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.
I am 6 weeks out from RP prostate removal. My first PSA test reads 0.6.
I was told by my surgeon that it should have read 0.1. I was told that this can happen and that it can take some time to drop to 0.1. I was also told that my cancer had microscopically broken the prostate wall. It was suggested that I take 6 weeks of radiation … Is this normal?
To get my life insurance policy my readings have to be 0.2 or better. This is so important to my family.
Thanks
Arthur replied as follows to this question:
Dear Wayne:
Arthur thinks that, first and foremost, you are going to be around for many years yet unless you have problems other than prostate cancer!
You appear to have what is known as a “positive surgical margin” in which a tiny (microscopic) amount of cancer has been left behind after the surgery. This is not unusual. However, Arthur thinks you (and he) would need a lot more information before deciding exactly what to do. So here is what Arthur suggests:
You need to get the following information together: (1) your age; (2) your PSA data before your surgery; (3) your Gleason score data before and after your surgery; (4) your pre-surgical biopsy data (numbers of biopsy cores; number of biopsy cores positive; percentage of cores positive) (5) your pre-surgical cancer stage (e.g., T1c); and (6) your post-surgical pathology report (which your surgeon will give you if you ask for it).
Once you have collected all this information, Arthur suggests you go to The “New” Prostate Cancer InfoLink Social Network, join the network, and post all of your available information under the heading “About Me” in your personal profile. You will then find that lots of experienced patients — and possibly some doctors too — will get back to you with their comments and suggestions.
Radiation therapy is just one of a number of things that you can do to prevent progression of your prostate cancer, but it is possible that you don’t need to do anything and that your PSA will continue to fall. You do not need to rush into radiation on Monday. Arthur thinks that the most important thing for you to do is to get a second opinion from another highly experienced prostate cancer specialist before you do anything else. Who you may want to see is likely to depend on where you live, but many specialists will be able to offer a telephone consultation if they are provided with all of the relevant information.
Hello Arthur,
I am so glad you are still around. I still have my crusade battle With the multiple doctors. The rad doc’s nurse called me last Friday and said that the rad doc conversed with the god uro doc and THEY decided that I should end ADT3. This occurred in the morning. I accompanied a friend to my clinic to get him an appointment with an onc doc and ran in to my god uro doc’s nurse who said that the two doctors never spoke and I am still on for a shot of degarelix this Monday (tomorrow).
Now I know that you are going to suggest that it is my body. As much as I need to get off hormone therapy after 1 year and try and find some ++ QOL, I know that my god uro doc is right and I need to stay on 2 more years. People 76 years old should not have to climb mountains, where are the green valleys where we can lay down to rest. So I guess I shall continue on with my daily training in preparation for the Greeley Senior Games where I am running in the 200 m and the 100 m track events. I guess when I win these races I can lie down in the green valleys?. Did I just answer my own question Arthur?
Arthur had this to say:
Dear George:
Well first of all Arthur agrees. Yes, it is your body! And continuation of your training for the Greeley Games seems like a good idea. Exercise is always good for the body and the mind — selective mountain climbing included, even for 76-year-olds if they are up for it.
With respect to your doctors and their communication issues, Arthur cannot help you any more than he has already. That one is between you, them, and the assorted egos (unless and until you decide to get a divorce!). Arthur has no reason to believe that degarelix isn’t a good drug, but he continues to be concerned that the combination of an LHRH agonist and an LHRH antagonist is at best an odd idea. Arthur just hopes all goes well for you.
Dear Arthur,
Thank you so much for your reply. Today I drank the Kool Aid, and got my double subcutaneous shot of degarelix, and the god uro doc said I should leave in the Vantas Implant. I wonder if I am a Phase I clinical trial of one.
The nurse informed me that if I die from the shot they will not be giving anybody else one. So … I have made myself count. You the best man!
George
Arthur responded as follows:
Dear George:
Arthur thinks it most gracious of your doctor and his nurse to inform you that they won’t make a really bad mistake twice based on their experiment with you … even if the nurse did (presumably) have her tongue firmly in her cheek! “May the hormones be with you!”
May as well give you the “rest of the story” Arthur.
On the evening of the first day of my double degarelix shot in my stomach — well there is a little more to it than stomach — you see Arthur — when I turned 60 years, I sort of had some whales tattooed on my stomach — so the twin shots were placed in the two baby whales and the large humpback was reserved for my insulin shots … makes sense if you think about it … well at 10:30 p.m. I started becoming very, very sick … throwing up, super hot flashes, cold sweats, shaking, and the two whales started turning bright pink and became very warm! At 6:00 am in the morning, I became very worried, so I headed for the hospital emergency room and checked in at 8:00 am and, after several doctors checked me over, including a psycho doc, and lots of IVs, I was discharged at 8:00 p.m, feeling a lot better. Saw the god uro doc today and he said “Hummmm … looks like a reaction.” Tonight I still have two pink whales. End of this story. Should I write a book Arthur?
Arthur is puzzled, see below:
Dear George:
So Arthur isn’t sure what to make of this, but he has a number of comments/questions, as follows:
1. Did the uro god doc make any comment about what he thought he might need to do before giving you another shot of degarelix?
2. Did you get any impression that there might have been a correlation between the timing of your degarelix injections (on Monday morning) into the baby whales, the timing of any subsequent insulin injection(s) into the adult whale (later, on Monday afternoon or evening), and the onset of what does indeed sound like some form of allergic reaction on the Monday night?
3. Was the psych doc able to reassure the baby whales that this was not their fault?
4. Is there any indication that the whales are beginning to return to their original Humpback colorations?
Arthur is aware that subsequent dosing with degarelix will be only one injection of 80 mg as opposed to the two injections totaling 240 mg that you received on Monday, so this reaction may not happen again, but Arthur is concerned that this reaction may in some way be related to the fact that: (a) you already have the Vantas implant; (b) you are also taking insulin (although Arthur has no idea who much or how often); and (c) the loading dose of degarelix is a high dose. Arthur also checked the prescribing information for degarelix and saw no sign of this adverse event reported in the “Adverse Events” section. If you want to report this adverse event, you can do so by calling the US Food and Drug Administration at 1-800 FDA 1088 or visiting http://www.fda.gov/medwatch.
Question #1. Answer: The uro god doc mumbled a lot of words to his NP and said to me that he didn’t think the 80 mg shot would cause this much reaction. I did leave a message for the local rep for degarelix who said she was sorry about my being sick.
