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Cancer: Prostate Message Board


Cancer: Prostate Board Index


[QUOTE=oldmarine;3465834]Jim...

I think this is the first time I've ever posted anything on a message board. Was delighted to discover this one today, and thank you for your posting.

I'm newly diagnosed with early stage PC, PSA 5.42, Gleason 6(3+3), found cancer in 3 of 12 biopsy samples. Percentages are 70%, 20% and <5%. Age 74. Type 2 diabetic, pretty well controlled. Also have Crohn's disease and am absolutely unwilling to undergo anything that might worsen bowel problems. My Doc is strongly advocating cryosurgery (he's done over 800, and well reputed.) His view is to freeze the quadrant that's cancerous, leaving me about 75% of my prostate.

But all I read from NCI and Johns Hopkins seems to me, at least, to indicate that I ought to be good candidate for Active Surveillance.

His argument is that there's no really established protocol for determining what "active surveillance" is, nor when to draw the line as to start treatment, if the cancer accelerates. I had the idea that it would be semi-annual DRE's and PSA's, and annual biopsies. But he says that PSA's don't cover the whole prostate, and PSA's are unreliable; and that it can get out of hand and metastasize (sp?) quickly.

I have appointment on 4 March with another Doc who has some folks on AS; plan to quiz him on those points. I've probably left out a lot of important information, would welcome some good ideas from you veterans.

Thanks & God bless,
Old Marine[/QUOTE]

Hello Old Marine,

I've got a hunch you've faced a lot worse things than prostate cancer during your 74 years, but it's still not pleasant to learn you have the disease. I've got a soft spot for the Marines, though I've got to admit I was in that other service. (I heard a marine give a toast once that went like this: being a Marine attached to the Navy is like being the handle of a pee pot: it's bad enough to be attached to it, but thank God you're not in it!) ;)

Please remember that I am a fellow survivor and not a doctor. Though I've learned a lot in dealing with a challenging case for eight years, I've never had any enrolled medical education. I can give you some facts, leads, and things to consider and discuss with medical professionals.

Any treatment decision should consider age, life expectancy, and overall health conditions as well as the nature of your prostate cancer and preferences, and you have identified four considerations that would help tilt the balance toward a less aggressive approach, particularly active surveillance: age 74; Type 2 diabetes; Crohne's disease; mostly good case characteristics; plus a decision to avoid anything that might worsen bowel problems.

Getting back to your focus on active surveillance, careful patient selection is a key tactic for the major active surveillance programs. While your doctor is correct that there is not a "standard of care" yet for active surveillance, there is an emerging consensus for active surveillance, with some differences, among some of the best prostate cancer institutions in the world involving some of the leading international experts. Key details have already been covered on this thread. It's not only Johns Hopkins (Dr. H. Ballentine Carter, MD, Dr. Patrick Walsh, MD, and others) and the NCI; others are the University of Toronto (Dr. Laurence Klotz, MD, regarded by some as the leading international expert, AS program started in 1995), Memorial Sloan Kettering (Dr. Peter Scardino, MD), Erasmus Medical Center in the Netherlands (Dr. Fritz Schroder, MD), MD Anderson (Dr. Babaian, MD), and UCSF (Dr. Peter Carroll, MD). There are others, but these are the major ones that stand out to me. (Dr. Warlick recently moved from the Johns Hopkins Program to the University of Wisconsin.) All of these physician/researchers have authored papers describing their research and results.

Your case characteristics would probably fit the U. of Toronto approach (not that you would have to go there, but you can see that they would think you would have a reasonable shot). Your Gleason and PSA are fine, and in that program there is evidence that three positive cores in twelve total is not an unreasonable risk. (Was the Gleason done or confirmed by an expert pathologist who specializes in PC?) I believe they would not object to 70% of one core being cancer, especially with your age and other medical conditions, though they would like it to be under 50%, as are your other two cores. This is one area where programs differ: Johns Hopkins likes to see all positive cores with no more than 50% cancer each; Johns Hopkins is also uncomfortable with more than two positive cores. Is your stage no more than T2b? That would be fine for Toronto; some of the programs want no more than T2a. Do you know whether your PSA rose more than 2.0 in the year up to diagnosis? Toronto now wants to see a rise of no more than 2.0, and the lower the better; I think other programs are also adopting that standard based on research led by Dr. Anthony D'Amico. Another point, the doctors managing patients under these programs use the standards as guidelines; the standards are not rigid - there is some leeway.

