The co-authors of Invasion of the Prostate Snatchers, blog alternate posts weekly. We invite you to post your comments.

Tuesday, January 20, 2015

Who Asked You for Your Opinion Anyway?


Unsolicited Advice from Survivors for the Newly Diagnosed

In 2014, approximately 233,000 men in the U.S. were told they had prostate cancer and to many of them it sounded at best, like the end of their sex life, and at worst like a death threat. In reality, the majority of them turned out to have an indolent form of the disease that was not life threatening and could safely be monitored without any immediate treatment.
Having said that, a diagnosis of prostate cancer is not a walk in the park. Just when you are most vulnerable you are obliged to confront so much complex and conflicting information that to say it leaves you reeling would be an understatement. So your first and most important decision is not to make a pressured decision, not to rush the treatment selection process or allow anyone else—including any doctors you consult—to rush you into undergoing an irreversible treatment until the shock has worn off and you have had time to carefully analyze all the data that applies to your particular case.
The first step after being diagnosed is to understand the concepts of staging and grading. The grade of your cancer will tell you how aggressive the cancer cells are. The stage tells you how extensive or advanced the cancer is. This information, together with your PSA level, will help determine your prostate cancer’s risk factor—whether you are in the low-risk, intermediate-risk, or high-risk category.
If your cancer is low-risk it can be safely monitored with “active surveillance” and does not require any immediate treatment.  If you are in the intermediate-risk category, you have many treatment choices, and in order to make the best decision you will need to get opinions from specialists with state-of-the-art knowledge.
You will already have seen a urologist who, if you are a candidate for surgery, is likely to have recommended a prostatectomy. If this is the case, it is essential to ask him the tough questions: What are the risks? How many prostatectomies has he performed overall and how many has he done in the past twelve months? Does he perform nerve-sparing surgery, and if so what is his success rate with preservation of potency and continence? And if you are over seventy, please consider prioritizing  almost any other treatment option ahead of  going through a major surgical procedure.
Before making a treatment decision you should consult a radiation oncologist about brachytherapy (radioactive seed implantation), and IMRT (Intensity Modulated Radiation Therapy), a precisely targeted type of radiation that delivers high doses to the prostate without damaging surrounding organs. In my opinion both these options are at least as effective as surgery at curing the disease and both are associated with significantly lower risk of long-term toxicity.
You should also consult a medical oncologist about hormone therapy, a treatment that blocks the male hormone testosterone and significantly slows the spread of the cancer, often for years. Hormone therapy does not promise a cure, but it is a viable, non-invasive alternative to surgery, an effective delaying action. A medical oncologist is a good doctor to consult with as they have no vested interest in either surgery or radiation and can often be helpful in sorting out the conflicting opinions you likely have heard.
If your cancer is in the high-risk category you will usually need two or more different kinds of treatment—probably hormone therapy plus radiation. Some centers even may mention chemotherapy such as commonly done for patients with colon cancer or for women with breast cancer.  And there are many new treatment methods in the pipeline, so even if your cancer is aggressive, you are not looking at an imminent death threat.
So do your research and take your choice. And always remember: Prostate cancer is about the best possible cancer to deal with.

Tuesday, January 13, 2015

Prostate Cancer: Starting at the Very Beginning


Yesterday I sat down with a new patient, Sam, a charming man who, unfortunately, was just found to have a prostate nodule and a PSA of 50. When I asked Sam why he had not visited a doctor for over 10 years or undergone any PSA testing, he responded, “I have always enjoyed perfect health. Why see a doctor?” Sounds sort of like a stupid response, but judging by his healthy appearance, (looking more like a 70 year old than an 80 year old), one would have to say that until now his policy has been pretty successful.

However, if Sam was going to participate intelligently in further discussions about the selection of optimal treatment, his prostate cancer knowledge would need a major upgrade. Since my instruction had to begin at a very elementary level, I thought I would use this blog to share the main themes of our almost two-hour meeting together.  Focusing on the basic first steps seems an appropriate theme for this, my first blog of the New Year.

Not All Cancers Are the Same
Many patients introduced into the cancer world fail to understand that lung cancer, breast cancer, brain cancer and prostate cancer are each a distinct illness, each with more differences than similarities. These different cancers are as different as kidney stone disease is different from pneumonia. Therefore, preconceived notions coming from personal experiences with one type of cancer occurring in family members or friends are frequently misleading.

Prostate Cancers are a Mixed Bag
It’s fairly easy to see why dissimilar cancer types, such as bladder cancer and skin cancer for example, behave differently; it may be harder to understand that prostate cancer itself comes in many different and distinct subtypes. Part of this varied behavior can be explained by the disease stage: No one is surprised by the fact that cancer diagnosed at an early stage has a different outlook compared to cancer diagnosed after it has metastasized.

However, beyond the issue of variable stage, when comparing two different prostate cancers of exactly the same stage, what we call “prostate cancer” can be extremely variable. Consider the following: In 2014, 70,000 men were diagnosed with a type of prostate cancer considered to be so harmless that experts universally agree it is best managed with active surveillance only. However, at the other extreme, also in 2014, a very different type of prostate cancer led directly to 28,000 deaths.

Prostate Cancer in the Bone is Not Bone Cancer
A common misconception that needs to be rectified is that cancer that originates in the bone, i.e bone cancer, is a totally different entity than prostate cancer that has spread to the bone. Primary bone cancer grows quickly, often spreads to the lungs and does not respond to hormones. Prostate cancer that spreads to the bone tends to grow much more slowly, only rarely spreads to the lung and usually regresses radically with hormone therapy. Prostate cancer in the bone and primary bone cancer are two separate and distinct illnesses that should not be confused with each other.

