This is a follow up to a prior question. A week ago I wrote:

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

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

“Should I go undergo radiation therapy, and how soon? Are there any advantages in starting radiation as soon as possible or it doesn’t matter. My surgeon wants to see me in a month from now to do the PSA test.”

Now I have got my first PSA test results at 0.04. And my surgeon says that the positive margin was very small, no actual measurement was given. He thinks radiation is absolutely unnecessary.

My questions are: (1) if all cancer cells have been removed, why do I still have a detectable PSA and (2) should I consider radiation at all and if not how often do I need to have a PSA test?

Thank you in advance,

Abbas

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Arthur responded as follows:

Dear Abbas:

Arthur says that a PSA level of 0.04 ng/ml after a radical prostatectomy is — to all intents and purposes — an “undetectable” PSA level. Remember that the serum PSA test is not measuring the level of cancer in your prostate. It is measuring the level of PSA in your bloodstream, and there are may well be very, very low levels of PSA in your bloodstream, but if you have no prostate, then you have no prostate cacner cells in your prostate.

Arthur also says that, with a pathological stage of pT2c and a very small positive surgical margin, it is possible (if unlikely) that your PSA could start to rise again at some time in the future, but no one can tell you that today. For the present Arthur thinks you should listen to your urologist and monitor your PSA carefully ewvery 3 months for the next couple of years. Arthur does not see any need for you to have adjuvant radiation at this time. If your PSA does start to rise, then salvage radiation can be implemented at some point in the future, but you may never need this.

It sounds to Arthur as though your surgeon has done a very good job for you, so let’s take a little rest from treatment and hope that you will be “all done” with risk of prostate cacner for the rest of your life!

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

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

Should I go undergo radiation therapy, and how soon? Are there any advantages in starting radiation as soon as possible or it doesn’t matter. My surgeon wants to see me in 2 weeks from now to do a PSA test.

Secondly, for my hypertension I am taking Norvasc, a calcium channel blocker, and some sites suggest stopping it, do you have any news on this? I also take Toprol for my hypertension.

I also am on a fish and omega 3 food diet but a new study suggest it actually has negative effect, do you have any suggestion?

Thank you in advance,

Abbas

*****

Arthur responded as follows:

Dear Abbas:

First, Arthur thinks it to far too early for you to be making decisions about whether you might or might not want to consider adjuvant radiation therapy after your initial RP. Unless you had a very significant (i.e., large) positive surgical margin, there are serious questions about whether you will ever need any form of subsequent radiation therapy at all. In addition, at your age, you need to be aware that having radiation therapy too soon after an RP will increase the probability that you may affect your chances of full recovery or continence and sexual functionality. Arthur suspects that if you talk to your surgeon he will tell you that you can afford to get at least two or three post-surgical PSA test results before you need to make any decisions about the need for radiation therapy. The most important thing you want to know first of all is whether your PSA has dropped to < 0.1 ng/ml.

Second, with respect to the Norvasc and the Toprol, you need to talk to your cardiologist about this, but Arthur is not aware of any good, general reasons why men treated surgically for early stage prostate cancer might need to alter their antihypertensive regimens. If you had been put on hormone therapy in addition to having the RP or radiation therapy, the situation might be different, but you aren’t, so stay on your current drug regimen and talk to your cardiologist about it if you feel you need to.

Third, with respect to your diet, Arthur thinks there is a lot of information and thousands of suggestions available about diet and very few really good facts. Arthur would point out that even today you are probably at greater risk from cardiovascular mortality than from prostate cancer mortality. Arthur suggests a good, mixed “heart healthy” (Mediterranean-type) diet and a regular exercise program. (These will also help your hypertension.) Any diet that over-emphasizes one particular food type is liable to come with its own set of problems. Just be smart: eat less, eat healthy, and eat better.

Thanks

Paul

Arthur responded as follows:

Dear Paul:

Arthur says he is not aware of any reliable information on the skill and experience levels of specific prostate cancer cryotherapists working in the USA. Your question would also need to take account of whether you are looking for someone with experience in focal cryotherapy (for first-line treatment of a very small and low-risk tumor); standard, whole-gland cryotherapy as first-line treatment; or salvage cryotherapy (as salvage treatment after first-line radiation therapy).

The only practical guidance that Arthur can really offer you is that many of the better cryotherapists are probably contributing data to the Cryo On-Line Data (COLD) Registry database coordinated by Dr. J. S. Jones who works at the Cleveland Clinic. The number of really experienced prostate cancer cryotherapists is still relatively small.

Arthur responded as follows:

Dear Alicia:

Arthur says that there are two basic categories of prostate cancer cell in men with progressive disease like your husband: hormone-sensitive cells that respond to drugs like Lupron and hormone-resistant cells that don’t. Your husband now has both of these types of cell in his body.

