Estimation of life expectancy for newly diagnosed men with prostate cancer

A critical question for every patient newly diagnosed with prostate cancer is going to be, “How long am I going to live”? That question may be particularly important if a second and associated question is, “How long am I going to live if I just monitor my cancer on active surveillance or watchful waiting?”

We know that many men with low-risk and even “favorable” intermediate-risk prostate cancer can be managed for significant periods of time on active surveillance before treatment actually becomes necessary (if it ever does) and that selected men with more aggressive or more advanced disease may be able to delay initiation of treatment because they have a limited life expectancy on account of their age at diagnosis or because they have other significant health issues. However, there has never been a simple tool available that a newly diagnosed patient could use to give him a reasonable estimate of how long he is likely to live and that took account of his prior and existing health issues in addition to his age.

A newly published paper by Kent et al. (available as a full text article in the journal BMC Medicine) describes the validation of a model that now provides us with just such a tool for newly diagnosed men with localized, lymph node negative prostate cancer. And better still, the creators have made this tool available as a “plug and play” tool on the Memorial Sloan-Kettering Cancer Center web site (click here, scroll down, and then click on the heading “Male Life Expectancy” or just click here). To use the tool, you will first be asked a number of questions about your health, your age, and your diagnosis with prostate cancer, and then those data are used to project your risk of death from prostate cancer and from other causes at 10 and 15 years after diagnosis.

For complex reasons this tool is not perfect. Few such tools ever are. But the authors have been able to show that their model does provide a good and reasonably accurate projection of life expectancy for most reasonably average men being diagnosed with localized prostate cancer. (Note that it can not be used by men who are diagnosed with node positive or evident metastatic disease.) The men for whom it may be less accurate are likely to include those who have hereditary forms of prostate cancer (e.g., because they are carriers of the BRCA1/2 genes) and those who have a long family history of male longevity.

Rather than get into the details of how the tool was created and validated (which are all available in the article itself), what we are going to offer in the rest of this article are three examples of what the tool can tell us.

So your sitemaster does not have prostate cancer; he will shortly be 68 years of age; he has a long smoking history (from the ages of about 16 until he was 47); he has a cardiovascular stent because of an acute myocardial infarction 10 years ago; and he takes drugs to manage his cholesterol levels. Other that that, he’s in pretty good shape for his age! So let’s assume first that he gets diagnosed with low-risk prostate cancer tomorrow (clinical stage T1c, PSA 3.7 ng/ml, Gleason score of 3 + 3 = 6). Here’s what the life expectancy tool tells him:

Screen Shot 2016-02-16 at 9.36.35 AM

In other words, out of 100 other men like the sitemaster, if they got no treatment for the prostate cancer, by February 2026, 50/100 would still be alive, just 2/100 would have died of prostate cancer, and 49/100 would have died of other causes. Similarly, by February 2031, just 27/100 would still be alive, 3/100 would have died of prostate cancer, and 70/100 would have died of other causes. Your sitemaster has noted before that if he got such a diagnosis tomorrow, he would not seek immediate treatment but would get himself on to a good active surveillance program (one that included annual multiparametric MRIs as opposed to annual biopsies). These data help to validate that decision.

Now if your sitemaster was unlucky enough to be diagnosed tomorrow with much more advanced disease (clinical stage T2b, PSA 32 ng/ml, Gleason score 4 + 4 = 8), but no immediate evidence of either positive lymph nodes or metastasis, the life expectancy tool tells him:

Screen Shot 2016-02-16 at 9.42.45 AM

By February 2026, again if they got no treatment for the prostate cancer, 37/100 similar men would still be alive, 15/100 would have died of prostate cancer, and 48/100 would have died of other causes. However, by February 2031, just 12/100 would still be alive, 18/100 would have died of prostate cancer, and 70/100 would have died of other causes. In other words, if I got no treatment I’d be more likely to have died of prostate cancer within 15 years as I would of still being alive. That doesn’t look like a very good bet. I’d get treated!