Question#2: My endo doc (the best of the best) a real Gold Standard Physician, despite my ADT3, has got my A1C, lipids, etc right on the mark. I take Lantus 30 units at night and use a Humalog, KwickPen before each meal every day. Shots go into mama whale every day. The 240 mg into the baby whales, within 1 hour were producing a bad stinging reaction that continued to get worse until suddenly I felt the full effect of something like a poison spreading all over my body. Now, The May 08, 4 month LUPRON shot produced the same reaction only it lasted for several days at a time and was off and on for 6 months. The Vantus Implant (last October) was very mellow and liveable. The Feb 09, 1-month Lupron shot was devastating, the 1-month degarelix had a bad initial reaction, but has now pretty much worn off. I believe that Arthur’s initial hypothesis about the two types, really three, GnRH reacting with each other is the culprit.
Question #3: As for the baby whales, of course they are pissed, wouldn’t you be. They stopped talking to me. Say, you know what, it was at this point when I told the psych doc that they stopped talking to me that he got very interested. “You mean you talk to whales?” Not anymore, I said, since they got the shot. Also at this point a real New York, Long Island psychiatrist was called into my room (named “Sidney” of course). He asked me some questions and when he found out I was a lacrosse player and he played in high school as a defense player and I immediately told him how much I hated defense players, he released me and said I was not crazy, only a lacrosse player.
Question #4. Just checked the whales in the mirror and they are now livid RED. Getting worse!
Final Comment: Don’t ever tell a psych doc that you talk to whales, they have no sense of humor. And don’t ever expect a psych doc to know a damn thing about men under the influence of hormone therapy. They had never heard of it or AD syndromone. “Of course I am depressed, I’ve got no testosterone!”
Arthur says:
Dear George:
Arthur thinks you had some sort of allergic reaction. Maybe everything’s OK … but if those baby whales start to hurt or “burn” again … get thee back to the ER pronto! And when you get your next shot of degarelix, Arthur suggests that you do NOT get it into either of the baby whales. Try a different spot.
How about the turtle?
Arthur replied as follows:
Arthur says don’t push your luck George! Pink turtles are an environmental nightmare waiting to happen!
Well, lets see? That leaves the Taeping, I don’t have an Ariel …., lighthouse, … gulls, rainbow, … porpoises, orcas, waterfall, Kika Kapulauhau, Moorish idol, …I don’t know where? Ahaa, I know! Papa Humpback. Thanks Arthur
Dear Arthur,
Regarding my previous question on partial urinary blockage. I read some place (but could not recall where and could not retrieve the site) that use of vitamins C and E would help in relaxing and allow urine to flow more freely. Did you come across any thing like this? Please check you knowledge banks.
Thank you, Yoshiro Yano
Arthur replied as follows:
Dear Yoshiro:
Arthur is sorry but he is not aware of any such data — which certainly doesn’t mean they don’t exist. Arthur carried out a couple of quick searches on PubMed (www.pubmed.com), but these did not identify any publications that appeared to be related to vitamins and their effects on partial urinary blockage.
Thank you Arthur. Maybe someone out there who reads this may have some input. Thanks anyway for your prompt reply and time. Aloha from Hawaii, Yoshiro.
Hi Arthur,
My husband is 71 and his PSA has jumped from 4.0 to 6.3 during the past 5 months. … Should I be worried? He has an appointment with the urologist at the VA on June 2. He has said that he is against surgery and he is hesitant to even get a biopsy if that is what the urologist says he needs. Just worried and was wondering what to expect. Thank you in advance for your help.
Arthur responded as follows:
Dear Worried Wife:
Arthur entirely understands and sympathizes with your concerns. Many men of your husband’s age have a rising PSA. This is not necessarily because they have prostate cancer. It is a common part of the aging process. What is more, even if it is because of prostate cancer, it may well not be the sort of prostate cancer that will ever cause clinically significant problems. So … The most important thing thing for your husband to do first is to have the visit with the urologist, make careful notes, and then come home and talk with you about whatever the urologist has to say. Arthur actually thinks it might be even better if you were able to go with your husband to see the urologist because this is very definitely a situation in which “two sets of ears are better than one.” However, only you and your husband can decide whether that would work for you. (Most urologists are actually more than happy to have a spouse attend that sort of discussion.)
Arthur says that if the urologist recommends a biopsy, you should make sure you are very specific about understanding why, and don’t let him do it then and there (which would be highly unlikely anyway). You need time to think about this. There are few “rights and wrongs” in this situation. The important thing is for you and your husband to understand your options and to make good decisions together.
Once you have met with the urologist, you can come back to Ask Arthur if you have more questions. There is certainly no reason for your husband to be worrying about the need for surgery at this point in time — especially if his only problem is the rising PSA and he has no other problems that might be associated with the rise in the PSA level.
Dear Arthur: Does anyone know how many deaths per year are caused by prostate cancer in men that have not been treated vs. the men that have been treated.
Arthur responded as follows:
Dear Reabon: First, Arthur very sincerely hopes that no one is dying of prostate cancer in America today without getting treated at all. That would be a very painful form of death!
Arthur suspects that what you mean by your question is: “How many men die from prostate cancer after they have been diagnosed with and treated for localized disease which still progresses, and how many men die after a diagnosis of truly metastatic disease?” That question Arthur thinks he can answer.
The American Cancer Association says that there will be about 27,400 prostate cancer deaths in America this year. And most of the men who die of prostate cancer this year are likely to have been diagnosed between 10 and 20 years ago. It’s been a while since Arthur looked at the SEER data to check, but he doubts if it has changed much. According to that data, 10 years ago, about 80% of men in America diagnosed with prostate cancer were diagnosed with early stage disease and less than 5% were diagnosed with metastatic disease. The other 15 percent either had some form of non-metastatic advanced disease or we didn’t know their stage at diagnosis. So, of those 27,400 men who will die of prostate cancer in America this year, about 80% or 21,900 will originally have been diagnosed with localized disease and less than 5% or maybe about 1,300 will have been diagnosed with metastatic disease.
Dear Arthur:
I finally had the Vantas Implant dug out by the uro onc doc. Quite a mining expedition. So now I am on pure
degarelix (inserted into the sting ray last week). By the way, to the many readers that have been asking about the two baby whales, they are doing fine and once again speaking to me. I have posted their picture on the other site for all to see under the “photos” section.
The question I submit today is that my uro onc doc stated that if the pure degarelix does not lower my testosterone below the new castrate level of 20, my only option is an orchiectomy. Are they really still doing these in the modern day world? Advise please.
Arthur replied as follows:
Dear George:
Arthur is aware that it can be a lot harder to take an implant out than it is to put them in. He has often wondered just how often they do have to be taken out for one reason or another.
