality of the biopsy process and the pathologic report based on that biopsy, Arthur would need to be able to see the actual report to be able to comment — but it does seem to have some deficiencies.

    Arthur is also not sure what you mean when you say that your local physicians don’t believe in using %free PSA or other preliminary tests. For example, if you clearly had clinical stage T2a or T2b disease on a rectal exam in combination with the PSA of about 3.7 to 4.0 ng/ml, there would have been no need for a %free PSA test before your biopsy (and there is certainly no need for this test after the biopsy).

    If you can answer some of Arthur’s other questions above, then it might be easier to determine whether additional tests might be helpful prior to making any decision about treatment. All that Arthur can really be certain about based on the information you have provided so far is that you appear to have intermediate-risk prostate cancer (based on the fact that your Gleason score is 7) that is potentially (but not certainly) localized to your prostate.

  16. I have just completed my surgery, and appear to be progressing well. I have been looking for some detailed reference material on what to do, or not do, during my recovery. I am looking for information that walks me thought each phase of the recovery cycle. For example, the first 10 days or until the catheter comes out. My doctor has said “Walk and don’t lift more than 10 pounds”. There must be more than that.

    Thanks, Bernie

    *****

    Arthur responded as follows:

    Dear Bernie:

    Arthur says that, regrettably, there are no “standard” recommendations on what a patients should or should not do to optimize his recovery after a radical prostatectomy. There probably should be, which is a different issue.

    Having said that, here is what Arthur can tell you:

    (1) Your doctor is correct. For the first week or until your catheter can be removed, you should limit your activities to gentle ones like walking and being careful not to try to lift heavy objects (because of the risk for inducing a hernia).

    (2) At the time of removal of your catheter, you should ask about starting Kegel exercises to optimize recovery of urinary continence. (Ideally you will have started to learn how to do Kegel exercises properly before you had your surgery so that your muscles can be relatively quickly re-educated … but not all doctors tell their patients to do this.) For a while you should continue to exercise caution about lifting heavy weights

    (3) You need to have a serious conversation with your doctor about so-called “penile rehabilitation” (making sure that you are able to optimize the potential recovery of optimal erectile and therefore sexual functionality). This can include the use of drugs like sildenafil (Viagra) and a medical device called a VED or vacuum erectile device to “re-train” your penis to fill with blood and become erect.

    Now the ability to regain good erectile function is going to depend on whether or not the surgeon was able to spare the relevant nerves at the time of surgery and on other detailed aspects of the surgery (as well as on things like your level of sexual function prior to your surgery). You might want to look for a copy of a book called Saving Your Sex Life: A Guide for Men with Prostate Cancer by Dr. John Mulhall (a specialist in male sexual function after prostate cancer surgery).

    It is hard to give “generic” guidance about post-surgical recovery because it is highly dependent on the age and health of the individual patient, the quality of their urinary and sexual function prior to their surgery, the extent of their surgery, and their individual expectations. If you want to join The “New” Prostate Cancer InfoLink’s social network, you will be able to communicate with other men about exactly what they did and what worked for them over time.

  17. Hi Arthur.

    My father, who was born in 1929, recently was diagnosed with a localized prostate cancer contained within the prostate itself.

    The doctor odered 2 months of radiation therapy, which my father underwent successfully. My father had never been hospitalized or had any serious heath issues. However, he was dehydrated, felt very weak, and had very little energy prior to the treatment.

    Poor nutrition, too much beer drinking, and smoking led to this condition. By the time he had finished this radiation thereapy, he was much more
    weak and felt like he had zero energy, but he was dealing with it.

    On New Year’s Eve, while sitting at the table, he had a major stroke, and is now recovering in the hospital, having been in intensive care,
    a nursing home, and now the VA hospital. He will start physical therapy soon.

    Since this happened, he has been getting proper nutrition, medication, and has gained weight; his color is better, and he has made very good progress. His mind is okay, but he slips out of reality at times.

    I never thought at his age that radiation therapy was a good idea, considering all these factors. I know smoking and drinking contributed
    but could this radiation therapy contributed as well?

    Thank you,

    Danny

    *****

    Arthur responded as follows:

    Dear Danny:

    Arthur says that he thinks it is possible that the additional tiredness induced by radiation therapy might have been a factor here, but it would be almost impossible to tell. Arthur is obviously in no position to determine what exactly may have happened in your father’s case, but it doesn’t take much to tip an 84-year-old man with poor nutrition and other unhealthy habits over the edge into having a stroke. The chances are high that this might have happened regardless of the radiation therapy … but it may not have helped.

    You don’t provide any details about the risk level of your father’s cancer (i.e., its stage, Gleason grade, or the PSA level) but it is certainly also possible — if he had relatively low-risk prostate cancer — that your father made a poor decision when he decided to have radiation therapy at all. Arthur says that one of the problems that faces men of your father’s generation is that in their minds the word “cancer” almost invariably implies a severe and rapidly life-threatening disease, even though that is not usually true in the case of an 84-year-old with low-risk, localized prostate cancer. The consequence is often unnecessary over-treatment, not uncommonly against the advice of at least some of the patient’s doctors.

  18. I have recently been diagnosed with prostate cancer: 3 of 12 biopsy cores were positive; a 6, a 7, and an 8. My DRE is normal and my PSA is 9.5. I am 65. Can you direct me to some evidence indicating that observation is not a reasonable option compared to surgery or radiation?

    *****

    Arthur responded as follows:

    Dear Ray:

    Arthur says that, much as you may not want to hear this, your fundamental problem is that you have high-risk, Gleason 8 prostate cancer. Unless you are expecting to die of something else in the next 5 years or so, this fact on its own is a near-guarantee that your cancer will progress, and rapidly, if you don’t have treatment — and soon. Assuming you are otherwise in decent health and have a life expectancy of 10+ years, Arthur knows of no physician who would even suggest (let alone recommend) that you just monitor a man with Gleason 8 disease.

    Arthur has taken the liberty of plugging all of your data into the Kattan pre-treatment nomogram, which then gives us the following output regarding your prognostic risk:

    – Probability of organ-confined prostate cancer, 51%
    – Probability of extracapsular extension, 41%
    – Probability of seminal vesicle invasion, 26%
    – Probability of lymph node involvement, 5.6%

    In other words, there is already a possibility that “the cat is out of the bag.” Arthur further assumes that your urologist has already advised you that you need a bone scan and a CT scan to check to see whether you already have any signal of metastatic prostate cancer (however small).

    Arthur needs you to understand that your other two biopsy cores being “only” a Gleason 6 and a Gleason 7 is irrelevant to the seriousness of this diagnosis. It is the Gleason 8 core that defines your diagnosis, and Gleason 8 disease needs to be taken very seriously. It is important for you to understand that yours could still be curable because it appears to have been identified relatively early (while your PSA is still < 10 ng/ml and you have a normal DRE). However, every specialist Arthur knows would tell you that this is the type of prostate cancer that needs early and aggressive treatment if it is not to metastasize.

    Arthur notes that several papers include data confirming that a man of your age with Gleason 8 disease has a 49 to 55% probability of actually dying of prostate cancer if his disease is treated conservatively (i.e., just monitored until therapy of some type, e.g., androgen deprivation therapy to relieve the pain of metastatic bone disease, becomes essential).

  19. Arthur,

    I am a 64-year-old with PSAs that are not significant, going from 1.7 to 2.7 over the past 10 years, with the last one being 2.5.

    I went to a free screening and they did the blood draw resulting in the PSA of 2.5.

    The urologist also did a rectal exam and said he could feel the perimeter of my prostate on the right side but could not feel it on the left. He suggested I get another urologist in his group (who does more prostate work) to have a look. After another DRE, that urologist said that he agreed with the previous urologist. He also said there was no urgency because of the relatively low PSAs but he suggested a biopsy.

    I called and spoke to his nurse and suggested an MRI to see what the prostate looked like. That is where we are.

    I know there is no guarantee that low PSAs mean no cancer. Am I following a good path and what else would you recommend.

    Mike

    *****

    Arthur responded as follows:

    Dear Mike:

    Arthur would point out that you are 64 years of age. This means that — if someone looks hard enough (using biopsies, PSA tests, MRIs, etc.) — there is about a 60% chance that they will actually find some cancer in your prostate. However, it will likely be low-risk disease; it will probably never be clinically significant (i.e., you will never actually be affected by it); and so the question is, even if you were to have a positive biopsy, why would you want to do anything other than monitor it?

    It is not Arthur’s position to try to tell you what you should or shouldn’t do. That is up to you and your doctors. However, Arthur would point out that — based on the available information — there appears to be no really good reason for you to even have a biopsy (other than a very high degree of caution indeed). If your PSA was to rise from 2.5 to 4.0 ng/ml (or even to 3.0 ng/ml), there might be much more reason … but your PSA appears to give every indication of a perfectly healthy prostate for a man of your age.

    Of course Arthur realizes that it is possible that a biopsy would show cancer with a Gleason score of 7 or higher, but ask your doctors if it is really probable before you decide what you want to do. The chances that anything other than a very sophisticated form of MRI would show anything at all is (as far as Arthur can tell) near to negligible.

  20. Re original question from Richard on January 29 …

    Additional information as follows:

    – PSA levels: 2.3 in 2003; 2.2 in 2005; 2.4 in 2008; 3.8 in April 2009; 3.4 in July 2009; 4.07 in December 2010; 4.0 in February 2011; 3.31 in 2011; 4.3 (“modified hemolyzed”) in April 2012; 3.74 in September 2012.
    – Sent to see the urologist when PSA was 4.07 in December 2010.
    – PCA neg 10.6; free PSA 21% in February/March 2011; no cancer cells in urine
    – CT scan normal; possible spot at apex, near to bladder
    – Believed doctors and was pressured into having a biopsy.
    – Biopsy result from 12 cores (six cores from left lobe put into one cup; six cores from right lobe put into second cup; do not have a nice 1-12 core readout).
    – Left lobe: single minute focus of Gleason score 3 + 3 = 6 in one of six cores, measures < 0.1 mm and involves less than 1% of tissue.
    – Right lobe: Gleason 3 + 4 = 7 in two of six cores, each measure 2 mm and involves 1% of tissue.
    – Clinical stage T1c, no symptoms or enlargement of prostate, no night waking up, all DREs normal and smooth.

    I am a 62-year-old, white male with no family history of prostate cancer, no medical problems, and not on any medications.

    The preliminary free PSA and CT scan data have been dismissed by the doctors, who stated "We do not see them as valid tests"; they wanted to go in for a biopsy!

    There was heavy pressure for the next step, "But it must be done soon!", even though no lumps could be felt, there was nothing on the CT scan, just cells floating around and not clumped "yet!" "We will treat it before it gets bigger", they said. I asked hard questions and got no good answers, so I did my own research and found out that with their procedure I would become a 75-year-old man and, by the time I reached 75, I would have lost control over front and back facilities.

    My question Arthur:

    – How much does hemolysis affect PSA? … a numerical answer please instead of the English "some".
    – How much does PSA rise after stimulation? … again a numerical number.
    – Lastly, with daily fluctuation of PSA, when is a decent time frame to have blood drawn for the PSA test?

    PS: I have worked in a lab and done some literature research and understand some of the factors affecting PSA and that it is a "soft" test compared to other lab tests — between labs and even machine models of the same manufaturer.

    So I receive pressure but no mentally calming answers for taking the next step and drastically change it. Wait and see from the doctors has been taken off the table, much les further, future PSA testing for monitoring.

    Richard

    *****

    Arthur responded as follows:

    Richard:

    So Arthur apologizes, but he is not going to be able to give you the sorts of answers to your questions that will really be very helpful.

    (1) You asked, “How much does hemolysis affect PSA?” Frankly Arthur hasn’t got a clue. He has no idea what you mean by a “modified hemolyzed” PSA test. He has never heard of this before.

    (2) You asked, “How much does PSA rise after stimulation?” The problem with trying to answer that question is that any answer is highly dependent on the physiology of the individual patient and the intensity of the stimulation. It is simply not possible to give a good “numerical” answer. However, what Arthur can tell you with certainty is that any PSA result taken after stimulation of the prostate should be discounted as potentially inaccurate anyway.

    (3) You asked, “with daily fluctuation of PSA, when is a decent time frame to have blood drawn for the PSA test?” Again Arthur doesn’t know that there is any specific “right” time. What Arthuirn does with respect to all his own blood tests (not just for PSA but for all blood-related tests) is that he always tries to have them done early in the morning, before any food or coffee, so that each set of results should be directly comparable to any prior results. In other words, try to be absolutely consistent about when you have the blood drawn for your tests.

    You are clearly not comfortable with the urologists you have been seeing. Arthur asks, can’t you get a referral to some other ones? The ones you have been seeing obviously don’t think you are entitled to an opinion about your own care. On the other hand, Arthur thinks it is something of an exaggeration for you to say that, if you got treatment, you would necessarily be incontinent at age 75.

    Arthur says you need to find a urologist who will listen to your concerns and not just tell you what s/he wants to do to you. Furthermore, anyone of age 60 who has any amount of Gleason 3 + 4 = 7 cancer (however small an amount) does need to at least monitor that with care and regularity — probably with PSA tests at least every 6 months.

  21. Hello, thank you for your reply.

    clarification regarding a psa of, say 4.7 moderate hemolyzed;

    The tube of blood was vigorously shaken in front of me; red top tubes are supposed to be gently rocked 2-3 times and let stand. The shaking hemolyzed the cells, i.e., broke open the red blood cells, spilling the contents into the serum to be tested. The red color also affects the backgound “noise” of the test — especially if utilizing a light source..

    The comment regarding, say, how I was listened to/treated are encouraging. The doctors that I have contacted are “cut from the same mould.”

    My research indicates that, as a consequence of treatment and the damage done, after recovery I will approach an elderly man quicker than my birth years. In other words, damage done to the muscles in the area,, the “rubber bands” of control have been damaged, loss of strength, will all lead to “aging” earlier than it would have happened through regular aging.

    But again Thank You for your response

    Ricahrd

  22. Hi. I am 62 years old I have had a PSA of 500; no real pain only fatigue. I am due to see a urologist in 2 days time. Does this high PSA mean I have advanced cancer? I was feeling chills before I did the test. Is this perhaps the reason for the high PSA? My prostate was found to be enlarged and firm by my doctor when he did a physical examination. I had back pain for 3 days before the PSA test and I took Mybulen, which helped, and I have not had any pain since. The 2-day wait is freaking me out, as I am reading everything on the internet.

    Regards

    Colin
    South Africa

    *****

    Arthur responded as follows:

    Dear Colin:

    Arthur says that a PSA of 500 ng/ml combined with a firm-feeling prostate and back pain is a series of signs and symptoms that is strongly indicative of risk for metastatic prostate cancer. However, Arthur wouold also point out that it is never wise to starting counting chickens until the eggs have hatched!

    In addition Arthur says to be careful about what you may find on the Internet. There is lots of accurate information but there is also a lot of rubbish and data from 20 years ago that do not necessarily represent current practice. The urologist is almost certainly going to want to give you at least a biopsy and a bone scan so that s/he can make an accurate diagnosis. Until you have such a diagnosis, in all honesty, worrying about what you should or shouldn’t do is of limited value. Arthur suggests that you try and relax, have a beer or a glass of wine.

    When you have an accurate diagnosis — if it is prostate cancer — Arthur suggests that you join the social network associated with this web site. It is set up to help men get guidance from others based on their experience.

  23. Colin:

    As one who suffered a similar diagnosis (and I don’t know the circumstances of health care provision in your country), once you have had your initial round of local consultations the best internet research you can do is to find your country’s centre of excellence in the management of prostate cancer and get a second opinion from there. Give yourself the best possible chance by seeing the best possible team of oncologists.

    As Arthur says, don’t go frightening yourself on the Internet. There is a lot of crap out there and treatment has come on a lot in the last few years.

    Charlie

  24. Arthur:

    The link to “How to select a brachytherapist” is no longer valid. Is there an alternative site?

    Brad

    *****

    Arthur responded as follows:

    Dear Brad:

    Arthur says here is the link to “How to select a brachytherapist” but Arthur would appreciate it if you could tell him where you found the broken link so that we can get it repaired.

  25. Arthur:
    I found the broken link by clicking on “Management” from the top tabs of the site, then click on “Established Radiotherapy …” option mid-page, finally click on “How to Select a Brachytherapist …”

    Brad

    *****

    Arthur responded as follows:

    Dear Brad:

    Arthur thanks you. He passed the information on to the Sitemaster, who appears to have fixed it already.

  26. Dear Arthur,

    My husband seems to be a mysterious case. For the past 5 years he has had a high PSA that is not rising. He has had two negative biopsies and always a negative DRE. He has never had any symptoms. After having difficult times with the biopsies he decided to be followed with a specialized color Doppler and a pelvic MRI each year. They were also negative.

    This year his PSA was 920 ng/ml. (Yes, 920.) A tumor was found by the color Doppler and confirmed by the MRI. A targeted biopsy was done and revealed that the tumor was a Gleason 9 (4 + 5); also a lymph gland was biopsied and found to be Gleason 8. He then suffered a severe infection from the biopsy and had to be hospitalized. His PSA went down to 320.

    Lupron and Casodex were started. His PSA is now 9.4 after 30 days. All scans were clear. Other blood work excellent. One oncologist said to just stay on hormones and see what happens. Another suggested to stay on hormones and start radiation after 3 months. My husband is 61 and in relatively good health. I feel radiation and hormones together are best from my research, but do not want him to go through radiation if the outcome would be the same. What do you think?

    Thanks

    Susan

    *****

    Arthur responded as follows:

    Dear Susan:

    Arthur says that your description of your husband’s care certainly does sound unusual and Arthur has no explanation for it.

    Arthur would also suggest that you may not want to make any decision about the radiation for another 30 to 60 days, to see just how low your husband’s PSA is going to go. Ideally, the androgen deprivation therapy (ADT, i.e., the Lupron and the Casodex) should drop your husband’s PSA down to near zero, and (given the fact that he clearly has aggressive disease) his best chance for curative therapy — which may still be possible — would be to combine the ADT with radiation therapy to eliminate as much as possible of the tumors that are in his prostate and his pelvic area. You both probably need to talk to the doctors some more about this.

    The one thing that Arthur would be most worried about in any man who had had a PSA of 300 to 900 ng/ml is whether, despite the lack of evidence of any metastasis on bone scans and CT scans, there really already is micrometastatic disease that is too small to show up on such scans. There are new forms of PET scan that can help to identify some of these micrometastases, but they are only available at limited numbers of centers at this time (e.g., the Mayo Clinic in Rochester, MN), but they might be able to help.

  27. I went to a prostate screening and was told by the physician that after doing the digital exam he could not feel the left perimeter of my prostate. Even though my PSAs are all 3 or less for the last 10 years, he suggested a biopsy.

    I went and had an MRI and it came back clean, but obviously I have BPH (hence the reason he couldn’t feel my whole prostate). My prostate is really enlarged but do I need a biopsy?

    *****

    Arthur responded as follows:

    Dear Joe:

    Arthur is not a doctor, and he really can’t tell you whether you “need” to have a biopsy or not. This is really a conversation you need to have with a physician who has examined you and who has seen the results of the MRI scan you had had.