Doctors and Patients, the Human Factor
The human factor further complicates the selection of optimal treatment. Doctors who treat prostate cancer come from different schools of thought. Not only are urologists, who are surgeons, trained differently from radiation specialists, the true cancer specialists, the medical oncologists, are practically never involved with early-stage prostate cancer. Differences among patients—age, fitness, prostate size for example—can also radically influence treatment selection.

Sam’s Situation
With a PSA of 50, Sam is going to need a bone scan. He may have already developed metastases. His initial color Doppler ultrasound shows a rather vascular tumor (about an inch and a half long) with some early extra-capsular spread. A targeted biopsy, a single core of the tumor, is scheduled for next week and will let us know the Gleason score.

If the scans turn out to be clear, and if Sam was ten years younger, radiation and hormone therapy would give him the best chance for cure. But in an 80-year-old, the possible side effects that can result are more problematic. Also, we don’t know anything yet about the pace of his disease. Might it be feasible for Sam monitor to the situation for a while? Alternatively, radiation alone or mild hormonal therapy alone (with Casodex) could be considered. Sam and his wife left our meeting with a copy of Invasion of the Prostate Snatchers promising to read it in preparation for our next meeting.

Tuesday, January 6, 2015

Confessions of a Treatment Conservative


While studies demonstrate that the new gold standard for detection of clinically significant prostate cancer with a high degree of certainty is a combination of systematic and MRI targeted biopsies, the practicality of this approach still poses problems.

Mark has written many times about the growing pains involved in the common sense use of this sophisticated technology, and also its tremendous potential to finally help distinguish men with non-aggressive cancer who do not need treatment from those with aggressive disease who do.

Making this technology available to every man with prostate cancer who would benefit from it is problematic for one main reason—the process is not very available due to the relatively few centers of excellence that have access both to the technology, and to the highly skilled uro-radiologists capable of reading the MRI scans with accuracy.

Prostate cancer affects men in many different ways. Its management is complicated by extremely variable behavior patterns ranging from slow-growing and insignificant to rapidly growing and life-threatening. Sometimes an abnormal PSA suggests cancer but none is found at biopsy. Sometimes a man who is thought to be a good candidate for surgery will turn out to have cancer that cannot be effectively treated surgically. Other times a decision has to be made whether to treat what appears to be a very small amount of cancer and risk the inevitable side effects. All of these are issues where prostate MRI is of value.

The biggest challenge in prostate cancer treatment is to try to find all the cancer, but treat only that cancer which is aggressive. Multiparametric MRI scans can help identify areas in the prostate that are suspicious for aggressive cancer that can be missed by biopsy. They also happen to be safer, minimally invasive, and less uncomfortable!

The main reason that Mark and I wrote our book—Invasion of the Prostate Snatchers—was to try to prevent the exorbitant number of biopsies performed every year in the United States leading to immediate radical treatment that in many cases was totally unnecessary.

There is no doubt that advances in MRI technology could dramatically curb the number of biopsies performed and reduce unnecessary treatment of non-life-threatening cancers.  From my own experience of co-existing with prostate for over 20 years cancer, I remain conservative when it comes to invasive treatment.

Tuesday, December 30, 2014

PSA, The Human “Check Engine” Light


Why all the controversy about PSA? How can people fault a simple blood test that uncovers cancer at an early stage? The problem is that the PSA test doesn't specify what type of cancer the patient has. In addition to the presence of cancer, there are two other common causes of PSA elevation—prostate gland enlargement that comes with age, called BPH, and chronic prostate inflammation, called prostatitis.

PSA by itself doesn’t diagnose prostate cancer.  It is a nonspecific indicator, like the “check engine” light on the dashboard of your car.*  Does this eliminate the value of PSA?  Of course not.  An elevated PSA reading is a useful indicator of the need for further research into the cause.

The biggest fear--and the primary argument used by PSA naysayers--is that so many urologists recommend immediate random biopsy with any PSA elevation whatsoever.  A million men are biopsied annually in the US, resulting in the over-diagnosis of innocuous prostate cancers in about 100,000 men each year.  Most of these men end up undergoing unnecessary radical surgery or radiation.

So how do we eliminate the bathwater (random biopsies) without throwing out the baby (PSA)?  The first step is avoiding the trap of rushing headlong into something before learning the whole story. Since we know PSA is nonspecific, most elevations will be from prostate enlargement, not cancer.  PSA needs to be interpreted in relation to prostate size.

One might think that only ultrasound or MRI can reliably measure prostate size.  And while imaging is indeed the most accurate method, practiced doctors can roughly estimate prostate size with a simple digital prostate exam.  Also, there is a PSA blood test variant called “free” PSA that is suppressed in men with BPH.  Free PSA is reported out as a percentage of total PSA.  When free PSA percentage drops below 10%, BPH as a cause for PSA elevation is less likely.

Sequential PSA testing is the best way to diagnose inflammatory prostatitis, the other common reason for benign PSA elevation. Inflammation can increase PSA, which often oscillates up and down as the inflammation in the gland waxes and wanes.  This bouncing PSA pattern is in sharp contrast to an elevation of PSA caused by cancer.  A rise in PSA from cancer is usually unidirectional—up, up and up.

Historically, despite the drawbacks from biopsy of over-diagnosis, infections and discomfort, it has been the gold standard for diagnosing prostate cancer. Only very recently have new advances in multiparametric MRI imaging enabled men with PSA elevation to consider this imaging alternative--rather than random biopsy--as a first step. Our recommendation to use a multiparametric MRI (at a center of excellence) followed by a targeted biopsy if a suspicious lesion is detected, has been discussed in more detail in previous blogs. 

*I wish I could take credit for the check engine light idea that so nicely conveys the useful but nonspecific character of PSA.  This little pearl of knowledge was passed on to me by a patient.