With respect to the potential orchiectomy, Arthur say he has a feeling that for some reason your uro onc is “yanking your chain.” Having said that, however, orchiectomy is still widely used in this wonderful modern world. In America, for those who have no insurance coverage and cannot afford to pay for drugs like LHRH agonists, it may be the only alternative available. In much of the developing world, it is the only opportunity.
Having said that, Arthur should note that a modern subcapsular orchiectomy is not exactly the same operation as carried out in the 15th Century to provide an appropriate team of eunuchs to “man” the hareem.
In May 2008 I had a prostatectomy. Every 3 months, I had a follow-up PSA, which all were “non-detectable” (less than 0.1). Last week I got test results from a different doctor that was 0.04. Since I don’t know what my earlier PSAs would have been at the second doctor’s laboratory, how often should I get PSA tests now.
—–
Arthur responded as follows:
Dear Russ:
Arthur says that your most recent PSA test used a method known as an “ultrasensitive” PSA test. Your earlier tests used standard PSA measurements. However, there is nothing for you to worry about. You should continue to have PSAs drawn every 3 months until your doctor tells you that he thinks that once every 6 months or perhaps once a year will be enough.
The advantage of the ultrasensitive test is that if your PSA does start to rise, you will know a little sooner. The disadvantage is that it may show very small variations from test to test, and you shouldn’t get too worried about this if (for example) your next result using the ultrasensitive test is 0.05 ng/ml, because it is perfectly possible that the one after would be 0.03.
Arthur thinks that so long as long as your PSA level is below 0.1 ng/ml, you should be in good shape.
Hey Arthur, it’s 12 years since I needed your help and reading your website in 1997 was so valuable. Thank you so much.
I was diagnosed as a follow-up to routine PSA testing without any other symptoms — but cancer it was. What about all this discussion of PSA testing. I think any man who doesn’t get it is really playing Russian roulette. Why are so many opposed to it. Obviously if one jumps into treatment after a PSA reading that’s very, very bad and to be avoided. However, to avoid getting the reading for fear of being scared into over-treatment — that’s not logical to me. What we need is PSA screening plus education as to how to deal with the results — do you agree?
Arthur responded as follows:
Arthur says, Hello Lee, glad to see you are another fine example of just how long people survive these days after a diagnosis of prostate cancer!
Arthur is of the opinion that the decision to have a PSA is actually a great deal more complicated than people appreciate because we are so very bad at understanding the concept of risk.
For many years Arthur did not have a PSA test. Why? Because he has detailed information on his family going back 5 generations, and there is absolutely no history of prostate cancer. He therefore considers his personal risk to be extremely low. Subsequently, for insurance purposes, he was required to get PSA tests. The last one taken was 2.3, and at age 61 years of age, Arthur would hardly consider that to be a risk signal. He does, however, have all the early signs and symptoms of mild BPH.
The real issue is that the PSA is a poor substitute for a diagnostic test. It is easy for those with extensive knowledge to come to the conclusion you have come to, that everyone should get a PSA test as suggested by the AUA and the NCCN guidelines and then act accordingly. However, “accordingly” depends on what physician you are seeing and not on the AUA and NCCN guidelines (which most men have never heard of, let alone read). The truth is that way too many men will be scared into a biopsy based on a PSA result — especially older men who are at minimal risk for clinically significant disease. At present, we do not have a situation in which men are monitored in a logical fashion for prostate cancer (i.e., in a manner that depends on their prior result).
Most men probably don’t need a PSA test any more frequently than every 5 years starting at age 40 or so. If they had that sort or regular monitoring, we would probably be able to do a good job of picking up most early stage disease and treating it accordingly. The problem absolutely IS the risk of over-treatment, because the average physician is caught between a rock and a hard place if he doesn’t put the patient into the position of making the decision whether to get treated or not, and when put in that position, many men will opt for (potentially unnecessary) treatment — and the doctor has protected himself from a later, possible lawsuit.
In other words, the decisions aren’t really about the PSA at all. They are absolutely all about the follow-up and the interpretation of the data. And that’s where all the problems lie — because histologic evidence of the presence of prostate cancer cells and clinically significant prostate cancer are NOT the same animals at all, but we don’t know how to tell them apart with accuracy based on any test available today.
Bottom line? We still need a MUCH better test that can accurately portray risk for clinically significant disease BEFORE the patient has to decide on a biopsy.
I agree we have much that is needed to learn about prostate cancer. Unfortunately you are probably right that we fellows as a whole don’t know what is going on re prostate cancer. I am wondering if there are analogies to breast cancer, where mammograms are revealing earlier and earlier stages of breast cancer. At least superficially it seems to me that diagnosis with DCIS, stage 0 noninvasive breast cancer, and figuring out what to do next, may be analogous to some diagnoses of early stage prostate cancer. Interestingly there are vast websites and discussions going on both among physicians and women as to what to do next: watch, lumpectomy, radiation, tamoxifen, mastectomy, double mastectomy — overtreatment? undertreatment? how big a margin, etc., etc., etc. Since my prostate cancer was 12 years ago, except for Ask Arthur, I didn’t become aware of anything like the nuanced discussions of breast cancer. On those websites newly diagnosed women get advice, experience, references, from “survivors.” Wow, what is with us men — ignoring all of this when it comes to our bodies.
Arthur responded as follows:
Dear Lee: Arthur says that there is a fundamental difference between breasts and prostates: the former are evident and of vast (if misplaced) cultural significance; the latter are not. This drives a great deal of the relevant behavior. And yes, it is true that there are many similarities between the issues around diagnosis and treatment of DCIS and the issues around diagnosis and treatment of Gleason 6, low risk, localized prostate cancer.
I’m wondering are there any studies of the reasons men chose treatment of potentially non-threatening prostate cancer — given that it’s been known for a long time that there is lots of over-treatment? Are the physicians pushing it, is it ignorance, fear, or a realistic assessment of predictions based on the evidence? There are a number of studies of why women choose mastectomy even though lumpectomy is often considered a less acute but equally effective treatment by their physicians.
Arthur responded as follows:
Dear Lee: Arthur says that he is not aware of what could be described as a really sound study evaluating precisely why men diagnosed with low risk disease (clinical stage T1c, a PSA of < 10 ng/ml, and a Gleason score of 6 or less) chose treatment as compared to some form of expectant management (active surveillance or watchful waiting, which are not the same thing).
There are many factors that come into consideration in making these decisions — from age, other health conditions, personality and trust in one’s physician to family history and simple fear and paranoia. It would take an extremely large and very carefully structured study to evaluate exactly what drives such decisions in a manner that accounted successfully for all of these factors. Furthermore, even if the study could be effectively conducted, Arthur is not at all sure what value it would have to helping men make better decisions. While the study might be of intellectual curiosity, Arthur would rather see the money spent on things that had the potential for more practical benefits!