    The answer to your question may depend upon all sorts of additional factors, including things like your age, your ethnicity, whether there is any familial risk for prostate cancer, etc. It may also depend on the precise type of MRI you were given; whether treatment is being recommended for your BPH; and other issues.

    What Arthur can tell you is that: (a) your PSA appears to be well within the “normal” range for someone of 50-60 years of age who has an enlarged prostate; (b) that there is no PSA level below which there is no risk for prostate cancer; (c) that there are other tests, such as the %free PSA test, that you could ask you doctor about having before you decide whether a biopsy is really necessary in your individual case.

  28. Dear Arthur,

    Thank you for your advice. We have an appointment to speak to the oncology radiologist next month. Getting a PET scan was mentioned as a possibility. We were told that he would not be considered curable, due to possible micrometastases and extensive lymph involvement. But a long term remission with hormone therapy and radiation was possible. We are waiting 60 days before radiation and they want his PSA to be around 0 when they start. He is being treated in a major center. He is also on a plant-based, organic diet since diagnosis. We are hopeful that if all efforts work well, a long-term remission could lead to more treatment in the future. I think at this time he plans on accepting the radiation treatments.

    Thank you,

    Susan

    *****

    Arthur responded as follows:

    Dear Susan:

    Arthur says that that sounds like a highly appropriate plan under the circumstances. Hopefully your husband’s PSA will indeed drop down to near zero and that the radiation therapy will then put him into long-term remission. Arthur also says that one of the questions you will want to discuss with the radiation oncologist is how long he is going to want your husband to stay on the androgen deprivation therapy after the radiation is complete. A period of 18 months to as much as 3 years would be quite normal in a case like this.

  29. Thanks. I am 64, white, and heathy; parents are 90 and healthy. I will see another urologist since the group I saw seemed to be all about billing for procedures (walk in the door — urine sample, bladder ultrasound every visit). Also tried to sell me on cystoscopy for BPH, MRI, biopsy, etc.

    I can see why several papers have been published regarding the over-diagnosis of prostate cancer!

    *****

    Arthur says that this sounds like a reasonable plan!

  30. Dear Arthur,

    T2, 4 + 3 Gleason, 7.4 PSA, three cores positive for cancer, don’t have a DRE score, 60 years old, and I am in the process of deciding between brachytherapy and laproscopic surgery. Survival rates are important to me, and I have seen studies where it is slightly higher for surgery. Any comments you have are appreciated.

    William

    *****

    Arthur responded as follows:

    Dear William:

    Arthur says that decisions about types of treatment for people like you become very personal because they reflect individual’s priorities about the relative importance of quantity of life as compared with quality of life.

    With that in mind, it is true that there are likely to be slightly higher probabilities of long-term progression-free and overall survival in favor of radical surgery as compared to brachytherapy for men with your characteristics (but we don’t have data from an appropriate trial to confirm this absolutely). Conversely, Arthur can tell you that the two-year side effect profile after treatment favors brachytherapy over radical surgery (to some extent) … and in this case we do have data from a randomized trial to support this.

    Having said that, however, Arthur’s baseline is that the skill and experience of the treatment team (or the individual surgeon) may actually be more important today than whether you have brachytherapy or surgery! It is certainly the case that whichever of these two options is more appealing to you (or perhaps “less unappealing” is a better way to phrase the issue), you absolutely want to try and make sure that you go with a really skilled and experienced treatment team who are absolutely focused on the overall quality of your outcome and not just on eliminating the cancer.

    You do need to appreciate that your risk for extracapsular prostate cancer is far from negligible. If we assume that you had 12 biopsy cores taken in total (of which three were positive) and that your clinical stage is T2a as opposed to T2b, then Arthur can use the Kattan pre-treatment nomogram to project that:

    – Probability of organ-confined prostate cancer, 56%
    – Probability of extracapsular extension, 48%
    – Probability of seminal vesicle invasion, 12%
    – Probability of lymph node involvement, 2.7%

    Some people would feel strongly that this level of risk is strongly suggestive that surgery would be a better option. Others — especially some specialists in the brachytherapy community — would argue that they can treat a cancer like this extremely effectively. At the end of the day, unfortunately, no one can make any sort of clear statement to you that either form of treatment is “better” for you than the other. At the end of the day, you are going to have to make the decision that “feels right” for you.

  31. Thank you Arthur for your reply.

  32. Is there a secret to signing up for the social network?? I have tried repeatedly today and all I get is a pink highlight on the e-mail address with the comment the words do not match.

    Brad

    *****

    The Sitemaster responded on Arthur’s behalf:

    Dear Brad:

    There is no “secret” to signing up to use the social network. However, you do not appear to have registered as a member. I can find no record of your existence as a member under the name Brad or by searching the (private) data records for your e-mail address. You do need to “Sign up” and be approved before you can “Sign in”.

  33. Brad here again … Where and how do I register as a member?

    *****

    Sitemaster responded … Brad: Right on the social network home page where it says “Sign up or sign in” in a large box. You need to click on “Sign up”.

  34. Brad here again:

    I clicked on the link provided, provided the info requested using two different e-mail addresses and six different password combos. Still got a screen with pink highlight on the e-mail address with the comment “words do not match”. Really confused now — Do you have a technical service contact for this web site?

    *****

    Sitemaster responded as follows:

    Dear Brad:

    I am sorry but I have no idea what the problem is; at least 5 other people have requested membership of this site over the weekend, but I see no sign of your application and we have never had anyone else ever let us know that they had the problem you are describing. When you apply you do need to be approved as a member; you can’t just log into the site, you have to request membership first, but (as mentioned above) I can see no sign that you have actually applied for membership at all.

    All you need to do is go to the home page and click on “Sign up” (not the “Sign in” link) and provide an e-mail address, give yourself a password (and then give it again to confirm it); give your data of birth; complete the ReCaptcha codes; and then click on the Sign Up button. It is really very straightforward.

  35. Dear Arthur:

    I have had an increasing PSA level for several years. I have had two TRUS biopsies that both came back negative. My urologist wants to a saturation biopsy. At this point I am tired of the blind biopsies and would prefer an MRI-guided prostate biopsy. Neither my PCP nor my urologist know of anyone in Florida that does them, so I am looking for suggestions as how to find someone. Simply trying to call around the state is both time consuming and futile since it is never possible to talk to anyone who actually knows whether the radiologist or urologist actually does them. I have already wasted a lot of time with this method. Any assistance would be appreciated.

    Bill

    *****

    Arthur responded as follows:

    Dear Bill:

    Arthur says that if you click here you will find a page on the Us TOO web site that provides a recently updated list of practices that supposedly offer MRI-guided prostate biopsy capabilities.

    Arthur further notes, however, that of the two practices listed in Florida, he is not sure that Prostate Solutions of America is still open and at the Diagnostic Center for Disease in Sarasota it is Arthur’s understanding that Dr. Wheeler only actually offers 3-T MRI-S scanning and not actual MRI-guided biopsy capabilities (but you may want to check for yourself).

    Arthur suspects that the closest facility to you that really is capable of offering MRI-guided biopsy capabilities may well be Emory University in Atlanta (unless this capability is now available at either the Mayo Clinic in Jacksonville or at the Lee Moffit Cancer Center and Research Institute in Tampa, which is possible).

    Please understand that it is simply impossible for Arthur to keep an accurate track of exactly which centers around the country are providing all of the newer types of service on a state by state basis.

  36. Arthur:

    My PSA in 2005 was 0.40; by late 2012 it was 0.80 but the doctor found very small lump on my prostate. The biopsy said Gleason 6 (3 + 3) in 1 core out of 12 cores. He gave me literature to read for 30 days and asked me what I wanted to do about my prostate cancer. I said active surveillance. I’m 62 years young and have a 43-year-old wife and a 3-year-old daughter. I’ve changed up my diet 95% and take many supplements like pumpkin seed oil, pygeum, turmeric, saw palmetto, vitamin C, flax oil, iodine, CoQ 10, vitamin E, and selenium; no red meat; little white meat; lots of fruit and vegetables (most by juicing), fish, nuts, and rice. I’m 5’10″ and weighed 170 lb but I have lost 10 lb since my diet change. I exercise about 5-10 minutes per day. I get up about once a night to urinate. The doctor said my prostate was a little bigger than normal. I really don’t want to do cutting, burning, or poisoning. My last PSA was the same again at 0.80 ng/ml; my doctor said I was “doing good.” My 10-year colon exam with scope was clean. Do you think I’m on the right track, or I should get surgery because of young wife and child? Also do you think cancer in 1 core can be spread to other cores during the biopsy? If the same hollow needle is used for each core, it would seem to me that a biopsy is bad to keep doing every year.

    Len

    *****

    Arthur responded as follows:

    Dear Len:

    Arthur says it has been just 6-9 months since you started down what is likely to be a long path, and it is probably much too early to be making any really serious decisions about whether or not you might need surgery at some time in the future.

    Arthur also says that there is every indication that you are making good decisions about your health if he assumes (as he does) that part of your reasoning is that you have a significant interest in the quality of your life (with a relatively young wife). However, you should be cautious about all those supplements; you don’t need to go overboard! In addition, the recommended daily exercise period is actually 30 minutes rather than 5-10 minutes, so you might want to gradually work your way up to that.

    As far as Arthur is aware, there has never been a specific case of a biopsy successfully “spreading” cancer within or outside the cancer such that new tumors start to develop (which is not the same as “needle tracking” of cancer cells at the time of a biopsy, which does occur, but the cells don’t survive). On the other hand, there are a lot of specialists who are starting to agree with you (as we get more experience with active surveillance) that annual biopsies are “overkill” for men on protocol’s like yours.

    Arthur would suggest that you probably do want to have a repeat biopsy at about 1 year after you started active surveillance, but that you should talk to your doctor about switching to an annual prostate MRI after that, with a biopsy every third or fourth year unless there is some good reason to suggest a biopsy (like a significantly rising PSA).

    Finally Arthur would note that men of your age very commonly have a slightly enlarged prostate (benign prostatic hyperplasia) often have some need to get up once a night to urinate. You could ask your doctor about getting treatment for that with a drug like tamulosin (Flomax) that should not affect your sexual function, but which might significant improve your urine flow and allow you to sleep through the night. This drug is now available generically, so it is not particularly costly.

  37. Arthur,

    Thanks for the suggestions. I had found that link and checked out those two Florida locations. As you suspected the one (Prostate Solutions) is gone. You are also correct that the other offers only MRI. They also accept no insurance plans and the cost of the MRI alone is $3,500. Mayo in Jacksonville does not do MRI-guided biopsies. I have been told that Dr. Julio Pow-Sang at Moffit does them but I have not been able to contact his office yet to confirm that. If I do confirm it I will post for the benefit of others. Dr. Sharif G. Nour at Emory University does indeed perform the procedure.

    Bill

  38. Dear Bill,

    Dr. Sperling in NYC offers MRI-guided biopsies, accurate and painless. $2,500 — our insurance covered half after we payed up front. You may need to get prior approval from your carrier. My husband had one done this past March. Good luck to you.

    Susan

  39. My husband’s PSA is 4,917; the doctors say there is no cure. They have not suggested any scans or biopsies, they would like to do an orchidectomy (castration). We have elected to wait a few months, we have changed his diet drastically and he is drinking 8 glasses of vegetable juice and 8 glasses of clean water per day as well as supplements, not much of an appetite. He has lost 18 kg and is very fatigued.

    It is 9 weeks since his diagnosis. He is having a problem sleeping at night but sleeps quite well during the day. He has no pain and passes water easily. Should we have a bone scan to show if it has spread? Will be doing another PSA at the end of the month. It is very upsetting to see him so tired and so thin. We have faith in the seven point five juicing and diet protocol which will make him alkaline but I would like to try the Budwig protocol (flaxseed oil and cottage cheese) as well. I have read about and met quite a few people who say they are now cancer free due to diet, juicing and supplements. Any comments are welcome. Regards Cheryl.

    *****

    Arthur responded as follows:

    Dear Cheryl:

    First, Arthur would ask whether your husband seen a medical oncologist with serious experience in the treatment of advanced prostate cancer? If he hasn’t, he should.

    Second, Arthur says yes he does indeed need a bone scan so that his doctors know exactly how far his disease has spread. He probably needs to have a CT scan as well to see if there is any sign of cancer in soft tissues like his liver.

    Third, Arthur says that the changes to his diet may or may not be helpful, but what your husband really needs is treatment with androgen deprivation therapy using drugs like leuprolide acetate and bicalutamide. This treatment should have the effect of minimizing his risk for bone pain and delaying the further spread of the cancer. Surgical castration is certainly another option, but most people here in the USA would consider it to be psychologically distressing to the majority of patients.

    It is true that we have no form of curative therapy available today for widespread metastatic prostate cancer. However, with careful treatment your husband may be able to have a good quality of life for a while yet, and he should be able to avoid serious pain associated with very late stage disease. Furthermore, it should be possible to avoid and even reverse the undue weight loss.

    Arthur says he has no idea where you live or where your husband is being treated. However, he would advise you to join the social network associated with this web site. People there may be able to tell you places you could take him to get a knowledgable second opinion about his care.

  40. Hi Arthur.

    I had an RP performed August 16, 2012: Gleason 3 + 4 = 7, with a positive margin; all of my post-surgery PSA test results (every 3 months) were undetectable (< 0.05), all tested by same lab.

    Well my last PSA test came back detectable at 0.028, tested by a different laboratory and my urologist is talking secondary treatment. From my understanding BCR is 0.2 and rising! Why would the other laboratory report a detectable PSA level when clearly 0.028 is lower than 0.05 ng/ml? Should I be concerned about this and rush into secondary treatment? Please help!

    *****

    Dear Mike:

    Arthur is not a doctor, but if he got results like this himself, he would be making very sure that no one rushed him into secondary treatment!

    First and foremost, Arthur would note that it is important to understand that comparing PSA data from different laboratories is a really bad idea. The two labs have probably used different PSA tests with different types of sensitivity (and this may well explain why the first lab reports PSA values of < 0.05 as undetectable whereas the second lab reports 0.028 as detectable).

    Second, as you clearly understand, 0.028 is lower than 0.05 ng/ml … so there is no evidence that your PSA is any different this month than it was the last time it was tested!

    Arthur suggests you have two options. The first is to go back and get your PSA tested by the doctor who sends your blood to the first lab and see if their result simply comes back again at < 0.05. The second is simply to tell the urologist that he can test your blood again in 3 months time using the second lab (when, if it comes back again at anywhere between about 0.025 and 0.030 ng/ml, you will know that it is still stable and still well below a lavel at with secondary treatment is necessary).

    If all these tests were prescribed by the same urologist, then you need to be very clear with him that you aren't doing anything else until you get another PSA test result in another 3 months done by the "new" laboratory because there is no evidence whatsoever that your PSA has risen.

    Arthur doesn't think you need to be "freaking out" over any of this. However, he does think you need to understand the importance of getting all your PSA testing done through one laboratory so that you are comparing apples to apples. If someone wants PSA tests from another lab, that's fine, but then you (and they) need to understand that the first result from that new lab is a baseline and cannot be compared accurately to data from another lab.

  41. Thanks Arthur.

    My next PSA test is scheduled for Monday, July 1, 2013. It was my urologist who used the different labs. I will suggest that he use the first lab for the retest!

  42. Dear Arthur,

    I have written to you before regarding my husband, who is 61 years old with a Gleason score of 9 (4 + 5). He was Dx in March with a PSA of 860 to 920. He has now been on Casodex for 14 weeks and Lupron for 12. His PSA came down to 9.2 ng/ml after 30 days and another PSA test is scheduled before radiation in 2 weeks.

    I have three questions:

    (1) What should the radiation dosage be with an MRI-guided, IMRT method?

    (2) How many sessions should he have? The radiologist is telling me 30 to 33.

    (3) Also — and I am not sure you can answer this, because most of the prostate doctors don’t seem to think anything of it — my husband has five involved lymph glands, all of which are enlarged and one is a Gleason 4 + 4 = 8. They are all bean-shaped, with smooth fatty borders. Everything I read says lymph glands that are cancerous are almost always round and have uneven borders. His type is usually indicative of lymphogenesis (which can be the body try to hold back the cancer from spreading, i.e., oliogometasasis). He is T4N3M0. The doctors don’t seem to think this means anything. What do you think?

    Thank you

    Susan

    *****

    Arthur responded as follows:

    Dear Susan:

    Actually, Arthur really isn’t in a good position to answer any of these questions for you because he just doesn’t have the relevant information — and he still might not be able to answer them even if you told him more. All three of these questions really need detailed answers from the physicians who are planning to treat your husband. However, Arthur can give you some guidance.

    With respect to the dose level of the MRI-guided IMRT … Arthur would expect a higher dose level to be administered to the prostate itself and a lower dose level to the surrounding pelvic tissues. The total dose administered to the prostate itself might run between 75 and 85 Gy, but the dose to the surrounding tissues would normally be significantly lower because of the risk for complications. In other words, the actual dose levels need to be planned with care depending on exactly what areas of tissue within and outside the prostate are being targeted, and a good, experienced radiation oncologist will know how to do this appropriately. The other matter that affects this is the precise form of technology that is being used to radiate your husband, and there have been major changes in the quality and technology related to IMRT over the past few years that Arthur simply isn’t competent to keep up with.

    With regard to the total number of doses (fractions) to be administered, this again depends on the technology being used. While it used to be customary for men to get more like 40 fractions over about 8 weeks, newer more accurate treatment planning and technology has allowed for effective total radiation doses to be delivered with fewer fractions. Arthur is (again) in no position to make any specific recommendation to you. The important issue for you and your husband is only “Does this radiation oncologist and his/her treatment team have the appropriate technology, skill, and experience?” Arthur simply can’t answer that question for you.

    Finally, with regard to the lymph nodes, your husband clearly has Gleason 8 disease in at least one lymph node (and he may well have cancer in other lymph nodes too). The only way to try to treat your husband with curative intent is to give him a combination of targeted radiation to the prostate itself (to try to eliminate the primary tumor) along with wide-field radiation to the pelvic area (to try to eliminate any and all extra-prostatic tumors, however small). Given that perspective, Arthur would tend to agree with the doctors that exactly what is going on with the evidently enlarged lymph nodes may be intellectually interesting but makes no real difference to the objectives of treatment. If they don’t use wide-field radiation of the pelvis, there is a very high probability that your husband will continue to have progressive, micrometastatic prostate cancer that will then metastasize.

    Arthur is very aware that these are not very good answers to your questions. However, there comes a point for every patient and caregiver where one has to say to oneself, “I have found a skilled physician and his/her support team. I know they know what they are doing. It is not my job to make detailed decisions about how they use the tools that they are recommending. That’s what they have been trained to do.” Of course if that isn’t how you feel about the radiation oncologist in question, then you should go get a second opinion somewhere else … but Arthur’s general sense is that you are just trying to protect your husband from unnecessary risk related to the radiation. Unfortunately, there is going to be some level of risk in any form of treatment that is going to help your husband in the long-term. This is just in the very nature of his diagnosis.