Each of the major programs has standards for when to offer a hopefully curative treatment to the patient instead of continuing with active surveillance. While your doctor is correct that there is no agreed standard of care in the prostate cancer medical community, there is an emerging consensus among the leading active surveillance programs, again with differences, just as in patient selection. For Toronto, the standard for curative therapy is a PSA doubling time of two years or less or an increase in Gleason Score in a followup biopsy. At Johns Hopkins, the standard for triggering curative therapy is a followup biopsy with any Gleason Grade (not Score) 4 or 5 cancer, more than two cores positive, or more than 50% of any core positive. Judging from published reports, major active surveillance programs succeed in keeping around 50% to 60% of their active surveillance patients continuing in the program, rather than having to have curative treatment, and a large majority of patients are able to defer therapy for at least two or more years even if they later need therapy. (That might be a big selling point when you are 74 years old; it would sure get my attention.) Those who do need treatment are getting it in time for it to be about as effective as treatment right after diagnosis. At the eight year point, Toronto reported overall survival of men in its program as 85% and survival of prostate cancer at 99%. (I think that means all men in the program, both those still on active surveillance and those that got treatment.)

Monitoring tactics vary somewhat among the programs, but most of the variation is with timing, as PSAs, DREs and biopsies are common. At one point, perhaps still, Toronto called for DREs and PSAs at three month intervals for the first two years, then every six months, with the first followup biopsy at 18 months to two years, then one at five years, and one at ten years.

Your doctor raised doubts about the DRE, PSA and quick metastasis. With the exception of a small percentage of patients, usually patients who do not have good case characteristics as I understand it, PSA is quite a good indicator of the disease status, though it is better for lower grade disease, especially below GS 7. Some high Gleason Score patients, especially grade 10, then grade 9, and even grade 8, make much less PSA than is normal for prostate cancer, and a rare group of patients (less than 1%) has prostate cancer cells that make almost no PSA. Usually it is pretty clear who those 1% are (for instance, those having small cell prostate cancer or endometrial prostate cancer). You don't have a high Gleason and are extremely unlikely to be in that less than 1% group. The DRE is certainly not perfect, but combined with PSA it is pretty good, especially when PSA doubling time is part of the picture. Results data from the major programs indicates that their patients are not suffering from quick metastasis surprises more than patients who get immediate treatment. Such metastasis in these favorable risk patients is infrequent if not rare, as I understand it as a layman who has read some of the abstracts and studies.

You and your doctor may have ruled out radiation because radiation is known for sometimes causing or aggravating bowel problems, something you are determined to avoid. My impression is that such problems are infrequent with modern techniques, but they may be a risk, especially if the radiation would affect an area impacted by or weakened by the Crohne's disease. I hope daff will followup on that particular risk with proton beam radiation as I'm not familiar with the odds and severity range of a bowel side effect with that approach. Seeds might also work, especially since your disease appears well confined from what you know, but an external beam approach (perhaps excepting proton beam) would probably have an increased risk of bowel problems. The doctor probably recommended against surgery, which is known for urinary but much less for bowel problems, because of both your age and other health conditions.

All this said, your doctor's recommendation of cryo seems like a sensible option too for your circumstances. With more than 800 cryo operations to his credit, your doctor appears to be extraordinarily experienced. Cryo to just part of the prostate is known as "focal cryo." Dr. Gary Onik, MD, of Celebration, Florida, is the pioneer in that technique, and he gave a presentation about it at the International Conference on Prostate Cancer 2006, held in Reston, Virginia (available on DVD). He may have also covered it in a book he co-authored with Dr. Centeno. I think I've heard that cryo does not lead to bowel problems, but you can surely find out about that from books and articles on cryo. Another well known expert in focal cryo therapy is Dr. Duke Bahn, MD, practicing in Ventura, California. Both Drs. Onik and Bahn have authored papers on their results.

Another option would be to combine a lifestyle program with active surveillance. Such a program involves nutrition/diet/supplements, exercise, stress reduction, and perhaps mild medications including a statin drug and either finasteride or Avodart. The statin drugs appear to go a long way toward preventing advanced or lethal prostate cancer. Finasteride and Avodart appear to have a lot of value against low grade prostate cancer, and may help against higher grade cancer, with data for finasteride fairly convincing and data for Avodart still preliminary. A lifestyle support program would probably help.

The final option, short of full blown combined or triple hormonal blockade, could be an antiandrogen drug like Casodex, probably combined with finasteride or Avodart and a statin. Unlike the LHRH-agonists Lupron, Zoladex, Viadur, etc., Casodex has "80% of the benefit but just 20% of the side effects," according to one expert, Dr. Mark Scholz, MD. Breast side effects are common with Casodex, but in most cases they can be prevented by a short course of radiation to the breast or by medication.

I hope you keep posting and let us know how your journey goes.

Take care, and good luck with your research and decision,

Jim





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