It has been standard practice for many years to maintain men like your husband, who have progressive, hormone-refractory disease, on an LHRH agonist like Lupron in addition to other forms of therapy. This is done to slow the overall progression of his disease by controlling the growth of the hormone-sensitive cells.

Arthur says that with the development of new drugs like MDV3100, we may find that this historic way of controlling the growth of hormone-sensitive and hormone-resistant cells with two different classes of drug may become unnecessary, but the relevant trials have yet to be conducted, and so yes, at present your oncologist is correct, your husband does theoretically need to stay on his Lupron.

Having said that, Arthur is aware of men with progressive disease who find that the effects of Lupron and similar drugs on their quality of life to be so distressing that they have stopped this type of therapy entirely or have asked their oncologists to switch them from Lupron-like therapy over to estrogen patch therapy (which can have similar clinical effects without necessarily the same adverse reactions). Arthur has no information on the long-term effects of stopping Lupron-like therapy in men like you husband. However, he is aware of at least a few men who have been able to do very well for a while on the estrogen patch therapy. These are issues that you and your hubsnad would really need to discuss with his doctors. Arthur is not in a position to recommend one or other of these strategies. He is simply informing you that he is aware of their use by other patients and their doctors.

Best regards

Mike (Feorais)

*****

Arthur responded as follows:

Dear Mike:

Arthur say that there are two quite separate things going on here …

On the one hand, you were originally diagnosed with Gleason 8, clinical stage T3b disease. Regardless of any form of treatment, this is a high-risk form of prostate cancer. No one can guarantee a “cure” based on a diagnosis like this. The question is only how long you will remain in remission and how fast your PSA might start to rise if/when it does start to rise.

On the other hand, your PSA is currently stable and you are off therapy. Your PSA might remain stable for months or for years. It is, however, probable that you are going to progress at some point in time. No one can tell you when, and that is why the “eminent oncologist” is telling you that “the cat is [almost certainly] out of the bag.” All that I can tell you is that I have seen men like you go for several years without significant recurrence … and I have seen men like you recur quickly and seriously. I don’t believe anyone can predict with any degree of accuracy what might happen in your specific case.

So Arthur thinks that the good news is that, as and when you need to, you are likely to respond well to a second and subsequent rounds of hormone therapy. Furthermore, there are now drugs coming available that will be usable after standard hormone therapy ceases to work. The way you need to look at this is that: (a) you are in good shape and off therapy and your PSA is stable; (b) if and when your PSA starts to rise, you will probably respond well to another course of hormone therapy; (c) this process could go on in cycles for years before you became castration-resistant, at which other therapeutic options would become available. There are some things you have no control over in life … but you also can’t agonize over this. It is just the way things are.

Arthur responded as follows:

Dear Chris:

Arthur says that that he is not actually aware of any significant, published data on the use of alcohol among men who have already been diagnosed with prostate cancer. For example, a study by Linsky et al. published earlier this year appears to give us no specific guidance about alcohol use among prostate cancer patients.

There are, however, several studies that have shown that risk for diagnosis with prostate cancer appears to be slightly higher among men who have higher levels of alcohol consumption (see, for example, this paper by Breslow et al.)

Having said that, Arthur would suggest that two things are important here:

(a) “Everything in moderation” is a good principle to work by, so a glass of wine or a beer a day is probably not a problem — but regular, serious drinking is just not a great idea anyway.

(b) You should ask your doctor or pharmacist whether any drugs you may be taking suggest the avoidance of alcohol. Your biggest risk if you are only a light drinker anyway is likely to be because of an interaction between alcohol consumption and a specific drug or drug combination leading to side effects of some type.

I met with my consultant oncologist 3 weeks ago and he disagreed that I needed any further assessment and will see me again in a year unless the PSA should start to increase again. You will see from my first letter that I had T3b disease (seminal vesicle involvement), Gleason 8, with a PSA of 6.7 ng/ml when first diagnosed nearly 4 years ago.

Do you think I have any need to be concerned or is the fact that my last four 3-monthly PSA tests have remained the same cause for real optimism?

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Arthur responded as follows:

Dear Mike:

Arthur says that your PSA has clearly stabilized again. This happens. This could have nothing to do with prostate cancer. It may reflect regrowth of a small amount of perfectly normal prostate tissue that was not completely killed by the radiation therapy, for example.

Your PSA level has effectively gone from 0.1 after your initial radiation therapy to 0.3 ng/ml today over a period of about 4 years, this is a very slow PSA doubling time, and therefore a good sign. Arthur suspects that you really do not need to see your consultant again for a year unless, as he says, your PSA starts to rise again. So … It would probably be a good idea to just keep getting the PSA test done every 3 months by your primary care doctor. If it’s still 0.3 ng/ml a year from now, then maybe every 6 months would be enough, but you should dioscuss that with the consultant.