  43. Hi Arthur! Does having sex 24 hours before a PSA test affect results if a man has no prostate?

    *****

    Arthur responded as follows:

    Dear Mike:

    Since a man with no prostate can’t produce PSA as a consequence of sexual activity, Arthur says he can’t really see how a man with no prostate could be producing PSA at all … unless (a) there is cancer somewhere else or (perhaps) (b) there was a significant amount of prostate tissue left behind at the time of the radical prostatectomy.

  44. Dear Arthur,

    Thank you for responding. I appreciate your time. Actually I am not trying to protect my husband; I want him treated very aggressively. I was concerned that 30 to 33 treatments are not enough. But I guess with newer machines less fractions can be given. I have faith in our doctors, but felt that at first they were going to do nothing — just androgen therapy — due to the extent of his disease. Then they had said they would try radiation also. My concern was that maybe they were doing palliative instead of long time remission aggressive therapy. Yes, I know you are correct; the lymph gland shape is curious, but does not change the facts.

    Susan

    *****

    Arthur responded as follows:

    Dear Susan:

    First, Arthur did not intend to imply that he thought you were worried about excessive radiation therapy. He was using the word “protect” in the generic sense of “care for” (i.e., help him to avoid poor decisions). However, clearly Arthur did not communicate this successfully and he apologizes.

    Second, Arthur would be interested in knowing whether your husband’s PSA falls further before he starts the radiation therapy, so please do let him know the results of the PSA test scheduled for 2 weeks from now.

    Third, Arthur had asked you earlier if you knew how long the doctors were planning to keep him on ADT after completion of the radiation therapy. The reason Arthur is asking is that if your husband’s PSA goes down to < 0.1 ng/ml (either before or after the radiation therapy) and stays there on ADT for a period of time (say 2-3 years), he may then be a candidate for intermittent ADT as opposed to continuous ADT over the long term. In saying this, however, Arthur wants to be very clear that he has emphasized the words may be. Given your husband’s starting point with a very high PSA and Gleason 9 disease, Arthur thinks that future intermittent ADT is a possibility but that continuous ADT (for life) is the more likely option.

  45. Hi Arthur.

    From our previous conversation on 06/27/2013! My PSA results came back this time at < 0.030, which indicates my PSA is stable. The urologist stated that cost was the main reason they used a different lab last time. With my PSA being so low, at what level would secondary treatment be advisable?

    *****

    Arthur responded as follows:

    First, GOOD!

    Second, Arthur says there are two possible reasons why you might need to think about second-line treatment at some point in the future. Neither of them is necessarily ever going to happen.

    Reason A is that your PSA starts to rise quickly (say from 0.03 to 0.08 to 0.15 ng/ml over a period of 6 months, implying that it is doubling every 3 months). Reason B is that it starts to rise more slowly but does (say within about 12 to 18 months) get to about 0.2 ng/ml.

    In the first of the above two circumstances you would want to have a serious conversation with your doctor quickly. A rapidly PSA doubling time associated with disease recurrence is not to be trifled with. In the second circumstance, you would have more time to make decisions, and a lot would depend on exactly how fast your PSA was rising because if it was happening very slowly (e.g., a PSA doubling time of 18 months or more) you might still never need secondary treatment.

  46. Hi Arthur! Other than cancer could the small amount of PSA (0.03 ng/ml) come from benign tissue left behind from my nerve sparing surgery since my PSA is stable and not rising? Is there any advantage to using ultrasensitive PSA testing vs. the standard test? I found out my blood is now being tested with the ultrasensitive PSA test; my first two PSA tests post-surgery were tested the standard way.

    *****

    Arthur responded as follows:

    Dear Mike:

    Arthur feels you need to understand that the PSA test really isn’t nearly as specific as you seem to think. The existence of truly tiny amounts of protein that trigger such a tiny level of PSA in a specific PSA test could occur for a number of reasons, of which one, yes, is that there may be a very small amount of remaining, non-cancerous tissue that is generating PSA.

    Similarly, Arthur would emphasize that it is not really particularly important whether you get your current tests carried out with the standard test or with an ultrasensitive test. What is important is that you get sequential tests assayed by the same laboratory using the same PSA testing system so that you know you are comparing apples to apples over time.

    There is a theoretical advantage to using the ultrasensitive test for men whose PSA may well be at higher risk for starting to climb again soon after their treatment. The ultrasensitive test would allow the patient and his doctor to identify such a rising PSA a little earlier in the process (even if they didn’t do anything about it for a while because it was rising very slowly). Arthur would point out that in your case there is no specific reason to believe that you are at risk for early recurrence. Furthermore, your PSA appear to have been completely stable to date at PSA levels below 0.03 ng/ml.

  47. Dear Arthur:

    I have written to you before regarding my husband Paul with a PSA of 940 down to 320 after IV antibiotics (biopsy infection) down to 9.2 after 30 days of Lupron and Casodex. He is a Gleason 9 with extensive lymph gland involvement. He just started radiation and his PSA prior to starting radiation and after 3 months of treatment with Lupron (one 4-month injection) was below 0.2 ng/ml (as per the lab report). An ultrasensitive PSA test was not done, so that is all we know. I feel this is promising news.

    Thank you for your information,

    Susan

    *****

    Arthur responded as follows:

    Dear Susan:

    Arthur thinks it is certainly a good thing that your husband’s PSA had dropped as low as < 0.2 ng/ml within 3 months after starting the Lupron. Arthur would also assume that his doctors are going to want him to stay on the Lupron for at least 18 to 24 months after radiation therapy is completed. If his PSA is still down at < 0.2 ng/ml after that period of time, it may be possible to try stopping the LHRH therapy for a while to see what happens. It will only be then that we can come to any significant conclusions about the long-term effectiveness of his treatment.

    In the meantime … you just want that PSA to stay as low or lower than 0.2 ng/ml!

  48. Hello Arthur.

    Can you please help me? I want to find out if local chemo is a good option to go for. I have low-grade prostate cancer.

    Yours

    Allan Priestley

    *****

    Arthur responded as follows:

    Dear Allan:

    Arthur says it is quite impossible for him to answer your question because he is at best uncertain what you mean by “local chemo” and he has no other information about you or your clinical situation.

    Arthur strongly suggests that you join this site’s “social network” where the site manager will ask you a number of specific questions to clarify your situation and will then be able to offer you specific suggestions based on your individual characteristics.

    The one thing that Arthur can tell you at the present time is that there are very few data to support any value of first-line, docetaxel-based chemotherapy in the treatment of low-risk prostate cancer — but that may not be what has been suggested as appropriate for you.

  49. Dear Arthur,

    Hello again, this is Susan. We just spoke with the radiation oncologist after my husband’s third treatment. He is only using 60 Gy to pelvis and prostate. He said he reserves 75 to 80 G only to cure and my husband is not curable. He does not want him to have side effects as his longevity is not there. I am devastated and depressed as I feel it is being done as pallative care, which I suspected but was not told. The radiation oncologist said he has a 5 cm lymph gland with Gleason 8 and this is not curable and did not lead us to believe it was possible for a long-term remission. He did not seem impressed with the 0.2 PSA. Our family doctor was thrilled! Just said that is good.
    I had told him that I had read studies of using over 70 Gy and producing long-term remissions. He said he was not aware of any such studies. My husband, who feels so well and has no symptoms has been told to retire, which he is not ready to do mentally or financially. We are unsure if we should continue with the 60 Gy and a doctor who feels there is no hope or stop treatments and seek another opinion. The radiation oncologist said he normally does 8 weeks of radiation but does not feel that would change the outcome so is only doing 6 weeks. We were told that my husband was not considered curable but we thought they were going to fight it a bit more. Again, there is no documented distant metastasis found and he was just scanned again. All his blood work is perfect. We left the appointment feeling very deflated. This is NYU Cancer Center — excellent reputation. I would appreciate your opinion.

    Thank you.

    Susan

    *****

    Arthur responded as follows:

    Dear Susan:

    First, Arthur needs to be very clear with you about some factual issues (some positive; some negative from your perspective).

    (1) Your husband’s initial PSA of > 900 ng/ml was always a PSA level that implied a very high likelihood of at least micrometastatic prostate cancer, regardless of everything else. Your husbaand does seem to have several unusual features related to his diagnosis and the behavior of his PSA, but the chances were never good that his cancer was “curable” (which is very different from long-term remission).

    (2) Arthur knows of way too many men with initial diagnoses that looked worse than your husband’s who were told that they had a limited life expectancy fo a year or two and are or were still alive 5, 10, and 15 or more years later. The individual prognosis of outcomes and death among men with even advanced prostate cancer is extraordinarily difficult, and it is Arthur’s entirely personal opinion that all men in good health other than their prostate cancer should be treated as if at least a long-term remission was a possibility.

    (3) Arthur says that the only way anyone could possibly eliminate a 5-cm positive lymph node would be surgically. One simply cannot give doses of radiation higher than about 60 Gy to the area outside the prostate. Doses of 70-85 Gy can be delivered with high accuracy to the prostate itself because the idea there is to kill all the relevant tissue. Wide-field radiation to the pelvis has to be given at lower doses.

    (4) Arthur thinks someone did a very poor job of making sure that you and your husband understood the situation before radiation therapy was started. They may well have told you things that you weren’t ready or able to “hear” … but if they did, they failed to make sure that you had actually heard them.

    So, having said all of that, what to do?

    In the first place, Arthur would ask who has told your husband he needs to retire? Is this his employer or some doctor? Arthur obviously doesn’t know what your husband does for a living, but that sounds like a slightly bizarre suggestion.

    In the second place, Arthur thinks you need to have a second conversation with the radiation oncologist at NYU and explain to him that you understand his perspective but it is your husband’s life that is on the line here, not the radiation oncologist’s, and that the objective from your perspective is at least long-term remission (even if this is potentially unlikely in his opinion), so why not go for the full 8 weeks of therapy? It may not be the best idea in the world theoretically, but what does anyone really have to lose?

    In the third place, as Arthur has noted previously, we really aren’t going to have a clue how well your husband will respond to the combination of radiation and ADT for something like 2-3 years (unless he does badly and progresses quickly). You and your husband are going to need to find a way to get a positive attitude to all of this becuase otherwise you will just start waiting for “the inevitable” as opposed to enjoying life for every day you can. We are all going to die in the end. In the interim, the idea is to have as much fun ourselves and make as much of a difference for others as we can … whether employed or retired! That doesn’t happen when one sits on the couch feeling sorry for oneself — although some of that is also inevitable; we are all human.

    Arthur would also point out that of course you are being emotional about all this and of course your husband is depressed about it. Arthur also thinks your family doctor is perhaps being overly optimistic on your behalf, believing that one of his responsibilities is to “keep your spirits up.” I think you need to have a conversation with your family doctor that goes something like, “Please don’t sugar-coat any of this for us. We get it. He has positive lymph nodes and almost certainly widespread micrometastatic (invisible) prostate cancer. What we need you to do is help us to get him the best possible care whether it is for 5 years or for 25.”

    You and your husband are going to need to “take charge” of his treatment. There are clinical trials of new drugs he could try once the first cycles of radiation therapy is complete (on top of the an drogen deprivation). There are lifestyle factors that can make a difference for some men. The attitude of the patient to what he needs to do to make the most of whatever life he has remaining is key (again, whether it is 3 years or 23).

    However, having said all of that, Arthur doesn’t think your husband’s prostate cancer is curable. The key question is going to be whether aggressive therapy can give him a year or 10 years or more. The fact that there is no sign yet of actual metastases is a very positive one, so the question Arthur would be asking every doctoir he saw if he was in your husband’s position would be “What else can we do to delay the onset of visible metastatic disease?”

  50. Dear Arthur,

    Another curious thing is that a pre radiation PSA was not ordered I had our family Dr do it. They ordered it 3 weeks from now.Is that unusual? We travel far to receive this care and I am suspicious of the quality, or am i just being overly emotional. My husband who has been so upbeat and positive, has lost his spark.

    Susan

    *****

    Arthur responded as follows:

    Dear Susan:

    Arthur is now confused. You told him just the other day that your husband had a pre-radiation PSA level of 0.2 ng/ml. There is very little point in getting another PSA taken until at least a month or more after radiation therapy is complete (whether it is just 6 weeks or the full 8 weeks, as discussed above). Your husband’s PSA level is currently being controlled by the fact that he is on androgen deprivation therapy.

    Re “being emotional”, see above. Arthur says that of course you’re “being emotional”! Who wouldn’t be? You are going through a series of emotional crises!

  51. My name is not Susan so don’t send me her stuff.

    *****

    Arthur responded as follows:

    Dear Allan:

    Arthur says that if you don’t want to receive messages from Arthur when he responds to questions, you need to go back and “turn off” your request to be informed when there are new posts on “Ask Arthur.” Arthur is sorry but he has no control over this. You do.

  52. Dear Arthur,

    Thank you for your reply and information. We were told very clearly by four doctors that my husband’s cancer is not curable. We unfortunately do know the facts. I think we both were being optimistic, hoping for a remission of some extended time. We did hear all the facts and did extensive research, but just wanted to give this thing the best fight possible. I was just asking the radiologist why he was not giving the prostate a boost of 75 to 80 Gy at the end and he went into the large lymph node saga which we knew. Then he threw in the thing about even another 2 weeks would not help. I guess he wanted to get his point across. You are correct about asking him to put himself in our place and seeing the situation from our point of view. We are trying to pull ourselves out of this funk, it was just a shock when the person you are depending on does not have a positive attitude. We are optimistic about his PSA response and continued good health and will hold on to that. My husband does now eat an organic diet.

    Thanks

    Susan

  53. Dear Arthur,

    I asked our family doctor to run the pre-radiation PSA, it has been ordered by his team for 2 weeks from now not before radiation. It is to be done at the appointment for his next Lupron shot.

    Susan

    *****

    Arthur responded as follows:

    Dear Susan:

    First, thank you for you other message below. Arthur entirely understands how difficult this can all be to deal with. You are doing the right things, and it is going to be important for you to make sure your doctors know you trust them to try as hard as they can. Sometimes physicians have “bad days” too and they don’t explain things as well as they might, or they forget to add the bit where they say, “Do you understand what I am saying, and is this OK with you?”

    Second, just be careful about understanding that you can’t always accurately compare results of PSA tests taken by different doctors — who will almost certainly be using different laboratories and/or even different methodologies to assay the PSA level. Ideally you want to get all PSA tests done by a single laboratory that is using the same methodology so that you know that you are comparing apples to apples on a regular basis. It is normal for specialists to take blood for a PSA test immediately prior to each shot of Lupron, and Arthur would suggest that if you want to get additional PSA tests at any time you might be better to ask for those through the urologist so that you know that the same lab will be running the assay the same way every time.

  54. Hi Arthur!

    Like cancer, does benign prostate tissue left behind after surgery cause the PSA to rise or just cause the PSA to become detectable without any increase?

    *****
    Arthur responded as follows:

    Dear Mike:

    Arthur says that there is no really good Yes/No answer to that question. I kinda depends on how much benign tissue is left behind.

    If there is only a tiny amount of benign, PSA-generating tissue left behind, the the PSA may initially drop down to an undetectable level and then rise again a little bit, but not usually to much more than about 0.1 ng/ml. However, if there is a significant amount of benign, PSA-generating PSA tissue remaining after surgery, the patient’s PSA may never drop down into the undetectable level at all — leaving the patient (and his doctors) worrying about what they may need to do next, if anything.

    Arthur realizes that this isn’t exactly the most helpful of answers to your question … but at least it has all the benefits of being truthful.

  55. Hi Arthur:

    Could you please tell me if Zytiga is chemotherapy or hormone therapy?

    Thank you.

    *****

    Arthur responded as follows:

    Dear Nidia:

    Arthur says that Zytiga, which is also known as abiraterone acetate, is a new type of hormonal therapy (properly known as androgen deprivation therapy or ADT) that blocks the conversion of adrenal androgens into dihydrotestosterone. It is not chemotherapy.

  56. If prostate cancer has spread to a single lymph node, is there an alternative to testosterone blockers, for example using an estrogen blocker? If so, are the side effects less than testosterone blockers? Thank you.

    *****

    Arthur responded as follows:

    Dear Will:

    Arthur says that it isn’t really possible to answer your question without a lot more information.

    You can either provide more information to Arthur, and he will do his best to answer your question here, or, perhaps better, you can join the social network associated with this site and you will be able to get sound guidance there.

    In either case, assuming that you have already had surgery (which was when they found out that you had a single positive lymph node), here is the core information that will be necessary to help to answer your question:

    – Your age
    – Your PSA level at diagnosis
    – Your PSA level now, post-surgery
    – Your pathological Gleason score post-surgery (e.g., 3 + 4 = 7)
    – Your full pathological stage post-surgery (e.g., T3aN1Mx)
    – Whether you had cancer in your seminal vesicles at the time of surgery
    – Whether you had extracapsular extension of your cancer at the time of surgery
    – Whether you had positive or negative surgical margins at the time of surgery
    – Exactly what type of therapy your doctor is currently recommending (for example, is he recommending some type of hormonal therapy prior to radiation therapy as a follow-up to the surgery?)
    – Any other useful details that you know

  57. Hi. My name is Cheryl.

    My husband had a PSA of 4,917 ng/ml 3 months ago. Our hospital refused to do any tests and suggested castration as the only thing to prolong life a bit.

    We decided not to do castration and embarked on healthy diet and extensive juicing. When your house is burning you need more than one hosepipe. We have used bicarbonates, hydrogen peroxide, DMSO, MSM colloidal silver, and MMS to name but a few, and he is slowly gaining weigh; the fatigue is better and his appetite is much better. We will be going for a PSA soon and will let you know.

    Regards

    Cheryl

    *****

    Arthur responded as follows:

    Dear Cheryl:

    Arthur says that, contrary to popular wisdom today, it used to be quite common for men to be diagnosed, like your husband, with a very high PSA level and yet no obvious symptoms of metastatic prostate cancer (e.g., severe bone pain in the lower back or elsewhere). We therefore know that there are two quite different things that go on under such circumstances.

    The first issue is whether anything that you are doing can actually affect the progression of your husband’s disease. Arthur is not aware of any data to suggest that this will be the case, but he is also aware that “strange things do happen” and that traditional medicine has no explanations for this.

    The second issue is whether what you are doing can lower your husband’s PSA level (even if that is not significantly affecting the progression of his disease) and/or improve his quality of life. Arthur can tell that you certainly believe it is doing the latter and that you are hoping it will also do the former. And you may well be proven correct about this.

    What Arthur is truly horrified by, however, is your statement that “Our hospital refused to do any tests.” In Arthur’s entirely personal opinion it is and was unethical not to give your husband at least a bone scan to determine the extent of his disease so that there is some clarity about the potential progression of his disorder over time. Furthermore, since there are different ways in which to lower a man’s testosterone level and thereby lower his risk for the early onset of the symptoms of late stage disease, it would appear to Arthur to have been unethical not to review all of the possible options with you … so Arthur hopes that they did. (Since you simply state that the only form of treatment offered was “castration”, it is unclear to Arthur exactly what was being offered as treatment.)