The third scenario is particularly interesting, however. Let’s assume your sitemaster was diagnosed with a small amount of unfavorable, intermediate-risk prostate cancer (clinical stage T1c, PSA 4.2 ng/ml, Gleason score 4 + 3 = 7). Then the tool tells him the following:

Screen Shot 2016-02-16 at 9.47.07 AM

By February 2026, again if they got no treatment for the prostate cancer, 46/100 would still be alive, 6/100 would have died of prostate cancer, and 48/100 would have died of other causes. Similarly, by February 2031, just 22/100 would still be alive, 8/100 would have died of prostate cancer, and 70/100 would have died of other causes. In all honesty your sitemaster has to wonder whether getting immediate treatment for a small amount of even unfavorable risk prostate cancer in one’s late 60s with his sort of health history is worth all the hassle — but that’s a very personal decision (as, of course, they all are).

Remember, this tool is only valid for newly diagnosed patients with localized disease (TxN0M0) who have had no treatment. However, what this tool does do, in particular, is help such newly diagnosed men to determine whether active surveillance or watchful waiting is or is not a reasonable idea for a specific patient — based on his age and some important elements of his health history over the years.

40 Responses

  1. Encouraging Numbers and Scenarios — Useful Tool

    I have not had a chance to read the references yet, but one highly encouraging aspect of the first and third scenarios stands out: the mortality numbers due to prostate cancer are predicated on the patient getting no treatment. That is clearly a watchful waiting approach, and to me it just does not make sense unless the patient has other health conditions that are very threatening.

    For the patient who chooses active surveillance, as Sitemaster implies, it will become quite clear if and when treatment is needed, and sound treatment will be virtually certain to improve the odds even over the already encouraging odds in the original scenario forecast, with the result that it should be extremely unlikely — closing in on a probability of zero — that the patient would die of prostate cancer.

  2. Dear Jim:

    Let me be very clear that the authors of the paper are not, under any circumstances, suggesting that a patient doesn’t get treatment if it becomes evident that treatment is needed. The entire point of the paper is that it helps patients (and their doctors) to get a much clearer idea of if, whether, and when, treatment is actually needed. For example, there is near to no point at all in getting treatment for low-risk, localized disease if you have a life expectancy of only 10 or 15 years. You should just be monitoring the situation and reconsidering your options if your PSA is rising and a repeat biopsy were to show that your Gleason score had also changed. But if by then your life expectancy has dropped to only (say) 5 years, it might still make no sense to get treated for something that’s not going to kill you.

  3. Applying the Tool to My Own Case as it was at Diagnosis

    Here are the results, based on my circumstances at diagnosis: age 56, mild asthma, stage T3, Gleason 4 + 3, PSA 113, and no “treatment intended to cure” the cancer.

    — At 10 years 62 men would still be alive, but 27 would have died from prostate cancer (11 other causes).
    — At 15 years 45 men would still be alive, but 35 would have died from prostate cancer (20 other causes).

    I conclude that it’s wise that I got treatment, though for 13 years the intent was to “control” rather than to “cure,” a strategy not exactly matching the nomogram.

    I found this an easy tool to use –- not many questions, and all made sense as predictors; also, most of us will know the answers in our heads about these major characteristics of our health history.

    I look forward to reading the linked paper.

    PS: I certainly agree with Sitemaster’s comment.

  4. I wish the nomogram clearly addressed the question of how many men will progress to uncurable status (albeit not death) at different times during the 10- and 15-year periods. It is one thing to do active surveillance as a 68-year-old with very low risk disease and good general health for some years, but what are the statistics for how long the curable window might be open, versus management with its own side effects.

  5. Dear Kas:

    We would like to be able to see methods to predict that sort of information as well, but to do that accurately would require sophisticated analysis of data from tens of thousands of patients on whom all data had been collected in a standardized manner over the best part of 20 years … and data like that just don’t exist yet — although they are beginning to become much more available in countries like Sweden and Australia and the UK.

