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Cancer: Prostate Message Board


Cancer: Prostate Board Index


[COLOR="DarkGreen"]Hi Irvin,

Welcome to this board that hopefully you will not need for detailed questions about therapy - just a memory of some good help. :D

I'm inserting some comments in green. I'm responding after reading the nine good posts to date. It's always good to have a devil's advocate, especially when that's the way you worded your title, so I'll be happy to play that role. I truly think that whether to have a biopsy now, in your case, is a tough call :confused: - good points on both sides, but fortunately unlikely to be a high stakes call. (In part that's because even unlikely fairly to highly aggressive cancer would very likely be caught soon with follow-up monitoring. :)) I fully understand the anxiety about having a possible cancer and the desire to resolve that - anxiety that is well described in some of the posts, but the problem for me is that there's a pretty large chance that a biopsy would miss any cancer at this point even if it were there. It still might be wise to go ahead if there were not other alternatives, but there are. That's what makes the call more difficult.

By the way, I'm a now savvy survivor at nine plus years of a challenging case of prostate cancer but with no enrolled medical education.

I can support each one of my statements, so please ask if you want more detail. That doesn't mean that each statement is necessarily right or the best viewpoint, but it does mean there is a basis beyond my personal hunches or preferences, though those are important too for all of us. Much of the evidence I consider important is readily available with a few keystrokes from a site we can use on this board because it is Government sponsored: PubMed, www.pubmed.gov, an agency of the National Library of Medicine under the National Institutes of Health, our taxpayer supported gift to ourselves and the world. :angel: I'll give a few examples in this post of how you can search the site.
Jim[/COLOR]

[QUOTE=Irvino;3959385]My name is Irvin. I'm 65, and I live a healthy lifestyle.

[COLOR="darkgreen"]A healthy lifestyle appears to be very important for our success as prostate cancer patients and in prevention, though the evidence is more persuasive than conclusive for almost all lifestyle tactics at this time.
Let me ask a few key lifestyle questions:

--- Do you exercise, and does that exercise include strength training as well as aerobic training? Both appear to be important for prostate cancer patients, but strength training has emerged as particularly important. (You could try a PubMed search for (without the quotes before the start and end) " prostate cancer AND exercise ". I just did that and got 339 hits. To narrow the list down a bit, I used the Limits button and selected only papers with abstracts that had been published this year. That winnowed the number down to 9 hits. You can see that this is an active area of research interest! (Exercise is especially important for patients on my form of therapy - intermittent hormonal blockade.) If you click on the blue hypertext authors list for each paper, you will see the abstract, if there is one.

--- Do you know your vitamin D level using the test for 25-hydroxy vitamin D? Many of us are deficient, in fact vitamin D deficiency and some loss of bone mineral density are epidemic among prostate cancer patients. There is a growing body of evidence that an adequate vitamin D level is very important to both coping directly with prostate cancer and to bone density for prostate cancer patients. (You could search PubMed for something like " prostate cancer and vitamin D ". I just did that and got 772 hits with the Limits feature off, 23 hits with it on for abstracts and papers published just this year. Obviously, this area of research is hot! :cool:

--- High quality pomegranate juice or extract appears to be important for dealing with prostate cancer. It's possible that any products will do, but it is known that heat and light can reduce the strength of the juice. The Pom Wonderful company, whose product is refrigerated, funded the key research, adding an element of doubt to the findings, but the UCLA team that did the work is extremely highly regarded. An extract, based on their research, is marketed by the Pomella company and distributed under a number of labels. The key clinical trial run by UCLA researchers showed that men with prostate cancer that was recurring after surgery were able to lengthen their PSA doubling times (PSADTs) from an average of 15 months to an average of over 50 months. That is an awesome increase; if sustained, it basically makes the recurrence so mild that major follow-up therapy is unlikely to be needed. :jester: :D :cool:

--- Do you eat red meat and pork? We patients are advised to eliminate both or to reduce them as much as possible, mainly due to the relatively high level of arachidonic acid in each, which fuels prostate cancer. Many other foods also have some arachidonic acid, but the levels are much lower, and a number of those foods have benefits that offset the risk from arachidonic acid. I stopped eating red meat and pork shortly after being diagnosed, except for rare social occasions where I eat a little. I really miss those ribs, a good steak, and a good burger, but I've grown to like my more vegetarian, fish and poultry oriented diet. :)

--- Do you avoid flaxseed oil? That oil appears to be beneficial to women, at least younger women, and probably also to patients primarily concerned about cardiovascular health issues, but there is accumulating evidence that it is bad for prostate cancer patients. Ground flaxseed is another matter, and may even be beneficial. Canola oil is also fairly risky, but olive oil is a fine substitute. (You could search for " alpha linolenic acid AND prostate cancer ". I just did that without limits and got 46 hits. Note that fish-based omega-3 fatty acids appear to be beneficial to us.)