  58. Cheryl:

    I genuinely love you and your husband’s response to your PSA news. I will not go in to my bona fides to speak on this subject — but I found this message board prior to my March 2011 radical prostatectomy. I regret agreeing to the procedure …. It took me a year to be convinced to have the operation. One thing I’ve come to believe is that very little is known about this prostate cancer stuff. Outstanding physicians do not even agree on the usefulness of the PSA test. Apparently most times prostate cancer is very, very, very slow growing, but sometimes it is not. One thing for sure — it is a billion dollar industry. One other thing — this guy Arthur is (in my opinion) the most credible voice out there on this murky subject. I would listen to him before any urologist. Best wishes to your husband and you.

  59. My apologies for the lack of information in my question. I have not had treatment yet but have opted for brachytherapy. My PSA when diagnosed was 7.4 ng/ml; my Gleason score was 4 + 3; there was no cancer in the seminal vesicles, but a single lymph node with involvement (7 mm in size). I am 60 years old, and am scheduled for a needle biopsy to confirm cancer in the lymph node. Thank you for your reply.

    *****

    Arthur responded as follows:

    Dear Will:

    So Arthur thinks (rather obviously) that if the suspicious lymph node is actually positive for cancer, then it may be necessary to re-think the idea of brachytherapy alone as being a viable treatment plan. The first thing is clearly to establish whether there really is cancer in that lymph node. (Arthur is also assuming that the suspicion of cancer in that lymph node is based on data from an MRI scan or similar. Yes?)

    Conversely, it would be Arthur’s opinion that, if the lymph node is negative for cancer, and so are your seminal vesicles, then brachytherapy is certainly an option as a first-line treatment, although some people would argue that if you want to have brachytherapy it might be best done together with a short course of neoadjuvant androgen deprivation therapy (ADT, also known as “hormone” therapy) for — say — 6 to 9 months. This is a matter you would need to discuss with your doctors.

    Given your Gleason score of 4 + 3 and a PSA of 7.4 ng/ml, you are on the “upper end” of having intermediate-risk prostate cancer, with a reasonable life expectancy of another 20+ years, Arthur says you do want to make sure that your treatment is curative (if at all possible) while simultaneously minimizing risk for long-term side effects.

    Now … It is certainly possible to use low-dose estrogenic patches as a form of hormonal therapy instead of standard forms of ADT. However, we have very little information about the long-term benefits and risks of doing this in men like you. You also need to appreciate that there are different types of ADT that are available (e.g., oral antiandrogen monotherapy as opposed to LHRH agonist or antagonist injections). The problem is that very few prostate cancer specialists have much experience using these alternative forms of hormone therapy today, and so they are resistant to using them as first-line treatment. So if you need to consider long-term treatment with hormonal agents of any type because the lymph node is positive, you may have a bit of a battle to convince your doctors to try something different like use of estrogenic patch therapy or antiandrogen monotherapy.

  60. Hi. What is Arthur’s opinion on the expected lifespan for my husband with a PSA of 4,917 if we do nothing.

    Regards

    Cheryl

    *****

    Arthur responded as follows:

    Dear Cheryl:

    Without some additional data (like what his age is now, how fast his PSA is rising, how widespread his cancer is, and what his Gleason score is), Arthur thinks that that is an extremely difficult question to answer with any degree of accuracy. It could be anywhere between as little as 18 months and as much as 5 years. It might even be more than that, although Arthur thinks that that would be unlikely for a man with a PSA of near to 5,000 ng/ml if you do nothing.

  61. Hi, my name is Dan.

    My brother’s PSA jumped from 4.5 to 390 in the space of 2 years. Alkaline phosphatase > 1100; serum Ca normal. MRI report indicates metastases from lumbar thru thoracic spine. Prostate palpable but not particularly enlarged. No pathology results yet.

    What is “normal” therapy for metastatic prostate cancer? Are there any interesting experimental combination therapies? Is there any institution that will culture a tumor and test for in-vitro sensitivity to various treatment modalities?

    Thanks in advance

    *****

    Arthur responded as follows:

    Dear Dan:

    Arthur is sorry to hear about your brother’s diagnosis. This type of highly aggressive prostate cancer is relatively unusual.

    Here are the answers to your questions:

    (1) Standard, first-line therapy for metastatic prostate cancer is one of several forms of androgen deprivation therapy or ADT (also known as “hormone therapy”) intended to block the conversion of male hormones (primarily testosterone) into dihydrotestosterone (DHT), which is the metabolite that drives prostate cancer cell growth. ADT today is most commonly based on the use of injectable drugs known as LHRH receptor agonists (e.g., leuprolide acetate/Lupron) and antagonists (e.g., degarelix/Firmagon). LHRH agonists may be given in combination with other drugs known as antiandrogens (e.g., (bicalutamide/Casodex).Your brother will almost certainly need long-term, continuous treatment on this type of therapy (unless he is willing to undergo surgical castration).

    (2) This type of treatment is not curative. It may delay progression and it will also delay the onset of severe bone pain, but it is not going to stop the progression of the disease over time. There will come a time when his cancer becomes refractory to this type of treatment and he enters a state known as “castration-resistant). There are several drugs new drugs that can be used at this stage, including drugs like abiratone acetate/Zytiga and enzalutamide/Xtandi, and docetaxel-based chemotherapy.

    (3) There are a vast variety of other drugs in clinical trials, including immunotherapeutic agents like Prostvac. Arthur would strongly encourage your brother to at least get a second opinion at a center that is a member of the Prostate Cancer Cinical Trials Consortium (PCCTC) if he is able to do this. Medical oncologists at these centers are highly involved in trials of a spectrum of new agents for advanced forms of prostate cancer.

    (4) There is one center that has a highly sophisticated procedure investigating the correlations between tumor biology, genetics, and specific types of drug therapy. That is a research unit at the Unversity of Michigan Cancer Center in Ann Arbor led by Dr. Chinnaiyan. If your brother wants to go there, I would encourage him to see if he can get an apppointment to see Dr. Maha Hussain, who is one of the world’s most respected specialists in the management of advanced prostate cancer and is closely involved with the work being done by Dr. Chinnaiyan. The University of Michigan group is a key member of the PCCTC.

    Arthur hopes that this information is helpful.

  62. Arthur:

    Thanks for the information. Since I last talked to you I had an prostate MRI. Everything was clear outside the prostate. They said that there were two (2) suspicious areas in the prostate. I already know there was a Gleason 6 in 1 out of 12 cores. I guess they missed the other. My PSA has dropped from 0.80 to 0.70 the last 6 months. The doctor wants me to do a second biopsy next month (1 year after the first one), but being my MRI was so good and my PSA level is so good, I really do not see a need to do this second biopsy. What is the chance the second suspicious area is more than a Gleason 6 with such a low PSA? What would you do? Again I’m 63 and have a younger wife and a 3-year-old daughter.

    Thanks,

    Len

    *****

    Arthur responded as follows:

    Dear Len:

    Arthur says that he can’t really give you any meaningful guidance about this because there are far too many missing pieces of information about the precise nature of the MRI you were given and, even if Arthur knew this, we really don’t have any good guidance yet about the risk factors for false positives and false negatives associated with the use of MRIs in this manner.

    Arthur also suspects that your urologist’s desire to do another biopsy is being driven as much by his own difficulties in understanding what the MRI is telling him as anything else. By contrast, he knows how to do a biopsy and has confidence in what the results will tell him. The general guidance given to urologists today has been to give patients a repeat biopsy after a year on active surveillance … but that guidance is based on pretty weak data, and is not a formal “guideline”.

    Arthur thinks that you and your urologist need to have a heart to heart about the real value of the biopsy in your case. There are arguments for having one, and there are arguments against it. What there are not are any compelling data to support one argument over the other.

    Arthur’s entirely personal bias would be to tell the urologist that he just didn’t see the need for the biopsy based on the falling PSA level and what could be identified on the MRI … but then we are back to the fact that Arthur would want a lot more information before he could tell you that he thinks it would be reasonable for you to follow such a strategy. The best strategy for you is to have that “heart to heart” with your doctor and see if you can come to a mutually acceptable decision together.

  63. We live in Cape Town, South Africa. My husband Colin is 63 years old and he is experiencing pain in his shoulder blades. Is this normal for prostate cancer? Also intermittent pain in the lower back but this I expected. His appetite is almost back to normal and he is not nearly as tired as before. He has regular live blood analysis and it looks better every week, except for last week after treatment with DMSO, MSM, MMS and the rest of the protocol when it was clogged with debris from dead microbes. The MSM taken orally and the DMSO applied topically helps for pain its quite amazing. I also noticed that his weight gain slows dramatically when he does not have enough veg juice. We are going to have him tested by a SCIO/QUANTUM feedback machine this week-end and will keep you posted if you are interested in alternative cures. Our hospital is Groote Schuur (Chris Barnard — first heart transplant) and the idea of not doing anything is because they say it is useless when the PSA is so high (4,917 ng/ml). We have met quite a few people who are now cancer-free after alternative treatment. I know most people trust their doctors and this is good, but we believe that God made our bodies to heal itself, given the correct nutrition.

    Regards

    Cheryl

    *****

    Arthur responded as follows:

    Dear Cheryl:

    First, Arthur would say that it is not at all unusual for a man with metastatic prostate cancer and a PSA of > 4,000 to be having pain in his shoulder blades. This is a common site for metastasis as the disease progresses over time. Arthur had asked you before whether Colin has had a bone scan. You did not respond to that question. It still seems extraordinary to Arthur that he would not have had such a scan (unless he refused this) … especially at an institution of the stature of Groote Schuur.

    Second, Arthur is utterly unable to understand what you mean when you say that “it was clogged with debris from dead microbes.” Are you saying that Colin has had some type of serious infection on top of his prostate cancer? Cancer on its own would not lead to a blood sample being “clogged with dead microbes”, but a blood sample from a man with metastatic prostate cancer may well include all sorts of abnormal factors for all sorts of possible reasons.

    Third, Arthur knows what DMSO is (dimethyl sulfoxide). Its use in the treatment of any form of cancer is controversial (to be polite) but it may be helpful when used topically to relieve pain. MSM (methylsulfonylmethane) is a supplement used to treat a variety of pain-related issues. It’s use may be safe for up to 3 months if it is being taken orally. However, MMS or Miracle Mineral Supplement is pretty much just a form of strong bleach. It is banned in many countries, and Arthur would strongly suggest that using this product is probably not in Colin’s best interests at all.

    Arthur also has very grave concerns about the value of the SCIO/QUANTUM feedback process that you refer to. He suspects that you are going to be changed a lot of money for something that has no proven clinical benefit whatsoever, but Arthur cannot make decisions for you and Colin.

    Arthur fully understands that you are trying to do everything you can to help your husband, and some forms of alternative therapy may not be a bad idea at all. Others, on the other hand (e.g., MMS) can be extremely dangerous, and you need to be very sure that what you are doing with some of these products and procedures really is in your husband’s best interests. Arthur also appreciates your belief that “God made our bodies to heal itself, given the correct nutrition.” He would point out, however, that God has also left a lot of people on this planet who sell dangerous things to unsuspecting people. Your God would want you to remember that not all the hype you hear is true (regardless of the apparent beliefs of those who think they may have benefited).

  64. Hi Arthur!

    Is it unusual for the pathology report to not include the length and Gleason score of the positive margins found? Where can I get this information if my pathology report doesn’t include this information? Also is it possible to get a second opinion on the entire specimen after RP to see if there were benign tissue at those margins identified as positive?

    *****

    Arthur responded as follows:

    Dear Mike:

    Arthur says that the quality of pathology reports can vary to a quite extraordinary degree, depending on the individual pathologist and the standards set and required by the organization/institution at which he or she works.

    Your first option is to see if it is possible to contact the pathologist who examined the original tissue and wrote the original report. However, if the report originally provided was of poor quality, the value of trying to contact the pathologist is at least open to question because he/she is going to be on the defensive from the get go.

    Arthur thinks a much better option would be to ask for the slides prepared from the original specimen to be sent to a recognized specialty prostate pathology center for a second opinion (which is perfectly possible and regularly done). Your urologist will need to assist you with this, however.

    Respected specialty pathology centers that can and do frequently provide “second opinion” services include the laboratory of Dr. Jonathon Epstein at Johns Hopkins in Baltimore, MD (click here for details); Bostwick Laboratories (click here for details); and OURLab (click here for details).

  65. I had EBRT about 3.5 years ago and my PSA went down to 1.36 ng/ml. My PSA today is 15.98 and I have been diagnosed with stage 2 cancer recurrence inside my prostate. What are your thoughts? Thanks,

    Glenn

    *****

    Arthur responded as follows:

    Dear Glenn:

    Arthur says that he has way more questions than answers. They start with whether you know your current PSA doubling time and they include other factors like your current age as well as your original PSA level, clinical stage, and biopsy-based Gleason score. They also include what your current doctor has been telling you while your PSA has been rising over the past 3 years!

    Arthur would suggest that your best best is probably to join the social network associated with this site, where they will work with you to try to get a clear understanding of your current risk level. It seems highly likely that you need additional treatment. The question is going to be what kind of treatment is appropriate and available. Salvage surgery can be carried out, but it is associated with a very high rate of complications and side effects. Salvage HIFU may be available in a clinical trial setting. Cryotherapy might be a possibility. Or you may be better of accepting that some form of hormone therapy (androgen deprivation therapy or ADT) will need to be the next step and working with your doctors to determine when that would be appropriate.

  66. Dear Arthur,

    Hello, I have written to you in the past regarding my husband’s T4 D1 prostate cancer. His initial PSA this past February was in the 800s and 900s, with Gleason 9 disease. Extensive regional lymph involvement was evident but no distant metastasis was found.

    His PSA went down to 320 ng/ml after IV antibiotics and down to 9.4 ng/ml after 2 weeks on Casodex therap. He is now finished with pelvic radiation (5 weeks ago) and has had two Lupron shots (each of 30 mg q4 months).

    Amazingly his PSA is stable at below 0.05 ng/ml. His serum testosterone is below 3. His alkaline phosphate is below 40. His doctors seem to be quite impressed. No side effects from radiation remain at present, although he did have them the last 3 weeks of treatment.

    He is mildly anemic and his liver enzymes slightly elevated (most likely from the Casodex). All other blood work is perfect. My question is: Would it be reasonable for me to ask the doctor for a Casodex-only vacation at this point (while he remains on Lupron). He does have some nausea and GI upset from the Casodex. We know he has to be on the Lupron for at least 2 more years. I can find no medical info on Casodex used intermittently.

    Thank You for your time,

    Susan

    *****

    Arthur responded as follows:

    Hello again, Susan.

    So Arthur is perhaps not quite as surprised as you seem to be that you husband has responded well to the combination of radiation therapy and androgen deprivation. On the other hand, as always, Arthur is delighted to see such an apparently excellent response.

    Arthur further thinks it would be perfectly reasonable to ask your husband’s doctors whether it would be possible to stop the bicalutamide (Casodex) therapy, given the fact that there seem to be some significant potential side effects associated with this drug. The primary reason for the initial use of Casodex has been met (i.e., to prevent any flare reaction associated with the introduction of Lupron therapy). Having said that, there may be specific reasons why the doctors do believe your husband should be maintained on the Casodex, in which case you might want to ask whether a smaller or less frequent dose might be possible to alleviate the side effects.

    Let’s hope that your husband’s PSA is still down at < 0.1 ng/ml 2 years from now and that he is able to adjust well to therapy.

    Arthur also says, do make sure that he is sticking to a good, "heart healthy" diet and a regular exercise regimen to help alleviate some of the potential side effects of the ADT.

  67. Dear Arthur:

    Yes, thank you for your response. My husband eats an organic prostate cancer diet (set up for him by a prostate naturopath doctor). He does cheat once a week as recommended. We go back to the oncologist in November. I will ask about the Casodex then. Should I ask about having the ultrasensitive PSA done? Is below 0.05 (as stated on lab reports) enough information or should he be watched closer than that? The doctor’s office sends me the lab work results by e-mail, so I have not had the opportunity to ask this question. I will ask at next appointment.

    I appreciate your time.

    Susan

    *****

    Dear Susan:

    By all means ask the oncologist about whether s/he is or isn’t using a sufficiently sensitive PSA test, but so long as your husband’s PSA is down below 0.05 ng/ml, that is certainly sufficient information.

    The other thing that Arthur would say is that a good oncologist would almost certainly be willing to discuss the Casodex issue over the phone if you ask for a brief phone call to explain the situation. If you ask for that phone call now, then it would give the oncologist time to think about this between now and the November visit, even if he or she isn’t ready to just let your husband stop the Casodex tomorrow.

  68. Dear Arthur,

    Yes after we spoke via this site, I did decide to call and asked if we could decrease dosage due to side effects. The call received back was from the NP who said doctor said to discontinue it and repeat blood work in 4 weeks instead of 8 weeks. They were very open-minded and responsive. I was given the impression that they respect outside research and input.

    This is the oncologist that I love. Such a different attitude than we were faced with in March with the urology branch of the practice, who were a bit different in their thinking.

    Thank you,

    Susan

    *****

    Arthur responded as follows:

    Dear Susan:

    Arthur is pleased to have been of a little assistance … but you’re the one who did all the hard work!

    :O)

  69. Dear Arthur:

    Thank you for your advice. It gave me the courage to trust my judgement after getting shot down on my last two suggestions to the urology and radiology branch of the practice. I just didn’t want to hear how serious his situation was again. We heard it and understood it the first time in March. We feel better all around now.

    Susan

  70. Having read all the comments I’m a lot better informed. Will have myself checked as soon as.

  71. Dear Arthur,

    My dad (who is in his mid 80s) is scheduled to undergo prostate biopsy in 2 days. His PSA is almost 70; he has been on two prostate medications (Proscar and doxazocin) for the last 10 years. My dad is an angina patient, and is extremely sensitive to pain. Is there anything you would recommend we ask the doctor to provide before the biopsy to help with the pain?

    Isn’t there an injectable anesthetic that might be more helpful to block the pain? Or anything else to help with the pain.

    The doctor has only recommended he take Valium to help relax before the procedure.

    I really appreciate your help and time.

    Thank you,
    Green girl

    *****

    Arthur responded as follows:

    Dear Green Girl:

    Arthur says you might want to check with the doctor whether he intends to give your father local anesthesia with lidocaine at the time of the biopsy procedure. This is now commonplace and is described in detail in this article on the Medscape web site. (You do need to sign up for Medscape to see the article, but it’s free and you don’t have to be barraged with junk e-mail.)

    Arthur also says that if the urologist is not used to doing this, then your Dad does not want to be the first patient he tries this on! If the current urologist has no experience of giving local anesthesia for prostate biopsies, can you get a referral to another urologist?

    Third, Arthur would note that you need to be very cautious about what your Dad wants to do if he is found to have some prostate cancer on biopsy. Many of the available treatments for localized disease may not be appropriate for an 80-year-old man with angina. Arthur thinks that before he did anything — if he was wearing your Dad’s shoes, and someone found some cancer in his prostate at 80 years of age with a PSA of 70 ng/ml — Arthur would want to get a bone scan done to see if there was any sign of disseminated prostate cancer. There very probably is not, but it would be a wise precaution before making any other decisions.