Some American physicians will tell you that they have a very hard time trying to get any prostate cancer patient to even consider active surveillance (the “Get it out of there” syndrome). By contrast, European physicians will tell you that they don’t understand the problem because many older European patients will happily go onto active surveillance without a further thought about it. There is clearly a huge cultural element to all of this. We Americans seem to suffer from a sad and delusional obsession with the idea that we are entitled to live forever in perfect health. We aren’t — and it ain’t going to happen.
The purpose of these sorts of studies is presumably to determine whether or not men are making educated decisions based on realistic understanding plus their own values. In any case, as is implicit in your description, just to get to the point of making a decision one needs to be getting PSA tests plus a biopsy if indicated. And it’s also my understanding that current practice would not just utilize the PSA value but other PSA dimensions such as PSA velocity, etc. As far as “active surveillance” is concerned, what does that mean. Back in the day (1997), watchful waiting was the option. That always bothered me because I didn’t know what one was waiting for. By the way how much risk is “low risk” — I think that is the key to many men (and women). Risk times loss is the important thing — whatever that means. So that if there is a low risk of a horrible outcome, this product can still be high compared to a higher likelihood times a good outcome. So it’s not just a question of the size of the risk, but what one is risking — which to me is why some men (and women) logically chose “get it out” — prostatectomy and mastectomy. It’s not necessarily a syndrome but perhaps a realistic decision in many if not all cases — which gets us back to the value of studying this decision process.
On 8/19/2009 I was just told I have prostate cancer with 2 tumors, 1 mm and 3 mm, with a Gleason score of 3 + 3 = 6. One tumor is located on left base and is 1 mm and the other is located right lateral mid and is 3 mm: core measured 1 cm carcinoma involves two cores. I am 55 years old and weigh 155 in good health.
My question is what would be the best treatment for me given the above information.
Thank you in advance,
Ray Rivas
——
Arthur says, Dear Ray:
So first, here’s the good news … Assuming that your PSA level at the time of diagnosis was less than about 7 ng/ml (which it probably was) you would appear to have low-risk prostate cancer that has been diagnosed early. This means that almost any form of standard treatment (and some investigational treatments) can likely be used to treat you with a high probability of success: surgery, brachytherapy, other forms of radiation treatment (including proton beam radiation), and even high-intensity focused ultrasound (HIFU). If you were in your 70s, or even your late 60s, Arthur would also tell you that careful monitoring using “active surviellance” might be an even better option than active treatment, but at your age, with a likely life expectancy of another 20+ years, there are good reasons to think that early treatment might be better.
The less good news is that no one can tell you with any degree of absolute certainty what “the best” treatment might be for you, because we just don’t have the data to support such an abstract decision.
You are going to need to do some “homework” in order to decide what you think “feels right” for you. All that Arthur can tell you specifically is that the skill and experience of the individual treating physician is a BIG factor in getting the best possible outcome with the least risk of adverse long-term side effects. So … for example … you want to go see a surgeon or a radiation oncologist who treats LOTS of prostate cancer patients every year, and has a really good reputation. Arthur also suggests that if you join the Social Network associated with this site, you will be able to get help and support from up to 1,000 or so patients and their family members who have “been where you are already.” They will be happy to share from their own experiences and help you to “think through” how you want to proceed.
Arthur feels very comfortable that you have time to come to a decision you are comfortable with, and he strongly recommends that you get at least one “second opinion” before you rush into a treatment decision. You might also want to read the article entitled “What? You mean I’m going to have to CHOOSE!” elsewhere on this site.
My husband has prostate cancer. He was diagnosed in 2004. He had radiation treatment at that time. His PSA fell to below 0 and was not much above 2 for a long time. Needless to say, it started rising again about 2 years ago. He was put on Casodex and monthly Lupron shots. This brought it back down to 1 or below — until about 3 months ago. Then it started rising again … and got to 7. He had a bone scan and MRI. No cancer in the lymph nodes but mets in spine, hips, ribs , shoulders. The doctor took him off Casodex for a while, and his PSA rose to 78 in a month. Then the doctor gave him the option of doing the Quadramet. He did that about a month ago … a very expensive treatement, mainly for bone cancer pain -.. although he really had no significant pain. Since then his PSA has gone from 78 to 340 and 2 weeks later it was 420. He had another bone scan and MRI. We will talk to the doctor next week for those results. But in the past month he gets sudden bursts of pain that are so bad they bring him to his knees and to tears. Why is this happening? They said he would have a surge of pain about 48 hours after the Quadramet, and he did … but why is he having them after 6 weeks? He said all over hurts … really really bad … after about 10 minutes, it’s better. Anyone have any ideas? It has happened three times in the last 6 weeks.
——-
Arthur replied as follows:
Dear Mrs Light:
Arthur says, first and foremost, that he is really sorry to hear that your husband’s cancer has progressed like this. He clearly has an aggressive form of prostate cancer that has not responded well to any of the treatments that have been tried to date.
Although Arthur cannot tell you exactly why your husband is experiencing the severe pain spasms that have been happening recently, it seems very likely that this has to do with metastases in his spine that, under certain circumstances, are affecting the nerves in his spinal chord and which therefore result in the types of debilitating pain that you describe spreading throughout his body very quickly. The nerves in the spinal chord are one of the main nerve channels affecting the whole body. If the metastases in his spine have started to grow into the spinal chord, or the bones of the spine are starting to break down because of the metastases, this could explain the type of pain you describe.
The MRI that your husband received recently may help to explain this situation, because it may show effects on the spinal chord. Depending on the precise circumstances, it may be possible to stabilize the bones of the spine so as to prevent this from happening for a while, and you will need to talk to your doctor about this. Clearly the Quadramet was not strong enough to affect the growth of the metastases that are leading to this specific type of pain.
If this is the only form of pain that yoiur husband has been experiencing to date (which you seem to imply), then it may be possible to alleviate it for a while in the way Arthur describes above, thereby avoiding any need to think about the use of opioid-type pain drugs for a while yet. It is clear that your husband needs help from a physician who specializes in pain management (perhaps a neurologist) who can give him a careful evaluation and make specific recommendations about appropriate treatment.
This situation is undoubtedly extremely distressing for you too, and Arthur would suggest to you (gently) that you may also need some help in coping with what you are going through as you care for your husband in these circumstances. If you look on The “New” Prostate Cancer InfoLink Social Network, you will find a Wives and Partners group, where some spouses will certainly understand what you are going through and may be able to offer help and support from their own experiences.
Please be advised that I have enlarged prostate and my PSA reading is 17 and the Doctor told me that I must go for a prostate biopsy which I refused to do. Do you think I shoul take the NALTREXONE? please let me know.