  6. Hi kas,

    While we do not have absolutely conclusive data yet for untreated men yet, as Sitemaster notes, a huge (or “yuge”) point about active surveillance is that it has proven highly effective at catching stealthy aggressive cancers at a time when cure is still virtually as likely as with initial treatment, thereby enabling timely treatment. Therefore, assuming the surveillance is soundly done (which means actively), the percentage of men progressing to incurable cancer is going to be tiny. This is based on now long-term active surveillance series at at least seven major cancer treatment centers around the world, which you can review via (University of of Toronto, Sunnybrook/Dr. Laurence Klotz; Johns Hopkins University/Dr. H. Ballentine Carter; Erasmus Medical Center/Dr. Fritz Schröeder; Memorial Sloan-Kettering Cancer Center/Dr. Peter Scardino; UCSF/Dr. Peter Carroll; M. D. Anderson Cancer Center/Dr. Richard Babaian; Royal Marsden Hospital).

    My impression from reviewing published active surveillance research is that the percentage of patients who progress to incurable cancer is about the same as the percentage for patients getting immediate treatment for similar cases. Moreover, active surveillance technology is steadily improving.

  7. Hi Jim:

    Many thanks for your take. I am a patient of Dr. Carter at Hopkins.

  8. Hi again kas,

    You’re welcome!

    I was a speaker escort for Dr. Carter at the 2005 conference on prostate cancer that was held in Washington, DC. (With the sharp eyes of a surgeon, he actually spotted a rat as we walked through the food serving area backstage toward the speaker waiting area.) The Johns Hopkins AS program was one of the first to publish results, as you may know.

    Is Dr. Carter still asking you to get annual biopsies? Some AS programs believe they can maintain excellence with fewer biopsies, and I’m curious whether Dr. Carter is taking that view now that more than a decade of additional follow-up has accumulated for his AS program since their initial publications on AS (then referred to as “expectant management”) in 2002.

  9. “In all honesty your sitemaster has to wonder whether getting immediate treatment for a small amount of even unfavorable risk prostate cancer in one’s late 60s with his sort of health history is worth all the hassle.”

    Indeed and that’s before considering that immediate treatment will only reduce your prostate cancer death risk by 30% at best, let alone improve overall survival, even if you cherry-pick the best two country results from the ERSPC.

    One really important issue you have left out of the above discussion is that the benefit of immediate treatment compared with alternatives is still highly uncertain and has still not been proven, even with the relatively higher prostate cancer death rate cases.

  10. jimwaldenfels: “with the result that it should be extremely unlikely — closing in on a probability of zero — that the patient would die of prostate cancer.”

    I have to point out that that is a very naive claim. Results from the ERSPC show that a lot of men who go through PSA screening and treatment still die from prostate cancer many years after screening begins. Not the same as years after treatment, but still indicative of long-term risk of prostate cancer death.

  11. Yes David. … But then if you run the estimator for a 55-year-old man diagnosed with unfavorable intermediate-risk prostate cancer (clinical stage T1c, Gleason 4 + 3 = 7, PSA 6.0) who is otherwise in good health (i.e., none of my cardiovascular history), you get a very different set of data suggesting that his risk for death from prostate cancer at 10 and 15 years if he has no treatment is actually as high as his risk of death from all other causes. I don’t think you are suggesting that such a man shouldn’t have treatment — are you?

    My point was that increasing age and increasing comorbidity at time of diagnosis makes monitoring a very reasonable option for many older males with even unfavorable intermediate-risk disease.

  12. Hi Jim:

    I have been a Hopkins AS patient for 2 years with Dr. Schaeffer, who recently left Hopkins. I sought out Dr. Schaeffer initially for robotic surgery, but he counseled me to do AS with curative intent. The Hopkins protocol has been annual biopsy and my first at Hopkins (second overall) was a year ago after a multiparametric MRI which I know some AS programs are relying on to slow biopsy frequency.

    I met with Dr. Carter for the first time last month as my new Hopkins doctor. As to your question, Dr. Carter did mention to me that Hopkins is beginning to think positively about fewer biopsies. He told me, for example, that he would schedule me this summer, which is some 6 months later than initially indicated and depending on results, maybe not again for 2 years.