  72. Dear Arthur,

    I had a TURP on December 16, 2011. There was no cancer. In November 2012 I had PSA of 2.0, and this week I had a PSA of 3.5. What I should do now?

    Please help.

    Nasser

    *****

    Arthur responded as follows:

    Dear Nasser:

    Arthur says that he has no good answer to your question because you haven’t provided enough information. Arthur would need to know all of the following to be able to offer a helpful answer to your question:

    – Your age
    – Whether you have any family history of prostate cancer
    – Whether you have or have had any symptoms of urinary tract problems since your original TURP
    – Whether your doctor can “feel anything” like a lump or hard spot on your prostate when he gives you a physical examination

    Is is possible that you need a biopsy? Yes, it is. It is certain? No, it is not. You could have a rising PSA fpor all sorts of possible reasons.

    The sensible thing for you to do is to go and talk to your urologist and get his opinion rather than Arthur’s! Your urologist will be able to actually examine you and answer your questions for you in a much more informed way that Arthur possibly can.

  73. Hi Arthur,

    I am 15 months post RP and my PSA has been low and stable around 0.030 using the ultrasensitive assay (LDL 0.014) until the last test came back at 0.040. Is this increase significant? Could this be a lab error? It has me a little nervous. Where do I go from here? Is it time to consider secondary treatment?

    *****

    Arthur responded as follows:

    Orson:

    Arthur says that a single, tiny PSA blip like this really shouldn’t be any cause for worry. It is well within the margins of error of the ultrasensitive PSA test, and so you can’t have any confidence in its clinical significance. Your next PSA could equally easily come back at a value of (say) 0.025 ng/ml. So the sensible thing is to try and “chill out” until you have your next PSA test is due (although Arthur is well aware that that is easier to say than to do!).

    Arthur does note that you could, if you want to, talk to your urologist about having your next PSA in 2 months time as opposed to 3 months. This would be one way to abbreviate the period of stress.

    Arthur is sure that your urologist has already told you that there is no need to get overly anxious at this point in time. Even if your next PSA level was to come back at 0.050 ng/ml in 3 months time, the really critical question to be considered would be the rate at which your PSA is doubling if it does start to go up slowly like this. That would help to determine what any next treatment might need to be (if further treatment does prove to be needed — which it may well not).

  74. Hi Arthur,

    Because of my PSA results were detectable at 0.030-0.040 ng/ml (15 months post-RP) using the ultrasensitive assay (LDL 0.014), my urologist had me take a CT scan of my pelvic and abdominal area. The only thing found was kidney stones; no sign of cancer spread. My question to you is, what did he expect to find with my PSA being at such a low level? Is it possible to find anything at such a low level?

    *****

    Arthur responded as follows:

    Dear Orson:

    Arthur says that you would need to ask your urologist what he thought he might be able to find with a CT scan at that PSA level. All that Arthur is able to tell you is that the people at the Mayo Clinic in Rochester, MN, will only give patients a choline-11 PET/CT scan post-RP if their PSA has risen to at least 0.2 ng/ml (i.e., something like five times higher than yours). We do know that choline-11 PET/CT scans are significantly more sensitive than a standard CT scan.

    It is possible that your urologist had a “non-standard” reason for giving you a CT scan (because of course Arthur doesn’t have all of the relavant information), but Arthur has no idea what that might be.

  75. Hi Arthur.

    With the advice of my urologist I have an appointment today with a radiation oncologist about my stable, low but detectable PSA (0.030-0.040 ng/ml) 15 months post-RP. This is a new journey for me, so, if possible, please give me at least 3 important questions to ask the oncologist at my consultation?

    *****

    Arthur responded as follows:

    Q1: I understand that this is a very small rise in my very low PSA level, and based on a single test result at this time. In order to minimize risk for over-treatment, wouldn’t I be wise to get at least one more repeat PSA test before actually committing to any form of second-line treatment?

    Q2: If I decide to defer any second-line therapy until I get a repeat PSA test, what PSA level would make you think I really did need to get immediate treatment as opposed to waiting. I mean, what if the next PSA test result 3 months from the last one just came back at 0.040 ng/ml again?

    Q3: If radiation does prove to be needed, what do we need to do to be able to make really good decisions about what areas might need to be radiated? My current understanding is that there is no available imaging test — even PET/CT scanning — that could accurately identify an area of recurrence of my cancer based on the current PSA level. Is that right?

    Q4: If we are unable to identify a specific area of recurrence, but my PSA was to rise again to (say) 0.060 ng/ml when I got another PSA test done, how would you suggest we moved forward? What area(s) would you think it would be wise to radiate? And would you think it was wise to combine that radiation with a brief course of androgen deprivation therapy?

  76. Hi Arthur.

    I had the consultation with the radiation oncologist and I really didn’t expect to get his unbiased opinion. His reasons were the same reasons as my urologist’s for recommending secondary treatment now as opposed to waiting, even though I’m 15 months post-surgery with a low, stable, but detectable PSA of 0.030-0.040 ng/ml.

    Their three reasons are: (1) I’m age 43 years; (2) the Gleason score of 3 + 4 and the stage pT2c; (3) one focal positive margin, even though the Gleason grade was only 3 at the margin.

    I told them I’m willing to wait and see what the results are for at least two more PSA tests (2-3 months apart) before making that decision. I need some guidance. Please help!

    *****

    Arthur responded as follows:

    Dear Mike:

    Please understand that Arthur cannot tell you what to do. In the end this is about what you want to do in consultation with your physicians.

    Arthur can only point out the obvious, as follows:

    (1) It is a lot easier for your doctors to tell you get treatment now than it is for them to suggest that you wait for a little while. If they treat you now, they know that they have taken immediate action to ensure that the disease doesn’t progress. They will also have increased your risk for complications and long-term side effects of treatment, but in their minds they may have “saved your life”.

    (2) If you wait for another few weeks to get at least one more PSA test and then make a decision, your cancer could, certainly, progress. However, if you don’t wait for another few weeks to get another PSA test, and you get immediate treatment, you are never going to be sure that that treatment was really necessary, and then you could end up second-guessing your decision.

    (3) Your doctors are giving you their unbiased opinions from their perspectives. The problem is that they don’t have your perspective, … and nor can Arthur.

    Arthur fully appreciates that you are in a very difficult position. Others have been here before you, and still others will be here after you. There is no “right” or “wrong” here. There is only what you feel comfortable doing. If you get another PSA test in a few weeks time and it is somewhere north of 0.070 ng/ml, then there will clearly be good reason to go ahead with second-line therapy. The question is not what you do in a few weeks time. It is what you want to do now.

  77. Hi Arthur.

    Could you please give me the meaning of this finding from my final pathothology report (John Hopkins):

    “The right anterior margin close to apex is positive where we cannot determine whether it is an area of intraprostatic incision or extraprostatic extension due to ambiguities of the histologic boundary of the prostate in this region”; Gleason 3 + 3. Does this mean I have aggressive cancer?

    *****

    Arthur responded as follows:

    Dear Orson:

    Arthur says, no, this does not mean that you have aggressive cancer if all your cancer is Gleason 3 + 3 = 6. It means that there was an area at the “apex” (the lower end) of the prostate where there was a clear indication that there was cancer right at the very edge of the surgically removed specimen. This does not mean it is aggressive, but it does mean that there might have been a tiny amount of cancerous tissue left behind by the surgeon. This may or may not prove to be important over time, and you need to discuss this finding with your surgeon because obviously Arthur does not have all the details.

    Arthur would also tell you that the incidence of small amounts of surgical margin disease are not uncommon, particularly at the apex of the prostate, which is associated with the greatest degree of difficulty for the surgeon in being sure that s/he has excised all of the relevant tissue. Such small, positive surgical margins, when they are of low grade (i.e., Gleason pattern 3) are not usually a significant clinical issue, and the surgeon may actually have removed all of the cancerous tissue anyway. The problems tend to arise when the surgical margins are larger or multi-focal and/or are of high Gleason patters (e.g., 4 or 5).

  78. Wonder if you could review the article below and provide comment:

    http://www.jci.org/articles/view/70354?key=4f436390394081ee2a50

    Thanks,

    mp

    *****

    Arthur responded as follows:

    Dear AKAI:

    Arthur says he thinks you will find what you are looking for if you simply click here. The sitemaster commented on this paper when it was initially published.

  79. Arthur … Are you aware of or have any comments about the FDA Phase II trial of GenEpic’s supplement for prostate cancer (see http://genepic.com).

    *****

    Arthur responded as follows:

    Dear John:

    Arthur says no, he was not aware of this trial. The only other thing he can say at this time is that this trial is not listed on the ClinicalTrials.gov web site, which would be a necessary requirement for almost any clinical trial that was to be taken seriously by the FDA. Indeed, no trial of the GeneEpic supplement appears to be listed on the ClinicalTrials.gov web site.

  80. Hi Arthur.

    Is it common to still have seminal fluid released during sexual intercourse after your prostate has been removed, along with the seminal vesicles? If so does this mean the surgeon left something (prostate tissue, etc.) behind which would cause a slight increase in your PSA reading after sexual intercourse? I thought if these organs were completely removed you could only experience a dry orgasm.

    *****

    Arthur responded as follows:

    Dear Mike:

    It seems extremely unlikely to Arthur that any fluid that is being expelled at orgasm after a full radical prostatectomy is actually seminal fluid. However, some men do continue to expel other types of fluid at orgasm after a radical prostatectomy, most commonly a small amount of urine (i.e., “climacturia”).

    Arthur says that you might like to look at this extensive discussion of orgasm after RP that you can find on the HealingWell web site.

  81. Arthur:

    This is clear sticky fluid (semen) not urine being released. It’s not a lot but it’s enough to where it’s noticeable. What could be the reason this is happening?

    *****

    Dear Mike:

    Arthur is not urogenital physiologist. You are going to need to talk to your urologist about this, but what Arthur does know is that a man with no prostate is unable to produce semen. It may feel like semen, but as far as Arthur is aware there is no way that it can be.

  82. I am 8 months post-prostatectomy and also have viscous secretions during sexual activity. I assume that these secretions come from the Cowper’s glands which remain intact after prostatectomy. Normally, these secretions are the pre-ejaculate and act as a lubricant. The Cowper’s glands may also produce some PSA.

    *****

    Arthur responded as follows:

    Thank you Ray. That is a very helpful piece of information that (in retrospect) Arthur thinks he may have heard once before but had entirely forgotten. (Arthur, like his readers, isn’t getting any younger!)

  83. Hi Arthur,

    My father was diagnosed with prostate cancer late October/early December. His PSA level was 18.9 at the time and his Gleason score was a 9. He is 58 years old and currently residing in Victoria. After his biopsy his prostate was found to be enlarged with a tumour. After doing a PET scan and MRI, it was found to have also spread to his pelvis bone. There is also suspicion it has spread to his hips but this cannot be confirmed.

    We were advised there is no cure and one doctor has told him life expectancy is 18 months. Another doctor who is much more optimistic has told him it is generally 2 years given that the hormone treatment he is on currently fails and chemo, which is the plan at this stage later down the track, also fails. BUT life expectancy can also be up to 10 years. The second doctor has also told him to be optimistic as there are lots of new drugs on the market.

    My father has now become quite depressed after hearing the news that he could only be alive for another 2 years, constantly reminding us that he wants to live to see his grandkids born. This is painful to hear. Can you provide your insights on life expectancy, and quality of life, for people in his situation? Also we were advised that chemotherapy could be preferred over radiotherapy given the spread of the cancer being uncertain. Do you believe this is the right treatment option?

    He just had his first hormone injection this week and has another medication which is tablet form he now takes daily. We were told to bring him in for a blood test in 3 months time to monitor his progress.

    Kind Regards,

    Melanie

    *****

    Arthur responded as follows:

    Dear Melanie:

    Arthur says he is sorry to hear about your father’s diagnosis. He clearly does have a relatively aggressive form of prostate cancer that has already metastasized. However, making individual assessments about life expectancy for individual patients is extremely difficult. Arthur is aware of men like you father who were, indeed, dead within 18 months to 2 years. He is also aware of men like your father that were still alive at 10 years or more. So much depends on the response of the individual patient to available forms of treatment, starting with the androgen deprivation therapy that he is already receiving.

    There are three things that Arthur knows about dealing with situations like this:

    (1) If your father is going to just accept the idea that he will be dead within 2 years, then he is doing himself no favors, and he may well be encouraging a self-fulfilling prophecy. Somehow you are going to need him to focus on the other thing he was told — that 10 years and more is not impossible and that there really are a LOT of new drugs that have recently come available and there are more on the way.

    (2) He needs to get himself to the best prostate cancer he can get to in Victoria, i.e., one where there are several physicians who really specialize in the management of late stage prostate cancer and understand how to optimize patient survival and the patient’s quality of life too.

    (3) He needs to talk to these physicians about getting involved (as and when appropriate) in clinical trials of the new drugs that are in development so that he is “ahead of the curve”, and not just a passive recipient of whatever form of treatment his doctor thinks would be appropriate when the earlier treatment has failed.

    And there is another thing that is harder to say, but Arthur needs to say it anyway … It is not fair of him to try to “blackmail” you over the grandchild issue. The way Arthur would deal with this is to tell him that if he wants to live to see some grandkids, he’d better d*** well be around to play with them as they are growing up because if there are going to be grandkids, his job it to be around long enough for them to be able to remember playing with him! The corollary is, “So Dad, stop whining and start doing something about living for 10+ years as opposed to just two!”

    How your father adapts himself to the changed circumstances is going to be critical to what everyone can get out of this situation — whether it is for 2 years or 20. Arthur says it’s OK for him to be depressed and angry for a while. It’s part of the journey. But sooner or later (and better sooner) he needs to decide that he isn’t going to just roll over and let this happen to him. His attitude and his actions are going affect the lives of all those around him … potential grandkids included.

  84. Arthur, I hope you can convey the following to Melanie.

    I, too, am 58. I, too, have Gleason 9 prostate cancer that has metastasized. I, too, had my heart sink when I read, in a well-known, widely respected book written by a world-class physician, that ADT (androgen deprivation therapy) would be effective for only about 18 months before my cancer became castration-resistant.

    I’m guessing that Melanie’s father took in the same news that I did, but may have failed to pay attention to several crucially important points:

    1. That particular eminent physician wrote his book more than 20 years ago. He was a surgeon, not an oncologist. The section on hormone ablation has been revised slightly in the subsequent editions, but it was already badly out of date 15 years ago. Today, no reputable physician who is conversant with the current state of the art would claim that the average length of effectiveness of ADT is only 18 months. The more you know — and there’s a LOT to know — the greater ability you have to play the cards you were dealt, not the ones you wish had been dealt.

    2. The term “average” has a technical meaning — actually, unfortunately, several technical meanings — and its meaning derives only from groups, not any one individual. To stake your future happiness on one number, the “average”, is insufficient and sometimes absurd. (“On average, an adult human being has one mammary gland and one testicle.”)

    In Melanie’s father’s case, even if the “18 months” represented a useful fact about some group of men (which it might very well not do; see point #1) it absolutely does not mean that anything in particular happens at the 18-month mark. The data set used to compute this average includes men whose PSA was in the thousands at start of treatment and who died within a few weeks. It also includes men who lived on for many decades.

    Almost certainly, most of the men in the group whose average was measured were men much older than Melanie’s father, and who lived and died many years ago. Are they representative of 58-year-olds in 2013? Probably not.

    3. More on “average”: We usually expect the average to be the “mean” — that is, the value most representative of the aggregate when summed together and divided by the number in the group. However, in many medical uses, the term “average” is used for the “median” — that is, the value where half of the group are below and half are above. The median is much easier to measure in a distribution with a long right tail, such as a group where a substantial number die within a couple of years but some go on to live for 20, 30, 40, or more years. In such a distribution (which is quite usual for many diseases and treatments), there is no way to compute the mean until several decades pass, and so the median is used instead. Melanie’s father’s goal is to get well to the right side of the median. Once he’s there, his mean life expectancy will not be hugely shorter than that of 60-year-old Australian men generally.

    4. Suppose ADT remains effective for only N months, where N = 18 or any other value. Nowadays, there are plenty of agents that continue to keep symptoms at bay that have very tolerable side effects. Although none so far have been shown to be curative, staying alive for another 5 or 6 years might well get this gentleman to a place where even more agents keep him alive, and even fairly healthy, for another 4 or 5 years; and during that second period of 4 or 5 years, even more agents will be developed such that (etc., etc.).

    Yes, the series of postponements does converge. We all must die at some point. And that leads me to …

    5. Melanie’s father has the same choice about how to live the rest of his days as we all do. All of us on Earth have the same horizon, and the west-bound sun: for some of us the horizon is farther, for others closer; the sun is higher or lower in the sky depending on our situation. We can curse the approaching darkness or make merry in the light that remains.

    Having said all that, my heart goes out to Melanie’s father. When I was diagnosed in 2007, my daughter and her husband-to-be postponed their previous plans to move away and start new careers a long way away. After a few months of shock, and initial treatment failure, they had a choice to follow their dreams or to stick around me. They made the choice that I hoped they’d make, and have found success in their careers far from home.

    Several years later, on their own timeline and not anyone else’s, they decided to start a family.

    Less than a month ago, I made it to the second of the milestones I had set for myself back in 2007 — I held my beautiful grandchild in my arms. Therefore, what Arthur said truly resonates with me; my next milestone is to leave an indelible impression on my grandkid. I expect it to take a while ….

    *****

    Arthur responded as follows:

    Thank you, Paul, for your very clear and “personal-experience-based” insights. Arthur has asked the site master to make sure that Melanie knows about this message.

  85. Dear Melanie/Arthur,

    I have written to Arthur several times regarding my husband Paul who has Stage 4, Gleason 9 prostate cancer. We too were told by four specialists the 18-month to 4-year numbers. I spent the next 6 months reading every medical study I could get my hands on and found this to be mostly untrue. My husband is now only 8 months into treatment but is in total remission and symptom free. His PSA was 928! His present PSA is undetectable!

    We decided if medical science could only offer us so much at present we could do the rest on our own and stay alive until medicine irons out the kinks in the latest treatments. First of all, only God knows how long any of us have, not medicine. I am a medical professional myself and have seen predictions be way off. It is a proven scientific fact that a positive attitude encourages longevity. We have control over our bodies more than medical science does.

    My husband is 61, works full time at a demanding job, and is enjoying his two new grandchildren, and the other 3 born a few years ago. He has changed his diet and added supplements I have researched extensively. At his last visit with our present oncologist (whom we love) his prognosis was changed from terminal to intent to cure! No promises, but being treated with a different attitude. His last two doctors old me I am probably more informed than they are (with regard to alternative treatment) and were asking me what I was giving him. Radiation treatment has improved dramatically in the past 5 years even for cancer in the bones.

    Do not let your father give up! We have our eyes on the 10-year mark right now. And if we are wrong and my husband becomes ill in 5 years, he has been happy and lived life to the fullest. Why be miserable waiting for something to happen that may not. Take charge! Once you get over the shock … and you will … put it on a back shelf. It is not the number of breaths you take, it is the number that take your breath away. Be hopeful. Plan a vacation!

