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.
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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.
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.
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.
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.
Thanks, Arthur
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.
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”.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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).
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.
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.
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
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.
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
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.
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.
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.
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.
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.
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!
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.
Thank you Arthur for your reply.