  13. Hi David,

    I have what I hope will be some very good and reassuring news for you.

    The critical point you missed in your post, the missing key element in your excerpt of my statement, is the context of active surveillance. Here is what I stated originally:

    “… For the patient who chooses active surveillance, as Sitemaster implies, it will become quite clear if and when treatment is needed, and sound treatment will be virtually certain to improve the odds even over the already encouraging odds in the original scenario forecast, with the result that it should be extremely unlikely — closing in on a probability of zero — that the patient would die of prostate cancer.”

    You have mixed apples and oranges: the extremely low odds of death from prostate cancer to which I referred are for soundly done active surveillance, and not for men diagnosed as participants in either arm of a screening trial, in this instance — the trial you reference in your post, the ERSPC. I have been studying the ERSPC for many years now, intently devouring each update, and pointing out major flaws in interpretation from the original report that featured 9 years of follow-up since trial entry (as contrasted with time from diagnosis, a critical point that I have been pounding on since the time of publication in 2009). I have complete copies of the major papers relating to that trial. Therefore, if you have further questions following this post, I can most likely answer them for you. But enough about my credentials (no enrolled medical education; long-time student in the School of Hard Knocks).

    Consider this about the men dying in the ERSPC. First, there is a substantially lower proportion of deaths in the screening arm than in the control arm. This difference becomes far more pronounced when non-compliance and contamination are eliminated –- basically counting men who are actually screened or not screened versus their randomized assignment, and after focusing on the countries where results are based on better procedures. (For instance, France did not have substantial enrollment in the early years, effectively starting much later than other countries, and Belgium ran short of funds for screening sometime after the initial screen; on the good side, Sweden screened every two years instead of the porous four year gap for other participants, the long gap effectively missing some aggressive cases.)

    But more to our issue here, a large proportion of deaths in the screening arm of the ERSPC likely came, at this point where the trial is still effectively immature, from men diagnosed at the initial screening with cases that were already challenging. This group has sharply different, less favorable case characteristics than men entering soundly done active surveillance. You can visualize men like me -– first PSA test at age 56 and a result of 113 with a short doubling time of 3 to 4 months -– being diagnosed in the ERSPC, with substantial odds of not making it to that initial 9-year point. You can also visualize men diagnosed with already detectable distant metastases in that screening arm group who have died. Remember also that most of these men, due to what was available as treatment when they were diagnosed, would not have had the benefit of the slew of drugs for advanced prostate cancer that have been approved in the past few years.

    All this contributes to the conclusion that well-done intelligent PSA testing, in combination with active surveillance when appropriate, is going to result in great improvement in survival for prostate cancer patients. I hope you find this reassuring.

  14. Thanks kas for your informative update about changes to the AS approach at Johns Hopkins.

  15. Many thanks for the Sitemaster for spotting and presenting this important article and remarkable prediction tool. It is important to keep in mind that the 10- and 15-year estimates are not exact, though I’m not sure how the confidence intervals around a given mortality rate could be conveyed. The predictions were derived from pooling very large data sets and models, including actuarial life expectancy developed by life insurance companies, Social security administration life tables, and outcome data from six of the SEER cancer registries. The tool and the very easily interpreted graph display of outcomes are remarkable contributions, and will make discussions of AS vs. treatment far easier for urologists and patients. The usual presentations of survival curves and lengthy tables of odds ratios are pretty much impossible to apply to a particular case, even for someone used to these sorts of data presentations.

    The next question a patient would have after seeing these displays is how much immediate treatment will reduce the mortality rate compared to AS. It would be very helpful to have a similar tool to generate predictions of prostate and other mortality at 10 and 15 year intervals after standard treatments (e.g. prostatectomy, IMRT). An identical graphic display would allow immediate graphic comparisons.

    Of course, there’s no escaping that fact the entire decision process will remain probabilistic. The matrix of outcomes has to be interpreted within one’s own values and risk tolerance. But the information a patient has access to in 2016 is so much better than that available even a decade ago.