    Susan

    *****

    Arthur responded as follows:

    Dear Susan:

    Arthur says, thanks for the additional input for Melanie and her Dad … and Arthur is very glad to hear that you and your husband are both doing so well.

  86. Well said … I was diagnosed with metastatic disease nearly 12 years ago and and still going strong despite dire prognosis from my oncologist … In fact, in that time I have had three of my friends pass away, one from pancreatic cancer, one from a heart attack, and one from a swimming accident all of whom were concerned and praying for me!

    Ignore the prediction as statistics can be misleading for an individual. However, educate yourself about prostate cancer to become an empowered patient. Take steps to change your lifestyle, eating healthier and exercising regularly to enhance your body’s chances
    to slow the disease progression. And, most important, enjoy every day.

  87. Dear Arthur,

    I have written to you before but, to refresh everything: I had a robotic assisted prostatectomy in November 2011, following positive biopsies and PSA of 5.8.

    Post surgical report: stage T2c, Gleason 3 + 4, no extensions, but a positive margin. My post-op PSAs were non-detectable till now, but the most recent result is 0.04 ng/ml.

    My urologist recommends waiting and re-testing in 3 months. My question is: Isn’t that too late? And does this not really mean that there is a definite recurrence? Then are there any statistics on what my chances are? What should be the next step? What else can I do meanwhile. I had not altered my lifestyle and diet. Will that make a difference? And what regimen do you recommend.

    I am 51 years old and otherwise in excellent health.

    Best,

    Abbas

    *****

    Arthur responded as follows:

    Dear Abbas:

    Athur says that a single PSA value of 0.04 after previously “undetectable” PSA readings could be a consequence of all sorts of things. For example, the test could have been done using a different type of PSA test, or at a different laboratory, or all your previous tests could have been about 0.04 ng/ml but reported as “undetectable” because any result lower than 0.1 ng/ml is classically defined as “undetectable”.

    Arthur thinks that you should listen to your urologist and see what your PSA is in another 3 months. However, if you are really, really worried about this, maybe he will “do a deal” with you and give you a repeat test in another 2 months rather than 3. There are may reasons to think that your next PSA will come back as 0.04 again, or perhaps even lower.

    The one thing you might want to ask the urologist is whether your most recent PSA value was carried out using the same PSA test type and at the same laboratory. If a different PSA test type was used, or the test was done at a different laboratory, there is a very high probability that that would explain the change in your report.

    Arthur does not think you need to “do” anything at this point in time. Recurrence at a PSA value of less than 0.2 ng/ml is defined by at least two increases in the PSA value (not just one).

  88. Dear Arthur,

    I have learned that math miscommunication is very common, and that whenever a result is unusual (not here) or there is a concern over a result thought to be unusual (as here), I would urge double-checking the figures and putting them in context.

    You correctly pointed out that the term “undetectable” has undergone a shift in meaning, and now means “less than 0.1 ng/ml, regardless of detectability”. (Why? In the 1990s, values < 0.1 could not be detected by then-current technology. The word was unfortunately retained even though the technology advanced.)

    Therefore, if Abbas's reporting is correct, nothing at all has happened to his PSA, so far as anyone can tell. His PSA has continued to be "undetectable", without any cause for concern, ever since his primary treatment. If his figure of 0.04 is accurate, then his doctor should have told him this: "Your PSA still remains at 'undetectable' levels, defined as < 0.1 ng/ml. Since there is no evidence whatsoever of recurrence, there is no reason to do anything different."

    Example: If the figures are as reported, his four PSA readings since November 2011 could have been reported in either of two ways:

    A. (Interpretation only): "negligible / negligible / negligible / negligible"
    B. (Observation only): "0.06 / 0.03 / 0.07 / 0.04"

    In either case, nothing of significance has occurred; every value is equal to 0.05 ± 0.03 ng/ml, indicative of no disease. But a change in communication style — from interpretation to observation for the fourth value only — might have caused a miscommunication.

    However, intercommunication between patients and doctors and labs has been known to get the decimal point wrong. For example, a PSA of "0.4" might be informally pronounced as "oh point four", misremembered as "point oh four", written down as ".04", and then slightly edited to "0.04". If this is what actually happened, then it would explain why there might be some concern.

    *****

    Arthur commented as follows:

    Correct. All true!

  89. Thanks so much Arthur, as usual you are a great source of information and wisdom. The test was done at the same lab and using the same method.

    Best,

    Abbas

  90. Thanks Paul and Arthur, I appreciate you guys informing me and at the same time putting my mind at ease a little.

    I checked with the nurse. According to her, all my previous six readings (last one in July 13) have been under 0.04 (they do not report the value of anything under 0.04; they report it as non-detectable in their system) and the new January 14 one is exactly 0.04, all done in the same laboratory using the same method.

    Thanks,

    Abbas

    *****

    Arthur responded as follows:

    In that case, Abbas, Arthur doesn’t think you should consider the single 0.04 ng/ml reading in January to be a clinically significant change in value. However, you do need to keep a close eye on follow-up PSA values. If they continue to rise, then there is clearly an issue of some form. You may also want to tell your doctor that you want another test done after 3 months as opposed to 6 months.

  91. Hi Arthur,

    My PSA has started to rise after 2 years on abiraterone + prednisolone. It’s been suggested to me that changing the steroid to dexamethasone could help. I can’t find anything that supports this — only that adding dexamethasone to abiraterone helps when no other steroid is being used. Have you heard anything about this?

    Thanks.

    *****

    Arthur responded as follows:

    Dear David:

    Arthur is not aware of any specific trial that has demonstrated a positive result from switching patients who have a rising PSA on abiraterone + prednisone or prednisolone to abiraterone + dexamethasone.

    Having said that, Arthur certainly doesn’t think there is a lot to lose from trying such a strategy. If your PSA was to stabilize or go down again, that would be good. If your PSA continues to rise, then nothing would have changed.

    You should be aware that the two earliest trials of abiraterone to treat men with metastatic CRPC actually used it in combination with dexamethasone as opposed to prednisone/prednisolone, and Arthur was somewhat surprised to see prednisone or prednisolone get substituted for dexamethasone when the Phase III trials were implemented some years ago. It seems that most of those involved with the trial designs felt much more comfortable using prednisone/prednisolone than dexamethasone.

    The one question that Arthur would raise with the doctors if he was in your shoes would be “What dose of dexamethasone?” Dexamethasone is a stronger corticosteroid than prednisone, and so it can have more significant side effects. Arthur would want to ask the doctors what they thought the lowest appropriate dose of dexamethasone might be to start at.

    For comparative purposes, Arthur notes that, some time ago now, it was shown by Rajkumar et al. that low-dose dexamethasone was actually better than high-dose dexamethasone when combined with lenalidomide (Revlimid) in the treatment of patients with multiple myeloma.

  92. Hi Arthur. What caused decrease in PSA?

    I’m 17 months post-surgery. My PSA result from October 2013 was 0.040 ng/ml using the ultrasensitive PSA test. Well my latest result was 0.033 ng/ml. My urologist was talking radiation (I had a positive surgical margin, with Gleason 3 at the margin) because of the 0.040 result from October but now that it has decreased, what am I to do next? Should I radiate anyway?

    *****

    Arthur responded as follows:

    Dear Steve:

    Arthur says that you appear to offer a clear case study for why it is not such a good idea to make decisions about things like salvage radiation therapy on the basis of a single ultrasensitive PSA result.

    The first issue, of course, is what your PSA was before you got the reading of 0.040 ng/ml last October. A result of 0.040 ng/ml is still extremely low, and few urologists of Arthur’s acquaintance would actually suggest immediate salvage radiation therapy on the basis of that single result, which might have occurred for a dozen different reasons, starting with laboratory error.

    The fact that your PSA has now dropped down to 0.033 appears to suggest there is no necessity for any panic at all. You probably should simply talk to your urologist about getting another PSA test in another 3 months’ time. If the next one comes back no higher than 0.040 ng/ml, Arthur still wouldn’t see the need to do anything. Lots of men have a positive surgical margin. Sometimes it is clinically significant; sometimes it isn’t. On the other hand, if the next one came back at 0.050 ng/ml, then you might want to open that conversation with the urologist again about the wisdom of salvage radiation therapy.

    However, Arthur is not your doctor. You need to discuss the situation with him/her in a calm and rational manner. Patients often tend to over-react to a single PSA result. The sensible thing is usually to say, ‘Let’s get another one in a month, or 2 month’s time, and see if there is a nything “real” going on here before we make any rush to judgment.’

  93. Arthur:

    My PSA results before the 0.040 result were 0.028, 0.030, and 0.030, then the 0.040 and 0.033, all using the ultrasensitive PSA test; the first two results (3 months apart) right after surgery were < 0.050 using the standard PSA test.

    I don't see any evidence of a doubling time or an upward trend to warrant radiation right away! Is it out of the question to suggest that we keep watching my PSA say every 2 months and, if the are any significant changes (say if it doubles or increases to 0.070), then maybe radiation? Right now it is low and stable 17 months post-surgery, even with the positive margin.

    *****

    Arthur responded as follows:

    Steve:

    Arthur can’t see any justification for salvage radiation therapy at this time based on the numbers you have provided. He’s not even sure that anyone could reasonably argue that there has been a meaningful change in your PSA level at all.

    Arthur would also point out that a possible explanation for the tiny increase in your PSA over 17 months could be that your surgeon left some normal (non-cancerous) prostate tissue behind at the time of surgery. This can happen. If he did, that remaining normal tissue might have grown slightly and could be the cause of the very small increase in your PSA.

    In Arthur’s opinion, it would be perfectly reasonable to just go on getting your PSA taken every 3 months. However, if you are going to feel more comfortable getting the PSA every 2 months, then by all means talk to your urologist about this, but Arthur really doesn’t see anything in your data to suggest that this is necessary. He thinks that a lot of what is going on her is (quite understandably) “in your head” rather than in your prostate.

  94. Hello Arthur: my husband Don who is 90 years old has Methastatic prostate cancer to the bone and no bone pain right now. He had Lupron for a year and then stop working. Then he had chemotherapy or Docetaxel but had very bad side effects so only took a dosis. He is thinking about having Xdandi but does not like the possible side effects. He would like to know if he does not follow any treatment what are the symptoms that he may experience as the cancer advances?

    Thank you for your answer.

    Nidia

    *****ANSWER*****

    Dear Nidia:

    Arthur says he is aware that the sitemaster has already posted an answer to your husband’s original question to Dr. Krongrad that Arthur would tend to agree with (just click here to see that answer).

  95. When are positive margins insignificant or significant? We all know that positive margins are an adverse finding on the path report after prostate surgery but do they always result in BCR?

    *****

    Arthur responded as follows:

    Dear Ron:

    Arthur says that interpreting when positive margins are significant or insignificant is an art, not a science.

    The best guidance that Arthur can give you is that a very small positive margin (say 1-2 mm long) that is Gleason pattern 3 in a man who had Gleason 3 + 3 or Gleason 3 + 4 disease has a lower likelihood of being significant and, conversely, a larger positive margin that is Gleason pattern 4 or 5 in a man who had Gleason 4+ 3 = 7 disease or higher (i.e., Gleason 8, 9 or 10) has a much higher likelihood of being significant. However, a bunch of other factors may also be important, and every case has to be considered on it’s individual merits.

    Arthur is sorry that he can’t be more specific, but your question is one that even specialists who have spent years studying issues like this can’t give you (or Arthur) a perfect answer to.

  96. I respectfully suggest, Arthur, that you may have over-answered this.

    Q1. (When are positive margins significant?)
    A1. Positive margins are always significant, because the finding indicates a higher level of risk than negative margins would have done.

    Q2. (Do positive margins always result in BCR?)
    No. There are some men, likely thousands, possibly tens of thousands, whose pathology report says “positive margins” but who never progress to biochemical recurrence.

    *****

    Arthur responded as follows:

    Dear Paul:

    Arthur thanks you for your comment, which is entirely appropriate. In his self-defense, Arthur would only note that he was trying to give an answer which might offer some specific additional insight for the individual asking the question.

  97. Hi Arthur.

    What is causing these fluctuating PSA results?

    Surgery on August 16, 2012. Subsequent PSA results: < 0.05, < 0.05 undetectable standard psa test, then 0.028, 0.030, 0.030, 0.040, 0.033, 0.038 detectable using the ultrasensitive PSA test!

    Is this up and down fluctuation a good enough reason to go ahead and start radiation? All of the tests were at least 3 months apart!

    *****

    Arthur responded as follows:

    Dear Tim:

    Arthur would respectfully suggest to you that this sort of variation in your PSA levels is well within the normal level of laboratory variance for what are, to all intents and purposes, “undetectable” PSA levels. These types of test simply do not have the sort of consistent level of accuracy that you seem to think they have. Arthur looks at these data as simply telling you that ever since your treatment, you PSA level has been < 0.05 ng/ml, and that is an excellent result.

    Furthermore, even if your PSA has risen by a tiny amount in the past 18 months (i.e., from 0.028 to 0.038 ng/ml), this could be a consequence of re-growth of some small amount of normal prostate tissue left behind at the time of surgery, and not have anything to do with cancer.

    In all honesty, Arthur thinks that you are over-reacting to these numbers. If we didn't have an ultrasensitive PSA test, an old-fashioned, standard PSA test would have told you that you consistently had PSA levels of < 0.1 ng/ml and you would be a very happy camper.

    If your PSA level was to suddenly jump to 0.08 and then to 0.10 ng/ml, the situation would be different, but as of now, if Arthur was in your shoes, there is no way he would be even thinking about salvage radiation therapy based on these data.

  98. Should we radiate anyway when there are positive margins?

    With positive margins being an adverse finding on the pathology report should we radiate anyway, regardless of favorable Gleason grade at positive margin, length of positive margin, or total Gleason grade?

    *****

    Arthur responded as follows:

    Dear Charles (or are you also Tim?):

    Arthur says that there is no absolute rule stating that every patient with a positive surgical margin needs to have immediate adjuvant radiation therapy. Every case has to be considered as exactly that — an individual case, on its merits. The decision as to the value of follow-up radiation treatment depends on all sorts of things, including the Gleason pattern of the tissue at the positive margin, the size of the positive margin, the patient’s post-surgical PSA levels and PSA doubling time, the patient’s age, etc.

    Arthur would note that one also has to bear in mind that adjuvant and salvage radiation therapy both come with risks for side effects and complications. Skilled physicians will try to ensure a balance of risks and benefits by not unnecessarily over-treating men in whom a small positive margin may have been present (but is showing little to no sign of post-surgical progression) while similarly ensuring sufficiently early treatment of men with a positive margin (or margins) that suggest or indicate a significant risk for progression.

    In Arthur’s experience, it is far from unusual for men with a small positive margin (especially one of low grade) to go for many years — or for the rest of their lives — without any sign of disease progression or any consequent need for radiation therapy (or any other form of follow-up treatment). The case for early adjuvant radiation clearly increases when the positive margin is larger; the Gleason pattern of the associated tissue is higher (4 or 5); and the patient’s PSA is rising significantly

  99. Hi Arthur,

    Which usually comes first when prostate cancer has spread: a fast, high-rising PSA or pain at the site where the cancer has spread?

    *****

    Arthur responded as follows:

    Dear Charles:

    Arthur says that, unfortunately there is no perfect answer to that question. It seems to vary from patient to patient, and it probably depends on the individual biology of the patient (the “host”) and the precise biology of the tumor (the “foreign body”).

    Arthur is aware of all of the following: (a) men who have been diagnosed with initial PSA values of > 20,000 ng/ml and widespread metastatic prostate cancer to bone but no evidence of actual bone pain at time of diagnosis; (b) men with have been diagnosed with PSA values of < 10 ng/ml, evident metastatic disease, and no bone pain; (c) men with PSA levels of 50-100 ng/ml, minimal metastatic disease but significant bone pain; etc.; etc. In other words, the possibilities are all over the map.

    Having said that, Arthur thinks it should be noted that (in general) in men getting diagnosed and treated in America today, the commonest signal of risk for metastatic disease is a PSA that is rising rapidly, i.e., men with a PSA doubling time of 6 months or less, but no sign of metastasis and no bone pain whatsoever. To that extent, in men at risk for potentially lethal forms of prostate cancer, a rapidly rising PSA does tend to occur prior to any indication of bone pain or metastatic disease. And a PSA that rises at that sort of rate would be extremely unusual in any patient with true Gleason 3 + 3 = 6 disease.

  100. Hi Arthur. I had corresponded with Dr Krongrad in September 2013 but since you have been answering questions directed to him for some time I thought I would contact you directly for an opinion.

    A brief history: PSA 8.69 July 2012 at age 63. Biopsy results were 3/21 cores positive, all three were Gleason (3 + 3) 6, stage T1c; negative bone scan and MRI. Brachytherapy was done in September 2012. PSA nadir of 2.21 reached 6 months post-op. A rising PSA at 9 months topped out at 7.6 in August 2013. MRI suggested metastasis to spinous process of L5 vertebrae. Urologist in South Africa recommended starting continuous ADT. Went to M. D. Anderson in Houston for a second opinion. They confirmed the metastasis with a needle biopsy of the lesion in L5. Their recommendation was a short course of ADT (6 months) followed by radiation to the L5 lesion, then cessation of the ADT while watching the PSA. I chose the latter approach, and returned to M. D. Anderson in March 2014 for 2 weeks of radiation therapy (12 fractions of 3 Gy each) After the 6 months of ADT my PSA was down to 0.20 ng/ml at the start of radiation therapy and a new CT scan showed a smaller lesion in L5 with sclerosis around the perimeter, which they said indicated new bone formation. Last week, at my first 2-month check of PSA and testosterone after the radiation therapy, my PSA was < 0.02 (undetectable?) and my serum testosterone was barely above castration level at 23. My oncologist at M. D. Anderson was hopeful that the L5 lesion was a solitary metastasis and the radiation oncologist there believed that the radiotherapy had eradicated what remained of the lesion. After 2 years of mostly bad news regarding my prostate cancer, I know it's too early to get too excited about this, and I will have PSA/testosterone tests every 2 months, but it does seem like very positive news. Dr Krongrad commented that the treatment plan at M. D. Anderson was somewhat unusual but thought it might be curative in intent. Are you familiar with others who have had similar treatment plans for metastatic prostate cancer? And secondly, would you attribute the drastic drop in PSA to the lingering effects of the short course of ADT or to the radiation therapy to the metastatic lesion? As an aside, I feel great and go to the gym 5 days a week for running and weight training. Enjoy your posts.

    *****

    Arthur responded as follows:

    Dear Allen:

    Arthur notes that the use of short courses of ADT in combination with “spot” radiotherapy for the treatment of men with apparently isolated areas of metastatic prostate cancer is not new, but it has started to become much more common in recent years. Why? Because it has become possible (with the development of new technology) to direct the radiation with much greater accuracy to isolated sites of metastasis, thus increasing the therapeutic benefit and reducing the risk for side effects of radiation therapy on surrounding tissues.

    While Arthur is not yet aware of any really sound, long-term data on the efficacy of this type of treatment in either eliminating metastasis or extending overall or prostate cancer-specific survival, there does seem to be a growing belief that this type of treatment is beneficial for carefully selected patients. Arthur hopes that someone, somewhere (e.g., at M. D. Anderson) is actually tracking long-term follow-up data on a large series of patients so that we can begin to get a clearer idea of the potential benefit of this type of treatment.