—-
Arthur replied as follows:
Dear Edgar: Arthur thinks that there are a number of things going on here.
The first is that you are obviously worried by the idea of a biopsy. You aren’t the first to have that reaction and you won’t be the last by any means, either.
HOWEVER, if you are unwilling to have a biopsy, naltrexone is WAY down the list of things that Arthur would think about using to treat your problem because there are no data to suggest that naltrexone is effective in the treatment of any prostate disease!
If you are absolutely unwilling to have a biopsy, Arthur thinks you should do the following: (a) talk to your primary care doctor about your fear of having a biopsy, and ask him whether he would be willing to give you an appropriate antibiotic in case the real reason for your PSA being up at 17 is prostatitis (a form of prostate infection). If that happened to be the case, the right antibiotic would rapidly drop your PSA back down again.
If the antibiotic therapy doesn’t work, and you are still unwilling to have a biopsy, then there ARE things you can do which MIGHT help you to prevent the progression of what would be likely to be prostate cancer. They include the following: (a) radically altering your diet to become effectively a vegetarian, with a much, much lower fat and carbohydrate intake and a significant amount of soy protein, and (b) taking up a serious and regular exercise regimen and losing any excess weight, as well as (c) carefully monitoring your PSA level on a 3-monthly basis to see what happens. Now you need to understand that this is NOT a way to cure prostate cancer, but it may have some impact on delaying progression. In addition, it is possible that a drug known as Avodart may be able to delay prostate cancer progression (at least in some men), so you could also see if you could persuade your doctor to to put you on it. It has a very minimal side effect profile and most men have no problems taking it at all.
So … with regard to naltrexone … if you don’t like what Arthur is suggesting … talk to your primary care doctor about it. Arthur can assure you that if he knew any good data suggesting that naltrexone actually worked to treat prostate cancer, he would tell you. … but he doesn’t. What you are reading elsewhere on the internet is fluff and nonsense. Taking a cheap generic statin like simvastatin would be much more likely to control early stage prostate cancer than taking naltrexone!
Dear Arthur:
I have a friend who had a TURP and found out afterwards he had prostate cancer. He is in his late 60s. He thinks he wants proton therapy because he believes he won’t have any side effects at all. I have tried to tell him that there are side effects with any radiation. (I have a degree in radiation therapy.) My husband had the da Vinci procedure with no problems. My friend thinks that because of the TURP he would have problems with his bladder control if he has the da Vinci procedure.
—–
Arthur responded as follows:
Dear Wanda:
Arthur thinks, based on just a little experience, that men tend to have very emotionally charged reactions to their various options for the treatment of prostate cancer (and indeed to the issue of whether they need treatment at all).
Given that your friend is in his late 60s and has been diagnposed with clinical stage T1a prostate cancer, the first question is, “What was his Gleason score?” If his Gleason grade was 3 + 3 = 6, the follow-up question is “Does he need treatment at all?” or could he be monitored with an active surveillance protocol designed to see whether he actually needs treatment.
With respect to the relative merits of differing treatment techniques: (a) You are of course correct, all treatments come with risks for side effects — including proton beam radiation therapy. (b) Whether a prior TURP might impact the ability of a specific patient to recover full continence is an impossible question for Arthur to answer. It depends on the quality of the TURP, how well the patient recovered from the TURP, and the skill of the surgeon who carries out the radical prostatectomy (RP). Arthur is not aware of any data to say that (in general) patients who have had a prior TURP have a higher risk for post-RP incontinence. However, there is little doubt that under certain circumstances a prior TURP could well increase the risk of post-surgical incontinence.
If your friend wants to go for PBRT, Arthur doen’t see any specific issue with this, but you could warn him that any form of radiation is most specifically associated with risks for some rectal radiation side effects and with a degree of loss of erectile function some time after the actual treatment — but of course he may do fine. Many do. On the other hand, as indicated above, he might well do just fine without any form of treatment if he has low risk disease, a low PSA level, and a Gleason score of 6. There are no easy answers for men like this, and in the end, most men are going to do what they feel most comfortable with, regardless of any logic that Arthur (or you) may be able to offer.
Great work! I also have my own blog I just find it hard to write quality content like this.
I guess I really dont have the time.
I have a trending, but low velocity PSA.
Can I have my physician that does my annual DRE run the ASR or do they need to have special training? I would like to have the urine test run just for my own information / baseline data.
Thank you!
B
*****
Arthur responded as follows:
Dear Bruce:
Arhur knows that there are a number of laboratories that can run PCA3 tests for you. The one Arthur is most familiar with is Bostwick Laboratories in Virginia, and you or your physician can certainly contact Bostwick Laboratories to see what would be required. It is Arthur’s understanding that at least some insurance companies have been covering the costs associated with this test, but obviously that would depend on your personal health care coverage.
I have been recently diagnosed with localized prostate cancer. I live in Orlando, Florida, and am torn between “watchful waiting” and external beam radiation.
My Gleason score was 6 (3 + 3) in a recent biopsy with the volume being LT 5%.
I am 63 years old and in generally very good health.
Is it worth waiting for the development of a sarcosine test, or should I go ahead and have the radiation?
Arthur responded as follows:
Dear Steve:
Arthur thinks that this question raises a whole series of issues that are a lot more complicated than “Should you or shouldn’t you wait for a sarcosine test?”
So, first, it is likely to take years before we can prove that sarcosine is an effective and accurate marker for aggressive forms of prostate cancer. Arthur wouldn’t expect resolution of this issue before about 2015 at the earliest.
Second, you haven’t given Arthur either your PSA score or enough other information for him to be able to make any accurate estimate of your real risk for progressive as opposed to indolent prostate cancer BUT … based exclusively on your Gleason score and estimated tumor volume you would certainly appear to be a good candidate for active surveillance as opposed to invasive therapy (e.g., radiation or anything else). So you could certainly go onto an active surveillance protocol if you were comfortable with this.
Under your circumstances, a great deal may depend on your own ability to decide that you can “live with” your cancer under an active surveillance protocol. Some men have no problem with this at all. Others find the idea absolutely terrifying. There is no “right” or “wrong” here. The one thing that Arthur does not think you should do is make any decision based on the expectation that a possible, future sarcosine test will give you a definitive answer to your particular question. If a sarcosine test becomes available, then you can have one if you still need it, but you need to make decisions and move on, not wait and hope that an unproven theory might be the answer to your particular problem. Science just doesn’t work that way.
Arthur:
Thanks for your helpful response. Three more pieces of information about me which might allow you to elaborate on your answer.
* My pre-biopsy PSA was 3.7, but rising from 2.5 a few months earlier.