  16. Available Research on Results of Active Surveillance Vs. Immediate Treatment, and Related Issues

    Hi Brian,

    There has actually been what at least to me is an impressive amount of research regarding your question “How much immediate treatment will reduce the mortality rate compared to AS,” with a concise study of key data presented in a complete document linked by Sitemaster recently under this heading: “ASCO generally endorses Canadian guidelines on role of active surveillance,” as follows. This is a long document, but go to Table 2 in the actual document referred to by Sitemaster and the immediately preceding text on pages 23 and 24 for the data.

    Some of us have been following work of the team led by Dr. Laurence Klotz, MD, of Toronto, for years, as their now large group of AS patients enrolled its first patient way back in 1995, now more than 20 years ago; it’s a virtual certainty that Dr. Klotz played a prominent role in developing the Canadian guideline.

    You asked about estimation of prostate cancer mortality versus other mortality. Dr. Klotz has emphasized this informative statistic over the years, and the Canadian document mentions it on page 23. Take a look at these eye-popping numbers in the text on page 23: “The hazard ratio (HR) for non-PC to PC mortality [remember, these are for active surveillance patients, not for all prostate cancer patients] was 18.6 at 10 years and the risk of non-PC mortality was higher in men > [greater than] 70 years of age compared with men < [less than] 70 years of age (HR 33.3 vs versus 8.76).<sup.13” In other words, for men older than age 70, the likelihood of other causes of death was 33.3 times higher than death from prostate cancer! Also, the odds of dying of other causes even for men younger than 70 were still 8.76 times greater than death from prostate cancer! (Reference 13 is this 2012 paper by Dr. Klotz. The link provides an associated link to a free copy of the complete paper.) It is worth bearing in mind that at least the Klotz group of patients included a fair proportion who had intermediate-risk disease, yet they still did awesomely well!

    I was not a suitable candidate for active surveillance, so I cannot give you first-hand experience about deciding whether active surveillance is appropriate. However, I am convinced that, because the research information is so compelling, so clear, the decision to choose active surveillance for an appropriate and informed/empowered patient should be pretty much a no-brainer in 2016.

  17. Puzzled by Apparent Absence of PSA Doubling Time in Tool

    PSA doubling time has been a great contributing discriminator between non-lethal and lethal prostate cancer in some important studies, with those with really short PSA dpoubling times having far less favorable odds of survival than other patients. (Though such patients should now do relatively better with the aid of technology advances.)

    I am puzzled that PSA doubling time does not seem to have been considered in the model described in this article; PSADT is not one of the pieces of data required by the tool. It may be that the authors were focusing on localized cancer, as Sitemaster reports, and perhaps they were mainly trying to help men decide whether active surveillance or watchful waiting were wise strategies. Men with short PSA doubling times would soon pass beyond the localized phase where this tool is appropriate, so there would not be many men in this group. Still, I’m uncomfortable with what looks to me like omission of an important clue for these few. For a brief time I would have been one of these few, and I would have been damn angry if I had been mislead in the early period of my case.

    Any thoughts?

  18. Dear Jim:

    That’s an easy question to answer. Even if the research team had wanted to do this, detailed and reliable long-term PSA data prior to diagnosis would not have been available for most of the patients in either the modeling cohort or the validation cohort, so it wouldn’t have been possible to use such data to include in the model or to validate the model.

    The tool is not ideal for all sorts of reasons, of which this is just one. The tool should not be used exclusively to make decisions about whether a man should or should not have active surveillance as opposed to treatment. It is just one of a number of helpful components … along, for example, with a multiparametric MRI prior to a repeat biopsy within the first 12 months after diagnosis.

  19. Dear Sitemaster,

    Thanks again.

  20. I’m coming to this late. I ran my data through the tool, including GS 3 + 4, which generated prostate cancer mortality estimates of 8 and 13 out of 100 at 10 and 15 years, respectively. Out of curiosity, I plugged in 4 + 3 and got the same results. Looking at the related paper, the authors express intent to improve the tool, which currently does not differentiate between the two grades, by so distinguishing. I have read sources estimating a risk difference on the order of 300% between the two. Which, extrapolating, I assume would yield a prostate cancer mortality risk of around 3 at 10 years for 3 + 4.