    Arthur is in no position to be able to tell you categorically whether your current PSA level can be attributed to the results of radiation therapy or to the lingering effects of the ADT. It may well, for example, be a combination of the two. This will probably become a little clearer over the next couple of PSA test results if you see your PSA re-stabilizing at a new level that might be closer to 1 or 2 ng/ml. Arthur would encourage you not to become too concerned if your PSA starts to rise a little over the next couple of PSA tests. Your serum testosterone level should also start to rise back to a normal level of 300 ng/dl or more now that you are off the ADT. Given that your serum T level was still only 23 ng/dl when you had your most recent set of tests, Arthur would have to say that there is certainly still a lingering effect of the ADT, and it may take a little while for this to wear off completely.

    The bottom line here is that Arthur thinks you should feel positive about what has happened to date, but that it may be another 6 months or so before you and your doctors will be able to make an initial, realistic determination about the success of this treatment strategy in your particular case.

  101. Many thanks Arthur. As usual, your response was concise and to the point. I appreciate that you dispense pertinent information in a timely manner. I’ve found that getting this kind of information from my doctors, both here in South Africa and at M. D. Anderson, can be considerably more difficult. I’m returning to M. D. Anderson in September for further evaluation and will let you know what they think.

  102. Dear Arthur, I am back with my questions to you.

    My husband, PSA 920 in March 2013. A mysterious case. Casodex, Lupron and 6 weeks of radiation. Presently his PSA has remained stable at below 0.05; he is only on Lupron.

    He seems to have an unusual reaction to the Lupron where — as happened in the first month after the first injection (starting 5 days after), he becomes ill, flu-like, very pale and weak, with GI issues and respiratory issues. It took us a while to see this pattern as we kept thinking it must be a virus, but now we know for sure it is the Lupron. We mentioned this to the oncologist and the nurse practitioner; they said it was unusual. Also, the month before he is due for his next injection, he feels “great” with no symptoms at all. We just switched from q4 months to q3 months. The side effects were less severe, but more shortness of breath for 2 weeks this time: very severe and he had to take off from work. He becomes a very strange, pale, almost grey color during these weeks on and off.

    After telling this all to the oncology department, they had said he is now considered as an “attempt to cure” (due to his PSA and no clinical symptoms) and may be able start intermittent therapy after he has completed 18 full months of Lupron therapy. It almost seems like he is metabolizing Lupron rapidly or unevenly. I suggested we repeat all scans and, if it looks like lymph nodes are shrinking and no evidence of bone involvement, we could try this. They agreed. Our next appointment is June. He is due for another Lupron injection, which he would receive. All his blood work is beyond excellent (like a 20-year-old’s); better than before the prostate cancer diagnosis, except that his liver enzymes are elevating. Do you think 18 months of Lupron may be enough? Most studies still say 2 to 3 years.

    Thank you again for your helpful input.

    Susan

    *****

    Arthur responded as follows:

    Dear Susan:

    Arthur is glad to hear that your husband’s PSA is low and stable at around 0.05 ng/ml. That’s a very good response for someone who started out with a PSA of nearly 1,000 ng/ml.

    Re the odd, initial reactions to each shot of the Lupron, and the fact that he feels really well near to the end of the time period for each injection … It sounds to Arthur as though your husband is having some sort of unusual immunobiological reaction to Lupron therapy which dies away each time after his body adapts to the new injection stimulus. Arthur really doesn’t have any particularly bright ideas about how one might try dealing with this. One possibility would be to ask about trying a different LHRH receptor agonist (such as goserelin acetate/Zoladex or triptorelin pamoate/Trelstar instead of leuprolide acetate/Lupron). This is something you’d need to bring up with the doctors and see what they think. Your husband’s reactions to the Lupron are certainly unusual, and you and the doctors do need to be monitoring this with care.

    With regard to the idea of switching your husband to intermittent ADT … Arthur can certainly see the argument in favor of doing this, particularly given the benefits of being able to cut down on the number of injections (with the odd set of side effects). Having said that, Arthur would be concerned about whether switching to intermittent ADT is an appropriate strategy for any man who had started out with a PSA level of 920 ng/ml after just 18 months. Could it be tried? It surely could! Is your husband likely to be able to maintain a low PSA level for more than about 6 months off the ADT? That’s a much harder question to answer!

    Some other things you might want to discuss with the doctors if you want to try the intermittent ADT approach are: (a) having your husband take a drug like dutasteride/Avodart alone while he is off the ADT (on the grounds that dutasteride will continue to block the conversion of testosterone to dihydrotestosterone during the “off ADT” period); (b) asking the doctors to monitor your husband’s serum testosterone and serum dihydrotestosterone levels during the “off DHT” period (as well as his PSA levels) to see how fast these are rising.

    The goal in all of this is not just to try to control your husband’s PSA level and keep it low and stable. The real goal is to extend his life for as long as possible while ensuring a good quality of that life. That is going to require a very careful balance intended to limit the use of Lupron (and perhaps other drugs) to the minimal amount needed to effectively delay progression.

  103. Dear Arthur:

    Thank you again for your excellent advice. It is true no one seems to know how long is too long with ADT and what time line would be too short. I was told another study may be released in June regarding the 18-month approach and how successful it was.

    I was also thinking possibly monthly injections? For the next 3 to 9 months whatever decision is made?Lupron seems to work so well and quickly for him as his T level is so low, below 20 and was that low after first injection. We get it checked every 2 to 3 months. I had asked to have his DHT done, and was told that with his T level so low he could not produce much DHT. Is this correct? I will question it again. I also know how blessed he is with his excellent response and am concerned with the 18 months (as no one really knows), but would like his quality of life to be better. As I had mentioned before, we also use alternative medical methods, supplements, and foods and will continue these. I am glad the new studies on vitamin D have been released. My husband had a vitamin D level of 11 at diagnosis. The study revealed that < 12 was associated with the most aggressive cancer. Who knew? I kept asking every doctor about it, no one seemed to connect his extremely low level of vitamin D to the prostate cancer. I pumped him up to 50 last year after reading older studies on vitamin D and prostate cancer. He does seem to be having an unusual path from diagnosis to response to side effects with this illness.

    Thank you for your time and knowledge.

    Susan

    *****

    Arthur responded as follows:

    Dear Susan:

    You need to understand that, with regard to vitamin D, there are all sorts of good reasons why a man with low vitamin D levels like you husband may need vitamin D supplementation. However, whether your husband’s prostate cancer was either caused by or is being in any way driven by his vitamin D levels is much more difficult to ascertain. The new vitamin D data are still based on epidemiological “association” studies. Such studies are hypothesis-generating but they do not offer clear data about causes and effects for specific disease and their outcomes. People can all too often over-react tho these types of epidemiological data, and they are often shown to be misleading … so just be a little cautious about over-interpretation.

    With respect to the DHT levels … Yes, in theory, if a patient’s serum T level is very low then he should have an extremely low DHT level. However, if your husband is going to come off the ADT, then the reason Arthur thinks it would be wise to assay his DHT level now is because his DHT will start to rise again, as will his serum T level. It might be wise to know the current baseline and then monitor the rise in his DHT level.

  104. Thank You , Yes a baseline DHT would be good. Susan

  105. Dear Arthur,

    Again I have to seek your advice. My husband just received his PSA after 15 months on Lupron. After being below 0.05 for almost 10 months his PSA was 0.08 this week. We were told it is not of concern and to have it repeated in a month instead of 3 months. His liver enzymes are also elevated. These are to be repeated again in a month also. Our oncologist suspects his metformin may be causing this. We switched to monthly injections of Lupron this week to see if his side effects would be less. His testosterone level had been below 20 but have not received results yet from this blood draw. Is there anything else we should be doing in this month’s time? Is this increase of concern? He has no prostate clinical symptoms, but never really did. We are scheduled to see his internist in 3 weeks to follow up on the liver enzymes.

    Thank you for your time.

    Susan

    *****

    Arthur responded as follows:

    Dear Susan:

    It sounds to Arthur as though you are already doing everything you should be doing. Arthur says that this is really a very, very small change in PSA level, and getting a repeat PSA in a month and then checking on the liver enzymes seems entirely appropriate. Hopefully your husband’s PSA will either drop back down to 0.05 or simply restabilize at 0.08. Of course if the PSA were to keep on rising then that will be a different story.

  106. Thank you again; good advice as usual; it will be a long month. All other blood work is textbook perfect. Testosterone below 3. The monthly Lupron shot is a whole different world so far. He has had none of the crazy side effects, just the documented common ones. Hope you are well.

    Susan

  107. Hi Arthur. A follow up to my post to you on May 14, 2014. I had my second 2-month check of PSA/testosterone post-radiation therapy at M. D. Anderson in March. As you predicted the PSA rose from undetectable 2 months ago to 0.13. The shocker was the total testosterone rose from 23 ng/dL to 674.35 ng/dL. The effects of the 6 months of ADT have really let go and there are no more hot flashes and sexual function has returned to the good level I had before beginning the ADT. I’m returning to MD Anderson in September for new bone and CT scans. Would you expect PSA to rise even more due to the higher testosterone? Any rise is worrisome but I still feel pretty positive.

    Thanks, Allen

    *****

    ARTHUR RESPONDED AS FOLLOWS:

    Hello Allen.

    Arthur thinks that the rise in your PSA to 0.13 ng/ml is reasonable under the circumstances and the rise in the serum T level is obviously near to ideal. The key question is probably going to be what your next PSA test results shows. Arthur would strongly suggest that you get a next PSA test result in South Africa (where you presumably got the most recent test done) before you go back to M. D. Anderson, so that you know you are comparing apples to apples (as opposed to apples to oranges). M. D. Anderson will certainly want to do their own PSA test, but you need to know that you can accurately compare your most recent test result to a follow-up test done at the same South African lab.

    If your next PSA result in 2 months time was to come back at 0.25 ng/ml or thereabouts, then Arthur would have a concern that your PSA was rising fast (i.e., doubling every 2 months) and that, consequently, the treatment given by M. D. Anderson had not had the fully desired effect of putting you into a long-term remission. However, if your next PSA results was to come back in the (say) 0.10 to 0.17 ng/ml range, then this would suggest that a long-term remission was a real possibility.

    The fact that your serum T has returned to truly normal levels is a good thing. That’s where you want it to be if you are truly in remission. If you are not truly in remission, then it will only be a matter of time before you have to be back on the ADT, and you’ll have to cross that bridge when you get to it (if you do).

  108. Many thanks Arthur. I’ll take your advice and have a new PSA done here in SA before I travel to Houston in September. Allen

  109. DRE clear; bone scan clear; PSA > 10 for many years, rising slowly to 24 ng/ml now. Why isn’t a 3 T MRI used to determine the location and extent of the tumor? I have had two random 12-core biopsies about a year apart. The first one showed a small amount in one core, with a Gleason score of 3 + 3. The latest one again showed a small amount of cancer in one core, with a Gleason score of 4 + 4. I’ve asked for a multi-parametric 3 T MRI to define whether or not the tumor is singular or not and if another biopsy is requested could the data be used to define the location of the cores. My HMO has refused this as not being a current standard practice. Yet I read that a large number of places are doing it. Is this an unreasonable request?

    I am 80, in very good health (some family members are into their 100+ years) and think that the more information I can gather now may be helpful in the future. The HMO want to do Lupron and then IMRT and are telling me that waiting much longer will be dangerous. What do you think?

    Allen

    *****

    Arthur responded as follows:

    Dear Allen:

    Clearly Arthur is missing a lot of information here, so it is a little difficult for him to address with accuracy all of the issues you raise. However, here are some of the key factors that may be relevant:

    – The exact nature of your insurance coverage and the HMO that you belong to.
    – Whether there is any provider within your HMO’s network that can actually give you an appropriate multi-parametric MRI (let alone a 3 T MRI).
    – The fact that until your most recent re-biopsy, you appeared to have low-risk prostate cancer that (arguably) could simply be monitored.
    – Whether you had been offered treatment earlier.
    – The use of MRI-guided biopsy for localized prostate cancer is not yet considered to be standard practice by anyone. Indeed, it is arguably only within the past 18 months that sufficient data have been published to start considering whether this type of biopsy should become standard practice in the future.

    Most of the people who have been getting 3 T MRIs to date have been paying for them out of their own pockets (unless they were getting them as part of a research protocol at somewhere like the NCI’s Clinical Center in Bethesda, MD).

    Arthur would politely but strongly suggest to you that you need to separate your irritation with your insurance provider about your belief that you should have the 3 T MRI from the fact that you have now been shown to have high-risk prostate cancer with a PSA level of 24 ng/ml and a Gleason 4 + 4 = 8. This is potentially highly aggressive form of prostate cancer and could kill you if you don’t get it treated.

    Arthur would advise you that surgery for prostate cancer in an 80-year-old would very, very rarely be wise. The recommendation of a short course of an LHRH agonist like Lupron (for say 3 to 6 months) in association with radiation therapy is, on the other hand, an entirely appropriate form of treatment under the circumstances. And the result of a 3 T MRI test is most unlikely to change that recommendation at this point in time.

    Arthur understands your belief that “the more information [you] can gather now may be helpful in the future”. However, there comes a point at which action may be more important that information. A good radiation oncologist is almost certainly going to want to give you a CT scan or an MRI as part of the radiation treatment planning process, and so this may help you to garner information. It is also relevant that lots of very smart radiologists and prostate cancer specialists are of the opinion that a well-conducted multi-parametric 1.5 T MRI can provide almost exactly the same amount of information as a 3 T MRI anyway (given a skilled uroradiologist who knows how to read such scans).

    Arthur thinks that you do need to get treatment and that you do need to get it soon, given your current situation. While being able to have a 3 T MRI as part of the planning process might well be “ideal”, waiting for the “ideal” to happen may be placing your life at risk.

  110. Thanks. I am 44, white, and heathy; parents are 60 and healthy. I will see another urologist since the group I saw seemed to be all about billing for procedures (walk in the door — urine sample, bladder ultrasound every visit). Also tried to sell me on cystoscopy for BPH, MRI, biopsy, etc.

  111. Hi Arthur. I am 67 and have prostate cancer. My Gleason score is 6 (3 + 3); my clinical stage is T1cN0M0; my PSA went from 1.2 to 1.95; my dad and three uncles on my mother’s side had prostate cancer; my DRE is normal. I live in southern New Hampshire. Where or how do I find a list of skillful urologic oncologists who specialize in da Vinci prostatectomy?

    *****

    Arthur responded as follows:

    Dear Paul:

    Arthur says that he is not aware of any good “list of skillful urologic oncologists who specialize in da Vinci prostatectomy.” However, because you live in southern New Hampshire there are quite certainly a number of highly regarded prostate cancer treatment centers within a couple of hours drive at places like Massachusetts General Hospital in Boston and the Lahey Clinic in Burlington, Mass. In addition, you could contact one of the Us TOO Support group leaders in New Hampshire or Massachusetts and ask them if they are able to give you specific recommendations. To find these support group leaders names and contact information, just click here and then look at the listings for New Hampshire and Massachusetts. A third way to find such a urologic oncologist is simply to ask the urologist who diagnosed you who he would go to if he wanted to have da Vinci surgery. Most good urologists are very willing to make such referrals for a second opinion.

    Arthur would also point out that one of the other things that you should really discuss with a good urologic oncologist, however, is whether you have a form of low-risk prostate cancer that can simply be monitored (on active surveillance) as opposed to needing immediate treatment. You haven’t given Arthur all of the relevant information that would help to determine whether you would be a good candidate for active surveillance, but you do appear to have either low-risk or very low-risk disease. The fact that you had several relatives who were treated for prostate cancer doesn’t necessarily imply, on its own, that you have clinically significant disease. Far too many cases of low-risk prostate cancer get over-treated when they could simply be monitored because they don’t actually need invasive treatment.

  112. Thank you, Arthur.

  113. I agree with Arthur that you may not need any treatment yet. I am close to you and am on active surveilance, now and hopefully a long time.

  114. Hi Arthur!

    Since April 2013 (after surgery in August 2012) my PSA has risen from 0.028 to 0.047 using the ultrasensitive PSA test (same lab) given every 2-3 months. There have been fluctuations at times — an example of that is the last three test results, which were 0.044, 0.042 and the latest 0.047. I am 2 years post-surgery.

    I know that using the standard PSA test (< 0.1) would have me still in the undetectable range but what could possibly be going on with my PSA at such a low level? Should I be overly concerned?

    *****

    Arthur responded as follows:

    Dear Mike:

    Arthur says that he would not be overly concerned about such a small rise in your PSA level at this stage — although you certainly need to keep a close eye on it.

    It is always very hard to know what might cause such very small rises in PSA level a couple of years after surgery. However, one possibility might be that there was a very small amount of non-cancerous prostate tissue (perhaps near the prostate apex) that your surgeon was unable to remove at the time of your surgery. Such a tiny piece of tissue can sometimes enlarge over time, producing very low amounts of PSA which then might account for this small rise in your PSA level.

    Your should really discuss this with your urologist and come to a decision with him (or her) about what you would both want to do about this if your PSA was to start to get up closer to something like 0.07 ng/ml and depending on the speed at which your PSA was increasing at that time. In other words, be ready in advance to take action at a predetermined PSA level so that everyone knows what they are going to want to do if action does seem to be appropriate.

  115. Hi Arthur!

    I went over my post-RP pathology report and the only two “negatives” found were my final Gleason total was 7 (3 + 4) and a small positive margin at the apex with a Gleason grade of 3 at that margin. Could this be the guilty culprit causing the minor increases and decreases in my PSA level? If so, would it be wise to start salvage radiation right away or will waiting until recurrence (0.2 ng/ml) is evident be sufficient? I ask this because I’ve heard that not all positive margins will cause recurrence. Also some men have reached 0.1 ng/ml and never progress any further!

    *****

    Arthur responded as follows:

    Dear Mike:

    Arthur says that, first, yes, your small rise in your PSA level could be in some way associated with the positive surgical margin; second, no, Arthur does not believe you need to be rushing off to a radiation therapy suite yet. As you have noted, there are men who do indeed have this type of small rise in their PSA post surgery and then the PSA can stabilize again.

    As Arthur said previously, you do need to keep a careful eye on your PSA, but (subject to anything that your urologist is telling you otherwise) Arthur thinks you can afford to limit your immediate management of the situation to just monitoring that PSA level.

  116. I read with interest your response to Mike because I too have questions about the practical usefulness of the ultrasensitive PSA test. I am a relatively healthy 67-year-old who had a prostatectomy 17 months ago. My pathology report indicated: (a) a Gleason score of 3 + 4 = 7 with tertiary pattern 5 and the tumour involving 5% of the gland; (b) pathologic stage pT3a with focal extracapsular extension and no regional lymph node metastasis; (c) negative margins, but many areas with the tumour < 1 mm from the margins; and (d) lymph-vascular and perineural invasion. Urinary and sexual side effects are relatively modest and manageable. I have had six post-surgery PSA tests with continuously increasing values: 0.009, 0.011, 0.012, 0.020, 0.026, and 0.032. Does this slow but steady increase in PSA give me early evidence that cancer has recurred and that it would be to my advantage to risk more side effects and begin salvage radiation now? Or are these PSA results of little practical value and I would have the same outcome without risking earlier side effects if I waited until my PSA reached the old 0.2 standard for recurrence? Is there any evidence or expert opinion that might inform my decision?