* My father died of PC 30 years ago when he was 70 years old. This was in the UK and he was only diagnosed a few months before death. No PSA tests back then.
* My personality would allow me to go through “watchful waiting” or active surveillance. Maybe I should worry a lot more than I do, but frankly I don’t. I sleep well at night and, if I don’t, it’s not the PC keeping me up.
Many thanks again.
Steve
Arthur responded as follows:
Dear Steve:
Arthur thinks that the additional data you have provided is strongly supportive of the idea that you have low-risk disease. However, the information that you have added regarding your father’s earlier death with prostate cancer obviously changes the risk equation.
If Arthur was wearing your shoes, he would go and get a second opinion at an academic medical center where there were physicians who had significant experience managing patients under active surveillance protocols to give you some additional perspective on how you should act. It is important for you to understand that Arthur is NOT a doctor, and this is just a lay opinion. You could also go back to the urologist you have been seeing and ask his opinion about active surveillance too. Recent data from Johns Hopkins seems to suggest that men with low risk disease who go onto active surveillance and subsequently need surgery still do well at the time of surgery, but these decisions are always incredibly personal, which is why a second opinion probably wouldn’t hurt.
The balance that you are trying to find relates to the risks you would take for cancer progressing under an active surveillance protocol as compared to the risks of loss of erectile function and/or other complications following surgery — and these latter risks are not insignificant. For some couples, their sex life is an absolutely critical aspect of their relationship. For other couples it may be less fundamental. All of these factors need to be built into the decision process.
combined Gleason score 7,with isolated foci of 8
extent of invasion T3bNxMx
lymph examined n/a
margin 1 mm from outermost bladder neck inked margin positive margin, 1 mm from posterior black inked margin, positive seminal vesicle sort tissue margins blue ink
extraprostatic extension :yes
seminal vesicle invasion: yes
8o% involved on the right
60% involved on left
there is also probable lymphovascular invasion section
8 out of 12 cores cancer
PSA was 17.6; Da Vinci removal of prostate; 4 weeks post-surgery PSA was 1.2; 7 weeks later 2.3; then 36 treatments of radiation
worried that will have to do hormone therapy; I’m tired most of the time and hard to keep mind on my job
4 weeks after radiation PSA went from 2.3 to 1.5
Oct. 26 PSA went from 1.5 to 0.07 see urologist Friday
What will be next? Wait and see if it lowers another 90 days or have treatment?
——-
Arthur responded as follows:
Dear Ron:
Arthur is sorry to hear that you have a clear case of relatively high-risk prostate cancer that has extended outside the prostate (although to date there is no specific evidence of either lymph node positive or metastatic disease). From what you have told Arthur, the treatments you have received to date appear to be highly appropriate (but Arthur found it difficult to interpret one or two of your comments).
Arthur says that the fact that, after radiation, your PSA has dropped to 0.07 is actually very promising. The question is going to be what your PSA does over the next few months. Any further drop in the PSA will be fairly minimal since the standard description of an “undetectable” PSA is any value less than 0.1 ng/ml — which your PSA already is. So long as your PSA stays below 2.0 ng/ml, radiation oncologists would consider you to have stable, non-progressive disease (based on what are known as the Phoenix criteria). Arguably, therefore, you should need no further treatment unless your PSA rises above that level.
There are no clinical data to support such treatment, but one thing you could ask the oncologist about when you see him/her is the possible value of additional treatment with a drug called dutasteride (Avodart). There is some evidence that this drug may be able to help to delay progression in some patients, and it has very minimal side effects by comparison with traditional forms of hormone therapy. Depending on where you are going for treatment, the oncologist may also want to talk to you about participation in clinical trials of development-stage agents that may have some potential in the management of high-risk disease after definitive surgery and radiation treatment.
With regard to the tiredness … This is a very common side effect of the radiation therapy. It should wear off quickly, and if you can establish a good, healthy diet and at least a mild exercise regimen (maybe starting with a mile walk each evening), you should find that you will recover your prior energy levels relatively soon. Clearly you should have your PSA closely monitored (at least every 3 months and maybe more frequently) for the next year until it is absolutely clear that it has stabilized.
Dear Arthur:
Please consider my case and the questions and concerns listed at the end of my digest. Your efforts have assisted so many to improved detection and treatment choices.
Thank you so much for your remarkable service in considering and addressing my questions and concerns and those of the many survivors you have counseled.
I would greatly appreciate your response and recommendations.
Sincerely,
Glenn H.
GH Digest
GB, Age 58, bPSA – 8.2, GS 3+3=6, DRE + , Clinical Stage – T2c
PV = 35.4 cc
Partin 2001 – OC/46 CP/46 SV/5 LN/3
Prior PSA’s
06/24/91 – 4.5
07/10/91 – 4.1
8/14/91 – First Biopsy
GROSS DESCRIPTION:
Specimen (A) labeled hypoechoic area left base. Specimen (B) labeled right base and Specimen (C) labeled right midgland are all similar pale tan cylindrical cores of prostatic tissue ranging in size from Specimen (A) which is fragmented and measures 6 x 0.5 mm to Specimen (C) which measures l8 x 0.5 mm. The specimens are completely submitted. BLB:bg
MICROSCOPIC EXAMINATION:
Specimens (A) through (C): The specimens are composed of prostatic glandular tissue and fibromuscular stroma. No active inflammation or tumor is identified.
DIAGNOSIS:
SPECIMENS (A) THROUGH (C), PROSTATE, TRAKSRECTAL NEEDLE BIOPSIES: NO PATHOLOGIC DIAGNOSIS.
Prior PSA’s
08/14/91 – 4.1
06/10/93 – 3.3
09/21/95 – 6.3
08/10/96 – 9.1
10/24/96 – 8.2
PSADT – Last 5 – 4.04 yrs.
10/28/96 – Second Biopsy
(A) and (B) Prostate Needle Core Biopsies, “left base and left mid”: No specimen identified from microscopic sections.
(C) and (F) Prostate Needle Core Biopsies, “left apex and right apex”: Adenocarcinoma, moderately differentiated. Predicted Gleason Score 6 (3+3). (10% and 70% of total biopsy lengths, respectively), (1 nun and 4 mm respectively).
(D) and (E) Prostate Needle Core Biopsies, “right base and right mid”: Benign prostatic glands and stroma.
(G) Prostate Needle Core Biopsy, “R lateral”: Focal area of atypical glands suspicious for malignancy^.