  21. Cliff:

    Optimism is good. On the other hand, I think you need to be rather cautious about that 300% estimate!

  22. 300% seemed overly optimistic. Any opinion on a realistic difference given current knowledge? Whatever it is, was enough for my doctor to recommend AS. He said he would not had I been 4 + 3.

  23. Cliff:

    Your Gleason score isn’t the only issue, but …

    Active surveillance is almost never suggested for men with a Gleason score of 4 + 3 = 7, and it is only usually recommended for men with Gleason score of 3 + 4 = 7 if they also have a percentage of positive biopsy cores < 50 percent, and a clinical stage of T1c or T2a and a PSA level of < 10 ng/ml.

    Do I want to put a percentage increase in risk to this? In all truth, no, I don't. I don't think it is meaningful. I think that the important thing is that you and your doctor monitor your status with care and attention so that if there is any sign that treatment may become an option to be considered, you catch it and consider that opportunity as early as reasonably possible.

    In someone with a Gleason score of 3 + 4 = 7, active surveillance really is a way to look at deferring the need for treatment for as long as possible, rather than as something that you may be able to use to manage the cancer for the rest of your life.

  24. Mike, thanks. In the final analysis what matters is obviously one’s own case, which is discrete from any statistical averages or probabilities.

  25. Hi,

    I am in the UK and I really would appreciate some advice.

    Early in February, I was diagnosed with prostate cancer and, on the basis of a PSA blood test results of 94, and a DRE, I was told by my urologist that I had terminal prostate cancer that could not be cured, and that I would not be offered radiotherapy either. This diagnosis was made, even before I had had a biopsy, or any scans.

    He put me immediately on bicalutamide 150 mg once a day.

    In view of the diagnosis, that I was pretty much a dead man, I refused to have a biopsy because I saw no gain whatsoever for me and didn’t fancy the pain and possible side effects. Since then, I have had a nuclear full body bone scan, and a chest, abdomen and pelvis CT scan, these both came back clear, showing no spread. They then gave me an MRI scan of the prostate and it has been graded PI-RADS 3-4, with the seminal vesicles clear.

    Although they think I probably have microscopic spread of the disease, as they cannot see it, they are now offering me the chance of curative therapy, but refuse to let me have radiotherapy, or enter any drug trials, unless I have a biopsy.

    I had more or less decided to stay on Hormone therapy in it’s various forms for the rest of my life and not risk the biopsy or radiotherapy. I am 72 years old, and already have a stent in one artery, but am otherwise fairly healthy. The hormone therapy so far is not giving me any unpleasant side effects to bother about, and I am due my first PSA blood test, since being treated, during the first week in May.

    I am really torn as to what to do. I set myself a target of living for another 5 years with decent quality of life, and I wonder if that’s likely by just staying on hormone therapy alone or do I really need to have radiotherapy and hence the dreaded biopsy. I would rather live a shorter time with good quality of life than many years with poor quality as a result of the various side effects from radiotherapy, etc.

    Can you give me any idea if my life expectation of 5 years is realistic or am I losing many years of life by staying on hormone therapy alone.



  26. Dear Terry:

    (1) I really think you should have the biopsy because until you have the biopsy we really don’t know how aggressive your cancer is.

    (2) We can worry about the radiotherapy and the clinical trials and other factors once we find out what your Gleason score is based on your biopsy.

    (3) I think you could easily live for 5 years on the hormone therapy alone, with a good quality of life. The thing is, you might easily live for another 10-15 years with a good quality of life if we can find out what the best therapy might be for you!

    (4) Tell someone on the clinical team you want to be looked after by the medical oncologist rather than that urologist. He didn’t give you good advice in the beginning. Was it possible that you had incurable prostate cancer? Yes, it was. Is it possible that you still have curable prostate cancer? Yes, it is. It’s not likely but it is possible. That’s why you need the biopsy, and if it is done properly and carefully by someone who is appropriately skilled then it really shouldn’t be that big a deal. Ask them if you can please have some form of local anesthetic prior to the biopsy.