    *****

    Arthur responded as follows:

    Dear Ray:

    Arthur says that without knowing the precise dates of each of your post-surgical PSA tests, and given the inherent difficulty of establishing accurate PSA doubling times for men whose PSA values are all < 0.1 ng/ml, it is hard to know exactly what your PSA doubling time might be. However, if Arthur assumes that these six PSA tests have all been taken at roughly 3-monthly intervals and processed at the same laboratory, then it appears that your PSA doubling time is of the order of 9 months or so. However, Arthur suggests that you can't read too much into this because all your PSA values are extremely low and so minor inaccuracies in any of the levels might substantially affect the overall estimate of PSA doubling time.

    Arthur's entirely personal opinion is that unless your PSA level was to make some sort of sudden jump (say to 0.070 ng/ml or thereabouts when you got your next test results) there is no good reason to be rushing to the radiation oncology suite as yet. Indeed, Arthur would argue that these data are of considerable value in helping you to appreciate that you don’t need to take that type of action as yet, even though your pathological data post-surgery do indicate that you are at a higher risk level than anyone might have wanted to see (most particularly because of the tertiary Gleason grade of 5).

    Quite why your PSA is rising is obviously impossible to determine with any level of certainty when it is this low, and Arthur assumes that you have already had this conversation with your doctors, who have also not been recommending salvage treatment as yet.

    Arthur cannot tell you with any level of certainty that you will or will not have a formal biochemical recurrence (defined by a PSA level of 0.2 ng/ml or higher), let alone a real clinical recurrence. If your PSA was to go on rising at the current rate, then you would probably hit a PSA of 0.2 ng/ml in something like 2 years time, and you would know within about 18 months that that risk was imminent. In Arthur’s view, that would probably be a good time to re-assess what you want to do.

  117. Arthur,

    It is very rare that I disagree with your analysis and recommendations, and my disagreement here is fairly minor.

    First: If the six data points occurred at regular time intervals, I calculate a PSA doubling time of about 2.65 to 2.80 times the interval between tests. If the tests occurred every 3 months, this translates to a PSADT of 247 days — closer to 8 months than 9 months, with formal biochemical recurrence (PSA ≥ 0.2) occurring roughly 650 days after the date of the “PSA = 0.032″ result.

    Secondly: The data points fit a curve of exponential growth remarkably well (chi-squared = 0.1 for hypothesis “PSADT = 247 days”). If there were only three or four points, or if the fit were poorer, there would be far less confidence that the calculated PSADT was a good metric.

    Because of this, I disagree with what you say about “a sudden jump to 0.070″. The six data points so far provide no reason to expect any sudden jump, and every reason to expect PSA = 0.070 to be reached through normal exponential growth about 9 months after the “PSA = 0.032″ result (if testing occurs every 3 months).

    Therefore, I think this gentleman’s case presents a very good reason for reconsidering the arbitrary “PSA = 0.200″ cutoff point. His data are superbly precise — vastly better than the data supporting the traditional guess.

    If I were in his shoes (and, actually, mine are fairly similar with a remarkably consistent PSADT of 61 days when I’m not androgen-suppressed), I would look for another two or three data points over the next 6 to 9 months and, if the regular clockwork doubling continues, to consider taking action at that time.

    The usual caveats apply:

    • If the PSA testing was conducted at regular intervals other than 3 months, then the analysis stands, but the timescale should be adjusted.
    • If the PSA testing occurred at more irregular intervals (aside from the “0.012″ value possibly being measured early), then the analysis is suspect, and action should be deferred until the data are better.
    • As always, one must consider the tradeoff between quality-of-life vs postponed-onset-of-symptoms. If the gentleman is 90 years old or in poor health, then it makes no sense whatsoever to consider a measure with considerable side effects that might, if successful, merely gain a postponement of onset-of-symptoms (e.g., at PSA = 200) from an estimated 8 years hence to an estimated 15 to 20 years hence.

    *****

    Arthur responded as follows:

    Dear Paul:

    Arthur thanks you for your observations.

    Arthur would just like you to note that your observations do not actually disagree with Arthur’s prior comments, for a couple of reasons.

    In the first place, Arthur was being very careful not to specify a precise PSA doubling time for this gentleman, based on the available data. Arthur wrote that “it appears that your PSA doubling time is of the order of 9 months”, which is not the same as saying that it is 9 months. This was a very deliberate statement, because there are almost no validation data on the use of PSA levels less than 0.1 ng/ml to assess PSA doubling times, and we have no precise dates for the gentleman’s tests.

    Second, Arthur wrote that “unless your PSA level was to make some sort of sudden jump (say to 0.070 ng/ml or thereabouts when you got your next test results)”. Does Arthur think this is probable in this particular case? No, he doesn’t, but these things do happen, and if there was to be such a sudden jump in the patient’s PSA level, this would (potentially) be indicative of a sudden acceleration in the patient’s PSADT and (for whatever reason) a change in his risk level.

    Finally, we do know this patient’s age. He states that he is 67.

    Please understand that Arthur does not disagree with your observations. Arthur would only note that he was very carefully trying to avoid the level of accuracy of interpretation that you are suggesting, precisely because of all the caveats that you list at the end of your comments, many of which Arthur also stated or implied in his comments.

    Arthur feels that the important thing, above all, for this patient is that he continues to monitor his PSA level, just as he has been, under the supervision of this doctors, and that he understands that the currently available data do not necessarily suggest immediate intervention. Precisely when any future intervention might be recommended is going to depend on actual future data (as opposed to speculation about what those data might be or when they might suggest intervention — if they ever do).

  118. Hi Arthur. A follow up to my post on July 14.

    I took your advice and had a PSA done here in South Africa 5 days before I was seen at M. D. Anderson. The test here showed an increase from 0.13 to 0.32 — a little discouraging. However, just 5 days later the lab at M. D. Anderson had the PSA at 0.20 which is the level it was at 6 months ago when I had the 12 fractions of radiation to the spot of metastasis to bone in L5. My oncologist at M. D. Anderson said that since I still have a prostate gland (treated with brachytherapy 2 years ago) I am allowed to have some level of PSA present. Since I have been off of the ADT and radiation for 6 months with a stable PSA he thinks I am in a remission that could last a year or 5 or 10. New bone and CT scans showed nothing new and healing of bone where the spot was on L5. I am currently under no treatment what so ever and am only to have quarterly PSA tests and only have to have another 6 months of ADT if the PSA reaches 1.0. I have never heard of active surveillance on a patient who has had brachytherapy, then metastasis to bone, then ADT and radiation therapy, but I think that is where I am at. I was told that I don’t need to return for new scans for the foreseeable future. I’m pretty happy with the results of my latest visit back to the States. Allen S.

    *****

    Arthur responded:

    Dear Allen:

    Arthur doesn’t consider “active surveillance” to be the most appropriate term for the type of monitoring that is recommended for someone who has had treatment and appears to be in at least potentially long-term remission (even though it has started to be used). As far as Arthur is concerned, the important thing is that you appear to be in remission; that remission could indeed last for years; and anyone in this type of remission needs regular tests to make sure that they are remaining in remission.

    As discussed with your oncologist (and as indicated by the slight differences between your PSA in South Africa and your PSA at MDA) you do need to be careful to ensure that you don’t over-react to small variations in your PSA level like this. If you see such an event, your first question for your doctors should probably be, “Do you think we need to get a repeat PSA level in a month to check this out?” rather than to assume there is a problem. Arthur says that least you now have a baseline from the lab in South Africa to work from in addition to the data from MDA.

    Hopefully your PSA will stay down at this sort of level for the next 20+ years!

  119. Hello Arthur, it is Susan again.

    My husband’s PSA stayed at 0.08 and is now down to below 0.05 again — a little bit of a bounce, due to radiation? Unsure. Has been 13 months since completed.

    All has been well and he feels great since receiving the monthly Lupron injections rather than the 3- or 4-month preparations. Unfortunately his liver enzymes (AST and ALT) continue to rise. Our internist and oncologist are stumped. They ran tests for hepatitis (not back yet). I also noticed that his triglycerides have been rising rapidly (no one mentioned them). His cholesterol is low: below 150, good ratio. The oncologist ordered abdominal and pelvic scans and a bone scan is set for next week. She is not saying the cancer is spreading but wants to be sure. I did some research on my own and found non-alcholic fatty liver disease. His lab values seem to fit this diagnosis perfectly. He has not gained any weight in the past 2 years, but I thought it may be related to the past Casodex or present Lupron. Have you heard of this? I guess we will know from the scans. He eats a relatively low fat diet.

    Thank you.

    Susan

    *****

    Arthur responded as follows:

    Dear Susan:

    Arthur says that it is really quite impossible for him to give you any meaningful advice about why your husband’s AST/ALT and triglyceride levels have been rising. It is true that this would occur in a man with non-alcoholic fatty liver disorders, but these liver enzyme levels could be rising for all sorts of other metabolism-related issues too.

    All that Arthur can really tell you under the circumstances is that you and your husband are going to need to work with your doctors to try to identify what the problem is. It could be related in some way to the Lupron treatment; it seems unlikely to be associated with the Casodex, since this has been stopped. And if your husband is on a low-fat diet, and doesn’t drink, it makes no sense that he would have fatty liver disease. (Arthur says, are you sure he isn’t sneaking out to the bar twice a day for a couple of shots!? )

  120. Does hormone therapy given 3 to 6 months before radiotherapy, during radiotherapy, and for 2 to 3 years after really destroy occult metastases?

    *****

    Arthur responded as follows:

    Dear George:

    Arthur says that it is clear that androgen deprivation therapy (ADT) can reduce the size of both evident and occult metastatic prostate cancer lesions. Whether it can actually eliminate them entirely on its own is less clear.

    The way Arthur thinks about this is that if one is able to limit the growth of occult metastases (in the lymph nodes and other tissues in the pelvis) among men with locally advanced prostate cancer, one increases the ability of other modalities (most particularly radiation therapy and the patient’s own immune system) to actually eliminate the remaining cancerous tissues.

    An analogy might be the way we use relatively mild weed-killing agents to treat the weeds between the cracks in our patios or driveway. These weedkillers don’t actually kill all of the weeds, but they reduce the overall size of the problem, making it easier to them eliminate the odd ones that remain (by simple weeding or more intensive forms of “treatment”).

  121. Dear Arthur,

    Ha, I am sure, he has a very mentally demanding job and no availability to do that. Cheesecake maybe! But I doubt it. He has been losing weight or has been stable for the past 4 years. Besides the ALT and AST ratio indicate non-alcoholic liver disease. He does drink socially on weekends but never more than two drinks a day. I guess we will have to wait for the scans. I thought maybe the Lupron raised his trigylcerides, although I can find little to document this. But I could find little to document his strange reaction to the Lupron 3- and 4-month preparations and how deathly ill he was after each shot for weeks. The oncologist feels it may have been a reaction to the extended release preparation that is used.

    Thank you

    Susan

    *****

    Arthur responded:

    Dear Susan:

    Arthur says that he is sorry that he can’t offer any more insight about all of this. The oncologist may well be correct that your husband was having some type of allergic reaction to whatever is used to create the 3- and 4-month extended release formulations of Lupron.

  122. Arthur,

    I am a 66-year-old white male, on no meds and healthy. I have been getting PSAs and DREs for at least 17 years. My PSAs have been low from 1998 to 2010. Since then they have been: 2010 PSA = 2.1, 2011 = 2.8, March 2012 = 3.4, May 2012 = 2.7, June 2013 = 3.0, June 2014 = 3.4, Oct 2014 = 3.9.

    Now, I have been told by a urologist friend that the thinking on PSA levels have changed a little and as you grow older PSAs can rise and the magical number of “4″ is no longer as critical as it once was.

    Should I be concerned about my PSA going from 3.0 to 3.9 in 15 months? Should I now have a PSA every 3 months to see where it goes from here? I know that the big jumps are of most concern. Would it be wise to have a biopsy? … I have always been very proactive regarding my health.

    Thank you,

    Joe

    *****

    Arthur responded as follows:

    Dear Joe:

    Arthur would first like to confirm for you that the “magical” number of “4″ has been known for some considerable time to be a lot less “magical” than it seemed to be back in the late 1980s and early 1990s. Your urologist friend is completely correct about that.

    Second, the important question that you need to get clear is whether there may be other good reasons why your PSA level has been rising. For example, does your primary care physician think that your prostate feels larger than it did a few years ago? Have you been having slightly more problems with urination (a slower stream, more difficulty fully emptying your bladder)? Things like this could indicate that your problem is more likely to be the very common benign prostatic hyperplasia (BPH) than prostate cancer.

    Third, Arthur would point out that a test called a free PSA test (which can be carried out in conjunction with your next standard or “total” PSA test) can help to discriminate between risk for prostate cancer and risk for BPH. Low “free” PSA levels (below 10%) are more likely to be associated with risk for prostate cancer; higher “free” PSA levels are more likely to be associated with risk for BPH. And BPH is a very common and near to “normal” condition among aging men.

    Finally, Arthur would note that if you and your primary care doctor do decide that a referral to a urologist and biopsy is a good idea, for any reason, Arthur would recommend that, if at all possible, you try to have such a biopsy done after a multiparametric MRI that allows for targeted biopsying of any suspicious areas of the prostate. While it is always possible that you have a small amount of prostate cancer, at 66 years of age you actually want to avoid treatment for low-risk prostate cancer of any type for as long as you can in order to optimize your quality of life. At 66 years of age, a low-risk form of prostate cancer would be highly unlikely to be the cause of your demise.

  123. Arthur,

    Thank you for your response. I do have BPH and last year had a CT scan after urologists in Florida scared me (and probably other seniors after a free screening) and the scan showed my prostate to be 4.8 x 5.5 x 5.7 cm with calculated volume of 79 cc. No focal mass or abnormal enhancement, etc., etc. My prostate is very large but my quality of life is fine. I have been taking saw palmetto and pumpkin seed oil. I get up generally once at night.

    Also, my Dad is 91 and has no problems at all with anything! And he only gets up once a night (and could put out a fire!). Mom is 90 in good health!

    Last year I had a small mass (16 x 13 x 13 mm) ablated from my right kidney and will see the urologist surgeon/oncolologist who did it for a 1-year follow-up so I will bounce what he says about my PSA with what my personal urologist (friend) says. I always get several opinions, always! Like you said and what I have read … men are getting too much treatment that they really don’t need!

    Part of my problem is, I worked in the pharmaceutical business and my team marketed prostate cancer medications so I know too much but anxiety tends to clouds my thinking?

    Thank you so much for your input!

    Joe

    *****

    Arthur responded as follows:

    Hi Joe.

    Arthur says that sounds like a potential plan.

  124. Hi Arthur!

    Does every man eventually progress to metastatic prostate cancer once his cancer has recurred (PSA 0.2 and rising) if he doesn’t get any secondary treatment?

    *****

    Arthur responded as follows:

    Dear Mike:

    Arthur says, “No.”

    Many men will die of something else long before their cancer metastasizes or at least long before metastasis is either evident or causes symptoms. The key issues that need to be considered are the speed at which the cancer is spreading (which can be estimated through the use of a PSA doubling time calculator) and the inherent risk for an individual patient based on things like his age, his life expectancy, other co-morbid conditions, his original PSA level at diagnosis, his Gleason score on biopsy or (better) after surgery, and his clinical or pathological stage.

    Arthur would emphasize that risk of metastasis can only be assessed individually for each patient, and he believes that any really skilled and experienced clinician who understands the natural history of prostate cancer would tell you the same thing.

  125. Hi Arthur. Is it possible to accurately calculate PSA doubling time with an ultrasensitive assay at very low PSA levels? For example, my PSA level was at 0.028 in April 2013 and went to 0.055 in October 2014 with tests given every 2-3 months apart. Given that information, is it 18 months? Or is the standard assay more reliable at calculating PSA doubling time?

    *****

    Arthur responded as follows:

    Dear Mike:

    Arthur says that the accuracy of PSA doubling time based on very low PSA levels needs to be treated with a degree of caution. Most PSA doubling time calculators were developed based on data related to PSA values greater than 0.1 ng/ml. It is not a matter of the type of PSA test being used (ultrasensitive or standard) but more about the size of the variation in the test result over time.

    Having said that, Arthur thinks that if your PSA has gone from 0.028 in April 2013 to 0.055 ng/ml in October 2014 over a period of 18 months, with a slow but steady rise that has been reflected in a series of something like 5 to 7 PSA tests, then Arthur would certainly think that this is highly suggestive of a PSA doubling time of about 18 months.

  126. Hi Arthur. With the slow but steady rise and doubling time of 18 months, would salvage radiation at this point be considered over-treatment, not knowing if I would ever reach BCR (0.2 and rising ) or will monitoring every 2-3 months be appropriate at this point? The only negatives from my pathology report (based on a radical prostatectomy in August 2012) were a positive margin at the apex (Gleason 3 at margin) along with a final Gleason score of 3 + 4, and I’m young age 44 right now!

    *****

    Arthur responded as follows:

    Dear Mike:

    Arthur says that the appropriateness of early adjuvant/salvage radiation therapy in cases like this is highly controversial, with different physicians having different views of the situation. You really need to discuss this in detail with your doctors.

    There are arguments in favor of immediate radiation in cases like this … and there are arguments against this too. A great deal depends on your own personal opinions about the risks related to disease progression, to further treatment, and to the potential impact of further treatment on your quality of life … and whatever Arthur may think is really rather irrelevant to this because it is what you think that is going to be important. What you think may also depend on the degree to which you have recovered good erectile and sexual function post-surgery and the importance of your sex life. It’s obviously all going to be of some relevance to “Mrs. Mike” too (if there is a Mrs. Mike).

  127. Mike,

    I am 54 years old. I had radiation 3 months after RP, because my surgeon and oncologist told me that 3 months is the limit for adjuvant radiation to have any real benefit. After that, it may spread (if it exists), if it hasn’t already. By this point it was clear to me that I probably wasn’t going to regain any substantial erectile function (I know, it can take 18 months, but I had made no real progress after the removal of one nerve bundle) … and plus, with a positive margin and a PSA of 25, and Gleason of 3 + 4, I was a bit worried about the cancer returning. Even with adjuvant radiation therapy, I stand a reasonable risk. .. It’s been 2 years and I am almost due for a PSA check after 6 months. (My first one with that much of a time gap … previously every 3 months). So far they have been undetectable. I wrote because you need to be aware that the radiation will kill the nerves involved with erectile function … according to my oncologist over a period of 18 months to 2 years. If you have regained any function, as Arthur said, it may be downhill after the salvage radiation. In addition, there is damage to the bladder … irritation, incontinence. I was lucky … I recovered and am dry, but still have to urinate often at night. The irritation clears up relatively fast, over about 3-6 months. For me, I felt I had little to lose, and eventually went with an implant, but as stated, just be aware of the side effects.

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