DNA Ploidy Analysis:
(F) Prostate Needle Core Biopsy, “right apex”: Normal
DNA. Diploid. (URO COR)
01/21/97 – 7.6
05/22/97 – 8.7
06/03/97 – 7.4
06/12/97 – 8.7
07/22/97 – 8.0
11/05/97 – 7.42
12/29/97 – 8.29
02/25/98 – 10.42
03/06/98 – 9.71
04/08/98 – 9.94
PSADT – Last 10 – 3.29 yrs.
3/10/98 – BONE SCAN
IMPRESSION: BONE SCAN WITHOUT SIGNIFICANT FINDINGS TO SUGGEST THE PRESENCE OF METASTATIC DISEASE TO BONE.
3/10/98 – CT ABDOMEN & PELVIS WITH CONTRAST
IMPRESSION:
1. MILD PROSTATOMEGALY, CAPSULAR INVASION, ADENOPATHY OR OTHER GROSS
SIGNS OF METASTATIC DISEASE IN THE ABDOMEN OR PELVIS.
2. AORTOILIAC ARTERIAL CALCIFICATION.
3. DEGENERATIVE CHANGES, LUMBAR SPINE.
4. NO OTHER SIGNIFICANT ABNORMALITIES SEEN IN THE ABDOMEN OR PELVIS.
4/21/98 – RP
MICROSCOPIC DIAGNOSES
Lymph nodes of right pelvic region; No tumor identified in five lymph nodes.
Lymph nodes of left pelvic region: No tumor identified in three lymph nodes.
Right and left seminal vesicles: Invasion of proximal seminal vesicles by moderately differentiated adenocarcinoma.
PROSTATE: Extensive moderately differentiated adenocarcinoma with multifocal extension to peripheral (capsular) margins of excision with invasion of perineural lymphatics and surrounding soft tissue; nodular prostatic hyperplasia.
Comment
Much of the right half of the gland is replaced by moderately differentiated adenocarcinoma which corresponds to a Gleason’s composite histologic score of 3 + 3 = 6. The tumor occupies approximately 40% of the gland and has an estimated greatest dimension of 4 cm. Anterior and posterior (urethral and bladder flap) margins of the prostatic urethra are negative for tumor. Tumor is present at the peripheral (capsular) margins of resection on the right half of the gland and it has penetrated into the surrounding soft tissue where tumor lies within perineural lymphatics. There is invasion of the proxirnal portions of both seminal vesicles.
6/26/98 – <0.2
7/20 to 9/10 – External Beam Radiation
Completed postoperative radiation therapy for adenocarcinoma of the prostate. He received a conformal treatment to the prostate bed, for a total dose of 6840 cGy. Initially a wider field was used to deliver 25 fractions totaling 45 Gy, and then a subsequently coned-down boost of 13 fractions totaling 23.4 Gy was delivered to the prostate bed.
PSA’s
06/26/98 – <0.2
10/15/98 – <0.2
01/14/99 – <0.2
07/12/99 – <0.2
01/20/00 – <0.2
07/03/00 – <0.1
06/14/01 – <0.1
01/23/02 – <0.1
01/08/03 – <0.1
03/22/04 – 0.1
03/11/05 – 0.45
04/22/05 – 0.51
07/25/05 – 1.53
10/27/05 – 1.21
02/27/06 – 1.60
PSADT – LAST 6 – 5.4 Months
02/28/06 – CT ABDOMEN & PELVIS W/WO CONTRAST
IMPRESSION
1. NO RADIOPAQUE URINARY STONES.
2. NO DEFINITE ENHANCING RENAL LESIONS.
3. TWO SMALL LOW DENSITIES IN THE RIGHT KIDNEY, TOO SMALL TO
CHARACTERIZE BY DENSITY OR BY ENHANCEMENT.
4. PRIOR PROSTATECTOMY.
5. DIVERTICULOSIS WITHOUT EVIDENCE FOR DIVERTICULITIS.
6. FUSIFORM, INFRARENAL ABDOMINAL AORTIC ANEURYSM, MAXIMUM DIMENSIONS
3.1 X 3.7 CM ABOVE THE BIFURCATION.
06/19/06 – 5.08
09/29/06 – 5.01
01/04/07 – 6.02
05/04/07 – 5.94
11/25/07 – 4.43
05/25/08 – 5.90
11/24/08 – 12.1
02/24/09 – 20.55
PSADT – Last 8 – 1.
03/06/09 – BONE SCAN
IMPRESSION: NO EVIDENCE FOR METASTATIC DISEASE TO BONE.
05/18/09 – 28.89
05/28/09 – CT SCAN
IMPRESSION:
1. PRIOR PROSTATECTOMY.
2. INTERVAL DEVELOPMENT OF MILD PELVIC LYMPHADENOPATHY. THERE ARE ENLARGED LYMPH NODES IN THE LEFT COMMON .1/\/ ILIAC AND EXTERNAL ILIAC CHAIN REGION, LARGEST MEDIAL TO THE PROXIMAL LEFT EXTERNAL ILIAC VESSELS MEASURING 1.8 X 2.3 CM. THESE WERE NOT PREVIOUSLY ENLARGED.
3. SMALL SUBCENTIMETER RETROPERITONEAL LYMPH NODES ARE NONSPECIFIC AND GROSSLY STABLE.
4. TWO OR THREE SMALL SUBCENTIMETER LOW DENSITY LESIONS IN THE RIGHT KIDNEY ARE GROSSLY STABLE. MILD RENAL CORTICAL THINNING IS SUGGESTED BILATERALLY.
5. INFRARENAL ABDOMINAL AORTIC ANEURYSM APPEARS
FUSIFORM AND POSSIBLY SLIGHTLY SACULAR POSTERIORLY. THIS IS SLIGHTLY LARGER NOW MEASURING 4.0 X 4.2 CM, COMPARED TO 3.1 X 3.6 CM PREVIOUSLY AT APPROXIMATELY THE SAME LEVEL.
6. FATTY CHANGE IN THE LIVER.
7. HIATUS HERNIA.
8. NO SUSPICIOUS PARENCHYMAL LUNG LESIONS. THERE IS MILD EMPHSYEMA NOTED. NO PATHOLOGIC LYMPHADENOPATHY IN THE CHEST. MILD INTERSTITIAL SCARRING NOTED GREATER IN THE BASES.
06/04/09 – 29.78 Testosterone – 320.24
PSADT – Last 5 – 5.15 months
06/04/09 – Casodex – 50 mg / Day for one week.
06/11/09 – Eligard – 30 mg (four month)
Questions:
Would you concur with the decision to start ADT as we did?
Would you recommend conventional constant ADT or Intermittent ADT in my case.
If intermittent, what would be your criteria for: (a) ending the first on cycle? (b) starting the second on cycle?
What would be your recommendation(s) for prolonging the off cycle?