    (5) Please join our social network, where it will be a lot easier to discuss the management of your condition over time with you individually, and to tell you about what to ask the doctors and other similar things.

  27. Dear Terry,

    Here’s a brief note just to back up what Sitemaster wrote.

    In the month of December I had my first ever PSA and it came back at 116 ng/ml, and the next morning a urologist did a DRE, finding a “rock hard” prostate. He was very pessimistic with my wife, out of my hearing. He did the biopsy within 2 weeks, and that indicated a Gleason 4 + 3 = 7 cancer, all cores positive, most 100%. Two respected urologists I consulted at well-known institutions told me I probably had a life expectancy of three good years and two declining years.

    The key point is that that fateful PSA test was in December 1999. I was on advanced androgen deprivation therapy for many years, but by the early years of this decade imaging and radiation technology had advanced enough that it looked like I might have a shot at a cure. After radiation in 2013, I have had excellent PSAs, none higher than less than 0.05. It is still on the early side, but I have good prospects of a cure.

    I hope you can find some good doctors to help guide your care, not including that initial urologist.

    Good luck.

  28. While your PSA of 94 is certainly a strong indication of metastases (and I agree that a biopsy is unnecessary if that is true), it is not definitive. I think it will be almost impossible right now to give you a good diagnosis — with or without a biopsy. The reason is that the 150 mg bicalutamide shrank the cancer and may have rendered what is there undetectable. You should have been given the scans before you were started on hormone therapy. I think your best course of action is to start the process over. You will have to come off the bicalutamide first, let your PSA rise, and then have a bone scan and CT. That should be first. If that detects metastases, you should begin on Taxotere therapy and restart hormone therapy. If it fails to detect distant metastases, your cancer may be curable. Then it may be time to have a biopsy, which may help determine which kind of therapy is best suited to your specific situation.

  29. Dear Allen:

    While you are right in theory, and ideally Terry could “go back” to baseline and start again, from a practical point of view I’d be very surprised if his doctors were willing to let him do that now. It may not even be practical anyway, because it would take too long for his cancer to return to a baseline state (if it even did).

    My suspicion is that the best thing he can do is get the biopsy done.

  30. The problem with a biopsy while on bicalutamide is a false negative. The hormones have shrunk the cancer there but not eliminated it, and reading a Gleason score off of a hormone-treated prostate is difficult if not impossible — it alters the cell architecture. Going off bicalutamide is really no different from intermittent ADT, which doesn’t seem to be worse than continuous.

  31. Thank you all for the kind advice. I have decided to take the advice from sitemaster and have the biopsy.

    I had a long chat to my oncologist nurse today and he convinced me of the benefits. As he knows I am terrified at the thought of the biopsy, and as they have an MRI scan showing the cancer, they have offered me a six-needle biopsy which will help a lot, I think.

    I know it will still be unpleasant but it will open doors for future treatment that I wouldn’t be eligible for if I don’t have it.

    I will let you know how I get on.



  32. Allen:

    I understand the issue. I just think you are thinking like a scientist as opposed to thinking like a doctor with a worried patient.

  33. I just stumbled on this nomogram. In my case there was no change in number of men dying of prostate cancer when I changed to stage from T1c (at biopsy) to T3 (at pathology). This seems odd, no?

  34. Dear Robert:

    Not necessarily at all. It would depend on all your other data.

  35. I was diagnosed with high-volume, high-risk prostate cancer with a Gleason score of 7 on October 21, 2013. (I had just turned 50 that year, and it was my first annual medical check-up.)

    My family doctor informed me that my PSA reading was 11.9. I was subsequently referred to see an urologist who ordered a biopsy and CT scan, and I went for both. So, on October 21, 2013, I was told by my urologist that I had Stage IV prostate cancer but I had no symptoms at all. I was frightened by his diagnosis, and was rushed into having a radical prostatectomy 10 days later on November 1, 2013. I had made that decision based on the urologist’s recommendation that I would be dead within 6 months or 3 to 5 years at the most and what a mistake I had made because I had believed his recommendation.

