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Cancer: Prostate Message Board

Cancer: Prostate Board Index

[COLOR="DarkGreen"]Hello Stephen,

It is a great thing for this board that we have a physician participating. I have come to realize that physicians typically have as much difficulty with the diagnosis as the rest of us. I dearly hope that you will continue to participate, and I hope you won't mind discussing some issues. Your comments could help us understand why some doctors look at things in certain ways. For instance, way off topic here but for future discussion, I have been amazed at how slowly and skeptically the medical community responded to the news that finasteride [U]safely[/U] prevents 25% of prostate cancer. There seemed to be a lot more emotion than reason in the overall response of the medical community. But, as I said, that is for the future, unless you care to address it. Ill insert some comments in green about your current thread.

I'm glad you have developed confidence in surgery as an approach to your particular case. I believe that confidence is a sign, perhaps not always perfect but a good sign nonetheless, that the therapy choice is a good match for the patient.[/COLOR]


Thanks for the email

... As you stated many men over 50, perhaps 30% have prostate cancer, undiagnosed.

[COLOR="darkgreen"]The main line of research I'm aware of was done at Wayne State University in Detroit based on very small scale autopsies of prostates of men of various ages killed in accidents. Their findings were roughly that prostate cancer, though often extremely small and causing no problem at the time, most of it probably indolent or dormant, was present in a percentage that roughly matched 10% times the decade of life: so for the fifties, 5 X 10% = about 50%, 60% for the sixties, 70% for the 70s, etc. They obtained data for at least white and black men as I recall. Their approach looked sound to me.[/COLOR]

It is also a fact that many with early or low Gleeson score cancers are found to be more extensive upon path exam after prostatectomy.

[COLOR="darkgreen"]Partly because of that the book "A Primer on Prostate Cancer - The Empowered Patient's Guide," strongly advocates getting an expert in prostate cancer pathology to grade the Gleason Score. It is common for the expert's reading to either upgrade or, less frequently, to downgrade the score. Of course, the path exam may find tumors that were not even sampled during the biopsy, and those may tilt even the expert's Gleason picture and of course the staging of extent of disease.[/COLOR]

Regarding active surveillance, I did speak with Dr. Carter at Hopkins. He did not recommend surveillance given my age.

[COLOR="darkgreen"]I've met Dr. Carter, conversed with him, and followed his research. (For those who don't know, he is one of the foremost surgeons dealing with prostate cancer on the prestigious, world-famous Johns Hopkins team.) My impression is that most doctors who are serious about active surveillance as an option still agree with Dr. Carter that it is a more risky approach for younger men, risky enough to give younger patients the advice he gave you. Still, I'm highly impressed by the careful work of Dr. Laurence Klotz, who does not see age as a bar, and of Dr. Fritz Schroeder, who uses 55 as his threshold. The decision obviously is a very personal judgement call.[/COLOR]

I have spoken with many urologists most of whom said if it were them, they would have surgery (radiation is not popular with them).

[COLOR="darkgreen"]I'm convinced their views are in part colored by the mental approach and particular discipline that surgeons have to have: when performing complicated surgery, they often need to be decisive and to be able to act quickly to implement a good solution without taking time to search around for an ideal solution, a search which may have found a "better" solution but too late to help or save the patient. Surgery is more a clear-cut tactic than radiation. Of course, they also believe in surgery because that is their calling in life. I sure would not want to be operated on by a surgeon who did not have confidence in surgery! ;) On the other hand, research early in this decade demonstrated that radiation doctors were equally strong for radiation - also what you would expect in the absense of significant differences in outcomes. What do you think."[/COLOR]

The problem with surveillance is one doesn't get treated until his disease has progressed as evidenced by rising PSA, change in DRE or histologic progression of the disease seen in repeat biopsy. Those parameters can be lagging indicators, that is, by the time there are detected the disease may have advanced a lot. Plus the PSA doesn't always go up with progression of the disease.

[COLOR="darkgreen"]The key question of course is whether well-managed active surveillance can achieve a switch to active intervention (such as radiation, surgery, etc.) in time to achieve a cure and before the disease has advanced a lot. The leading active surveillance centers mentioned below have enough experience now that they believe they can intervene soon enough to achieve nearly identical outcomes with those of patients treated shortly after diagnosis. Perhaps more important that the way they carefully monitor is the way they very carefully select those patients for whom they think delaying treatment will be safe and wise. However, the track record for active surveillance is not yet overly long, and the data are not yet conclusive.