Arthur responded as follows:

Dear Leo:

Arthur says that there are several factor that you need to consider and discuss with your doctors before making this decision. They include, but are not limited to:

– Your age
– How fast your PSA is rising (the so-called “PSA doubling time”)
– Your pathologic stage and your pathologic Gleason score at the time of your original surgery
– Whether you did or did not have positive surgical margins after your original surgery
– Where the recurrence seems to be

So Arthur thinks that the bottom line is that the younger you are and the more aggressive the disease recurrence seems to be, the sooner you should probably consider salvage radiation (with or without a short course adjuvant hormone therapy), but it is also important to try to determine whether the recurrence is limited to the prostate bed and surrounding area of the pelvis. If the recurrence is a distant recurrence, then radiation of your pelvis is unlikely to be particularly helpful.

I am worried that my DH (dear husband) is lying to me. When we married a few years ago, we were intimate. After the marriage, no intimacy. Last week, he came up with this story of having an ofranectomy (not sure if this is spelled right, or the correct term … he has claimed he had his prostate removed). He does have a family history of prostate cancer (his dad and his brother died from it). Is there a way to find out (or what questions should I ask him) so that I might REALLY know if he has had this surgery? I need proof that this happened. Please help!

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Arthur responded as follows:

Dear Jacie:

Arthur is a little puzzled by your question, so he thinks we need to try to clarify a couple of things first.

There are TWO forms of surgical treatment for prostate cancer.

The most common one is known as a radical prostatectomy, in which the surgeon removes the patient’s prostate through the abdomen. This type of surgery inevitably leaves scars: either a single vertical scar in the center of the lower abdomen or a set of three to five smaller “holes” in the lower abdomen if the surgery was done laparoscopically. In either case it takes the patient time to recover from this surgery, and while it might be possible for a spouse not to know that such surgery had happened, it would be hard to hide.

The second form of surgery is orchiectomy — the surgical removal of a man’s testes — which is usually only done when a man has been diagnosed with more advanced forms of prostate cancer. For a variety of reasons this may be less obvious, and Arthur supposes that it might be easier for a man to hide it because the surgery can be done in ways that may it less “obvious.” It has not escaped Arthur’s notice that “orchiectomy” sounds a lot more like what you described as “ofranectomy”. There is no such thing as “ofranectomy” that Arthur is aware of.

Do surgeon’s operate on men for prostate cancer when they have no evident symptoms of their disease? Yes, all the time. The best way to prevent progressive prostate cancer is to find and treat it early — before the patient has any symptoms. Arthur is aware of a few men being treated even before there was any clinical evidence of the presence of disease because of a family history of aggressive prostate cancer (in the same way as some women with a family history of aggressive breast cancer may decide to have a prophylactic mastectomy).

The real issue here, however, is the fact that you and your husband are having some sort of communication breakdown. That could be happening for all sorts of complex reasons, but clearly he doesn’t seem to want to talk about the issue and you haven’t found a way to “get through” to him to get your questions answered in a satisfactory way. This may require some real work on your part because your husband may also be very emotionally distressed by whatever it is that he may have felt he needed to do. Many men have very real problems accepting the consequences of prostate cancer treatment — particularly if and when loss of sexual function is one of those consequences. If your DH was always the “strong silent type” anyway, he may be having an even harder time dealing with this than most.

Arthur does not know enough about the nature of the relationship between you and your DH to be able to give you much specific help, but it is clear that you and he do need to find a way to talk to each other honestly about whatever has and is happening. Arthur does not believe it is a good idea for you to start from the idea that your husband may be lying to you. It is much more likely that he simply finds whatever has happened extremely difficult to talk about. Somehow you need to find a way to sit down with him quietly, make sure he understands that you are worried about him (as opposed to you or anything else), and try to get him to actually talk to you about what has happened and what you can do to help him.

PS … Arthur has tried to address all the issues that you brought up in both the questions you left on the InfoLink site, so you should not expect a second answer from Dr. Krongrad. He would only be giving you much the same answers.

Arthur hopes this is helpful.

Thank you for your clarification.

Paul

Thank you for your response. I contacted Dr Tom Pickles of the British Columbia Cancer Center and he informed me that for radiation-treated patients they only use PSA values greater than 1 in calculating doubling time. I do not see why I have met the definition of biochemical recurrence using the Phoenix criteria.Would not the PSA have to be greater than 2.2 (nadir + 2) ng/ml.

Thank you.