    If I knew then what I know now after reading many articles, including this one, on prostate cancer, I would have done nothing. I would just have let Mother Nature take her course. No cancer treatment is worth going through, in my opinion. It has now been 6 years after the radical prostatecomy, and believe me — I would rather die of cancer than deal with all the side effects because of the operation.

  36. Many patients and patient advocates might have very different reactions to Mr. Lee’s statements above. However, his opinion is entirely understandable if he had significant complications and side effects as a consequence of his procedure.

    One of the problems withe the treatment of prostate cancer is that individual patients can — for all sorts of reasons — have responses to prostate cancer treatment that are way outside of the norm. Another is that individual patients can be so badly affected by certain types of side effect that their entire lives are shattered by the experience — even when the side effect is one that others can cope with with a level of comparative ease (which doesn’t mean that they like the situation).

    The ideal, long-term situation is that we would all feel a great deal better if we could find a simple, cost-effective form of therapy for prostate cancer that simply stopped the progression of the disease in 90% of patients, and that came with a minimal risk for serious side effects and complications. Unfortunately, I see no sign of such a therapy on the horizon as yet.

  37. Are there any statistics that give an indication of life expectancy if chemotherapy and radiotherapy are used?

  38. There are extensive data on patient survival after treatment with chemotherapy and radiation therapy, but it would be very important to have a complete understanding of all the relevant background information about the specific patient if one was to be able to apply this information in a meaningful manner. There is no good, simple nomogram that can be used to make such determinations.

  39. Dear sitemaster:

    I was diagnosed with prostate cancer about a year and a half ago. A urologist was smart enough to give me a liquid biopsy as my digital rectal exam was normal and my PSA was 2.59 ng/ml. I’ve been under his care for a few years with a fluctuating PSA; the highest was at 5 ng/ml but it was deemed to be a consequence of taking testosterone supplements.

    Once the results came back from the liquid biopsy, he deemed it necessary or reasonable to have a biopsy done, which we did. The biopsy showed a Gleason score of 3 + 3 = 6, with a PSA score of 2.79 ng/ml at the time of that biopsy.

    We decided the health of my family which I am lucky enough to have two very smart doctors to advise me to do active surveillance. We did the PSAs periodically which stayed in the 2 ng/ml range and not exceeding 3 ng/ml at any time.

    We then did another biopsy a year and 2 months later. The cancer has slightly changed. The Gleason score went up to 3 + 4 – 7. The PSA was still below 3 ng/ml. Most of the cores (11 out of 14) were positive for cancer, with the majority of the cores being 4 + 3 = 6 and none of the cores having more than 10% of Gleason pattern 4 disease.

    My urologist’s advice, along with my family’s advice (especially my brother-in-law) was to remove it as soon as reasonably possible. I made that decision and was referred to one of the best robotic surgeons in San Diego. The surgery was performed in a little under 2 hours.

    It’s been about 5 weeks since my surgery. I’ve already regained almost full control my bladder, and I was able to get a full erection 3 weeks after the surgery. My first PSA is scheduled for December 1, which is about 8.5 weeks after my prostate was removed. My post-surgical pathology was very similar to that from the last biopsy. The lymph nodes were removed and were clear. She said that there was an area that was pressed up against the rectum but she wasn’t concerned.

    What’s your thoughts for long prognosis based on your experience look forward to your response thank you

  40. Dear David:

    Your long-term prognosis is going to depend on two things: (a) whether there was any sign of a positive surgical margin from the “area that was pressed up against the rectum” and (b) the result of your PSA test on December 1. No one can really give you any further guidance without both those pieces of information.

    If there was no sign of any positive surgical margin and if your PSA level has dropped to significantly less than 0.1 ng/ml (based on data from an ultrasensitive PSA test), then it is quite possible you have been cured. However, you will need to get regular PSA tests for at least the next 5 to 10 years in order to make sure that that is the case.

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