I'm impressed that some of the doctors who are arguably among the leading surgeons are favorably impressed with active surveillance. That includes Dr. Patrick Walsh, Dr. Carter, Dr. Peter Scardino, and Dr. Peter Carrol, whose reputations I'm more familiar with, as well as pathologist Jonathan Epstein of Johns Hopkins. My impression is that Drs. Klotz, Babaian, and Schroeder are also leading surgeons. On the other hand, another leading surgeon, Dr. William Catalona, is opposed to active surveillance. Do you have any thoughts to share about the stands of such leading surgeons?

Regarding PSA, my view is that it is an excellent indicator for most of us, but may not be reliable when there is extensive Gleason Grade 4 or 5 cancer included in the overall Gleason Score, and that is not a a good indicator at all for certain rare types of prostate cancer, such as small-cell prostate cancer and neuroendocrine prostate cancer, which produce little if any PSA. Unless you have specialized knowledge in prostate cancer, the ins and outs of the use of PSA are probably not familiar to you yet, though they no doubt soon will be. (Bet you could have done without that extra expertise! ;)) I'm assuming the major active surveillance programs are as careful as possible to check the usefulness of PSA in their patients, and also to monitor them carefully to reduce errors in such assessment to a minimum.

Bottom line is this: one with an early diagnoses has to decide whether he wants to risk overtreatment with surgery or compromise risk of cure by waiting to see if his disease progresses to a point where aggressive treatment then is mandated.

[COLOR="darkgreen"]I see it the same way. There are a couple of additional questions about active surveillance I would like to have answered. (I was able to ask an expert panel about the patient age issue, but time did not permit me to ask these additional questions.) First, granted that the statistics for cure for surgery look about the same for early versus after a period of active surveillance, are the outcomes for nerve sparing, potency preservation, and incontinence and other major side effects as good, with similar questions for radiation? Second, a related question but focusing on increasing age: in view of the fact that most patients in active surveillance programs will benefit from at least several years without needing active intervention, for those who are found to need active intervention, do the added years of age substantially affect therapy options and the ability to cope with side effects? [/COLOR]

Given the manner in which prostatectomy is done today versus many years ago, surgery is an easier choice.

[COLOR="darkgreen"]I see it this way too. My impression is that surgery was substantially declining as an option until robotic and laparoscopic surgery emerged, with clearly more favorable side effect profiles. Any comment? [/COLOR]

BTW, I am a physician and will tell you the right treatment is as confusing to me as for any nonmedical person. I have talked to about 15 urologists and read much of the medical literature. There is no clear consensus as to what is best with prostate cancer, unlike other cancers, say lung or colon. However, at least one fact cannot be contested and that is nothing will given better survival rates than surgery and that is the route I will probably go.

[COLOR="darkgreen"]I think that is true, but I can give you what the radiation doctors would say about that if you still want to hear it - basically along the lines that they are as good, not better.

Here's an issue you may not want to be thinking about yet, and of course I am fine with that. I am personally fully convinced, but still with an open mind I hope, of the value of ultrasensitive PSA monitoring to assess the success of surgery; however, conventional versus ultrasensitive monitoring of results is still controversial. Has the type of post-surgery monitoring come up as an issue? Some doctors ask what good it does to know a year or so early that the operation apparently did not get it all. My answers are (1) that very good ultrasensitive results give early peace-of-mind, (2) that follow-up therapy appears to be more effective when implemented earlier, triggered by the ultrasensitive results, (3) that adverse ultrasensitive results can motivate men and their wives to get serious about nutrition/dietary/supplement, exercise, stress reduction and low-key medication tactics (finasteride, Avodart, a statin) which appear to help combat prostate cancer, and (4) that analysis of changes in ultrasensitive PSA scores can indicate whether the tactics in point (3) are effectively controlling the remaining cancer. [/COLOR]

Kindest Regards,


[COLOR="darkgreen"]Kindest regards to you also, and I hope you find an approach that is ideal for you.:)

Take care,


-----Original Message-----
From: Message Boards [mailto:[email protected]]
Sent: Saturday, October 18, 2008 10:10 PM
To: [email][email protected][/email]
Subject: "Doc Put Off My Biopsy..Is This A Smart Thing To Do?" update[/QUOTE]

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