Arthur responded:

Dear Paul:

First, Arthur apologizes, clearly he was having a “bad math” day yesterday. You are correct, you have not met the definition of biochemical recurrence based on the Phoenix criteria. (Arthur misplaced a decimal point in his head and added 0.2 to 0.2 instead of 0.2 to 2.0. You would indeed need your PSA to rise to 2.2 ng/ml before you met the Phoenix criteria.)

Second, Arthur says that different groups have different opinions about exactly how to apply PSA doubling time data. Arthur is sure that Dr. Pickles and his colleagues have good reasons for only considering PSA values > 1 ng/ml in evaluating PSA doubling times. Remember that there is a big difference between data and decisions about what to do based on those data. What Arthur thinks Dr. Pickles is actually telling you is that they “only use” PSA values > 1 ng/ml in calculating doubling times because they are not certain that doubling times in men with PSA values < 1 ng/ml are clinically significant in men treated with radiation (and therefore would not change their decisions about what to do with a patient with a PSA value < 1 ng/ml). That doesn't mean that keeping an eye on your PSA doubling time is irrelevant to you as an individual. However, Arthur would tend to agree with Dr. Pickles that actually "doing" anything until your PSA was significantly greater than 1 ng/ml was probably not the best idea anyway.

Thank you very much for your prompt response to my question regarding the Phoenix definition of biochemical failure. I was treated for prostate cancer 4.5 years ago with IMRT and 4 months of ADT for an intermediate risk cancer. Not counting the first PSA (which was less than 0.1 ng/ml) as I was still under the influence of ADT, my PSA has bounced from a nadir of 0.2 to 0.54 in the last 4 plus years. My radiation oncologist has not ordered testosterone tests along with my PSA. Do you not think that the testosterone level should be monitored as well?

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Arthur responded as follows:

Dear Paul:

Arthur says you could certainly ask your physician about getting assays of your serum T levels at the same time as he is getting the PSA tests done. However, Arthur is not at all clear what you are expecting the serum T levels to tell you or your doctors.

It would be reasonable to assume that — since the brief exposure to ADT back in 2007 or thereabouts — your serum T levels have fully recovered and are back in the normal range. Furthermore, over a period of 4 years, your PSA has little more than doubled, which is hardly likely to be a signal of an aggressive recurrence of prostate cancer. (Your current PSA doubling time is probably somewhere around 3 years based on the data you have provided.) Technically your cancer has met the definition of biochemical recurrence according to the Phoenix criteria. Clinically, however, Arthur can quite understand why your physicians would be recommending that you just continued to monitor your condition (although your age and other health issues would also be important in making these decisions).

The currently available options for further treatment really come down to just two at this time: (a) enrolling in a clinical trial of HIFU as salvage therapy (which would require a biopsy-proven local recurrence) and (b) hormone therapy of some type. In neither case is your current serum T level relevant to the decision to take any action. (The theoretical option of salvage surgery would hardly be appropriate in a case like yours because the potential risks almost certainly far outweigh the possible benefits.)

Arthur thinks that — unless you have symptoms suggesting the possibility of disease recurrence — your “best bet” is just to continue to monitor your PSA and also your PSA doubling time. If the PSA doubling time starts to fall down to below 12 months, then it would probably be time to think seriously about hormone therapy. You could ask your physicians about the possibility of enrolling in a trial of salvage HIFU and therefore whether a biopsy to identify the presence of any recurrent prostate cancer could be established. The clinical value of such therapy, however, is open to considerable question in a case like yours.

With a PSA level that is still this low 4.5 years after IMRT, Arthur would point out that this could simply be due to regrowth of a small amount of non-cancerous prostate tissue since the original radiation. In that case, no therapy would be either indicated or appropriate.

—–

Arthur responded as follows:

Dear Paul:

Arthur says that that he is not exactly enthusiastic about either of the two “standard” definitions of biochemical failure used in the USA after first- or second-line treatment of prostate cancer with radiation therapy. There are all sorts of problems with the clinical application of both the Phoenix criteria and the earlier ASTRO criteria. However, …

The real problem is that no one has been able to come up with anything better! The surgical community (every so often) will try to use the argument that if radiation therapy was actually any good as a first-line therapy, then the PSA would drop to zero after radiation. But that is a silly argument because there is still tissue left in the prostate after radiation, and some of it almost certainly survives the radiation. If it is not prostate cancer tissue, then its continued existence as living tissue is fine … but it is going to produce some PSA.

The fact of the matter is that we need something much better than a PSA test to be able to assess the biochemical recurrence of prostate cancer after any form of treatment. A test that is specific to prostate cancer and not just to the presence of PSA. In the meantime, Arthur thinks we are stuck with the Phoenix criteria — whether we like it or not. They are, after all, generally considered to be an improvement over the ASTRO criteria.

Think about it, if we had a test that was specific to prostate cancer, then it would work regardless of therapy type (surgery, radiation, HIFU, cryotherapy, you name it).