Please relate any dietary and supplementary recommendations that could help minimize side effects and improve treatment effectiveness.
———
Arthur responded as follows:
Dear Glenn:
Arthur says, first and foremost, that much as he might like to be able to offer people the sort of detailed guidance you are seeking. it is simply not feasible for him to do that. In the first place he is not a physician, and in the second place, even if we was, he hasn’t examined or even spoken to you, and there are dozens of other issues that would need to be taken into account.
With respect to your questions, Arthur can offer only some general guidance.
Was it reasonable to start hormone therapy based on the data you have provided? Yes. Was it absolutely essential? Different physicians would likely have different opinions.
Would continuous or intermittent therapy be the better option? It simply isn’t possible for anyone to make any recommendation about that until there are clear data on your response to the initial hormone therapy, which is likely to take at least 6-9 months. At that point in time, Arthur would suggest a further discussion with your treating physician(s). There are several different types of intermittent therapy and in general Arthur encourages appropriate patients to consider these options if they have had a good response to the first few cycles of hormone therapy simply because it decreases the long-term risk for serious adverse effects of hormone therapy, but everything depends on the patient’s initial response. In Arthur’s view, intermittent therapy is unlikely to be a good idea for patients whose PSA does not drop to near zero after the initial 6-9 months on hormone therapy.
IF you were to go on to intermittent therapy, there are certainly patients and physicians who have had good experiences with prolonging the intermittance period through the use of 5ARIs like finateride and dutasteride (Avodart). HOWEVER, there are no substantiated data from randomized clinical trials to confirm the clinical value of this type of treatment to date. Again, this is a matter that you need to discuss with your personal physician(s).
The whole dietary issue is fraught with opinion rather than good clinical evidence. Arthur’s basic view is that a sound, heart healthy diet and a regular exercise regimen are a good idea. After that, it comes down to personal opinion, and is as much about what individual patients “feel good doing” as it is about any specific clinical benefit. There are no really good data that absolutely substantiate any specific dietary interventions for all patients with progressive disease like yours. If you really want that sort of guidance, you would be wise to consult with one of the very small number of physicians who really specialize in integrative management of patients with progressive prostate cancer, because these issues are highly patient-dependent.
Arthur,
I have been recently diagnosed with prostate cancer with a Gleason score of 7 and a PSA of 9.5. I am 2 months shy of 73. My urologists said that with the above facts all options, including watchful waiting, are viable. I am in the process of studying the different options in trying to make the best decision for me. I have found a facility that uses proton radiation to treat prostate cancer but there is very little info about the success of this type treatment or very little on the internet about it. My question, Is this type of treatment gaining any momentum and is it effective.
———–
Arthur responded as follows:
Dear John:
First and foremost, Arthur thinks some clarifications are in order. If your Gleason score is 3 + 4 = 7, you are at notably lower risk for progressive disease than if it is 4 + 3 = 7. Also, you should make sure that there is no mention of a tertiary Gleson grade of 5 on your pathology report.
Having said that, and assuming that you are indeed a “low risk” or possibly an “intermediate risk” patient (which depends on a bunch of factors), Arthur would agree with your urologists that “all options, including watchful waiting, are viable.”
With respect to proton beam radiation therapy (PBRT), this technique has been used to treat prostate cancer for most of the past 20 years, with the longest series of patients being treated at the Loma Linda facility in California. There is absolutely no doubt that PBRT is effective and at least as safe as other forms of radiation therapy. There is controversy, however, over whether PBRT is any more effective or safer than other forms of radiation. In the past 3 years there has been a growth in the number of proton beam facilities around the country. PBRT would likely be one of several appropriate options for you if you really think you need to be treated. The single most important factor that you should determine, however, is whether your health insurance will cover this form of treatment. PBRT is expensive, and not all insurers have agreed to cover this form of treatment for prostate cancer (yet) because of the controversy mentioned above. If you are Medicare patient, coverage varies from region to region.
Dear Arthur:
Thank you for answers and info on my previous questions. I would like to further clarify my situation and ask for your response. My PSA results have always been on the high side (2005 — 4.9, 2006 — 5.33, 200 — 5.9, 2008 — 8.46, and 2009 — 9.5) but my regular physician never felt any lumps during the DRE; however, he did continually advise me to see a urologist for about 4 years before I finally agreed.
Bostwick Labs tested the 12 samples taken during the biopsy and the six on the right side of the prostate all came back positive. Five were 3 + 4 = 7 and 1 was 4 + 3 = 7. There was 1 positive on the left side with a 3 + 3 = 6. There was no grade of a 5. PSA was 9.5
There is no diagnosed prostate cancer in my brother or father; however, my father did die of lung cancer.
With the above facts, what risk category would you say I fall into and is watchful waiting a viable option. I do feel that I am a heathly 72+ and my doctor agrees.
————–
Arthur responded as follows:
Dear John:
Arthur thanks you for the additional data above. You seem to have clinical stage T1c prostate cancer that would translate to pathological stage pT2c (or perhaps higher) if you were to have a radical prostatectomy. Your historic PSA doubling time appears to be of the order of 4 years, which is slow.
Based on the D’Amico risk categories, you appear to fall into the border area between intermediate and high risk groups because you have a Gleason score of 7 (which is characteristic of intermediate risk). However, your PSA of 9.5 would place you in the low risk group and it is only the fact that you have 7/12 positive cores that places you into a high risk group. Given the combination of the slow PSA doubling time and the fact that most of the cancer is in one lobe of your prostate, Arthur would suspect you are “more like” intermediate than high risk — but this is a judgment call and Arthur is NOT a urologist!
The question whether some type of expectant management (watchful waiting or active surveillance) would be appropriate for you is going to be very much your decision in consultation with your urologist.
One way to look at this is to assume that your PSA doubling time remains roughly what it is now. If that proved to be the case, then in 2013 it would be about 19; in 2017 it would be about 38; and in 2021 it would be about 76 ng/ml. By that time, you would be 84 and the chances are that you would still have absolutely no symptoms of prostate cancer. A second way to look at this is to consider that, given your current PSA doubling time, maybe treatment with dutasteride (a drug with few significant side effects) might impact your PSA levels and slow down even further the already slow progression of your prostate cancer. There are limited data to support this idea, but it is worth a discussion with the doctor.
At the end of the day, you are very clearly a man who has to weigh very carefully the risks of “doing nothing” against the risks of the side effects of treatment. This is not an easy choice, and is very dependent on each individual’s attitudes to risk in general and health risks in particular. Certainly in Arthur’s opinion some form of expectant management IS a potential option. Whether it would be the RIGHT option for YOU as an individual is a whole other question. Arthur can’t answer that one for you!