--- Some leads to other lifestyle tactics are in an archived thread: "Nutrition & lifestyle tactics - books, resources and a quick summary," initiated on 3/6/2008.
[/COLOR]

A recent PSA showed 3.5 (up from 1.6 two years ago). My Free % PSA was 17%. The lab report said that I had a 20% chance of having PC. I also had a negative DRE. I have BPH and suffer with Epididymitis, including one of its nasty symptoms, blood in the semen.

[COLOR="darkgreen"]Those numbers are not that bad in your overall circumstances, particularly considering the BPH and Epididymitis (had to look that up), but are grounds for concern regarding prostate cancer. The two year increase of 1.9 is above the rate of .75 per year that draws attention; in fact, more recently an increase of just .35 draws medical attention. However, the BPH and the epididymitis could both be influencing the PSA independent of any cancer. Also on the good side, that increase of 1.9 averages out to less than 1.0 per year, and since 2004 and 2005 (Dr. Anthony D'Amico and team) we have known that an increase of more than 2.0 in the year prior to diagnosis indicates a more serious case than would be suspected based on the PSA level, the stage, the Gleason Score, and other usual clues. Your annual increase is far below the threshold of >2.0, and that suggests a milder than average cancer, if there is cancer at all. Also, my impression is that the research minimized the likelihood that BPH or infection were contributing to the velocity of >2.0, and its likely that at least BPH is contributing somewhat in your case, making your low velocity even lower as far as it might stem from cancer.[/COLOR]

My family doctor suggested that I talk to a Urologist, but I would bet that he'll say that I should have a biopsy. I read many things about the horrors of that procedure.

[COLOR="darkgreen"]You've had some excellent replies about that. Properly done, it's not that big a deal. The key is to get an able doctor. My impression is that most urologists are quite capable of doing good biopsies. Some are not. If you decide to have a biopsy, you can help sort the good doctors from the not-so-good by asking whether they use some of the techniques mentioned in the earlier posts.[/COLOR]

I also read that BPH can cause a false positive PSA, as well as a false positive Free PSA, and that the Free PSA is not very accurate when the total PSA is under 4.

[COLOR="darkgreen"]It's true that BPH raises PSA, and it can raise it all on its own above whatever threshold you use as a standard for "positive." A research-based rule-of-thumb is that each cc of healthy prostate tissue makes about 0.066 ng/ml of PSA. Well, a prostate of 50 cc (20-30 is normal) would make about 3.3 units of PSA; one of 100 cc, quite large but not unheard of, would make about 6.6 units. Do you know the size of your prostate? A urologist can make a pretty good estimate of the size just based on the DRE; he can determine a precise size with the aid of ultrasound or other imaging.

A key resource I use, which is available to all of us, is "A Primer on Prostate Cancer - The Empowered Patient's Guide" by Dr. Stephen B. Strum, MD and Donna Pogliano. It discusses the free PSA test and notes that the percentage can be thrown off by infection. It discusses PSA and free PSA mainly in pages 35-39. It notes that free PSA in men with BPH is usually 25% or higher if they do not have prostate cancer, which makes your 17% look more problematic, though hardly definitive, especially if prostate infection is involved, which seems somewhat likely in view of your history of epididymitis. Infection could easily be causing most or all of your PSA increases. (By the way, that rule-of-thumb of 0.66 ng/ml of PSA for each cc of prostate is described on page F4 of the Primer. I just checked, and my book flopped open to that page; now that's a well trained book!)

I don't recall that the free PSA test is less reliable for a PSA under 4.0, and the Primer does not mention that. I got 1,491 hits when I looked for help in PubMed with this search string: " PSA <4 AND free PSA AND prostate cancer ". I think I'll leave any follow-up research to you. ;)[/COLOR]

None of the articles that I read stated whether or not BPH can "dramatically" raise the total PSA score. And, there wasn't any mention as to whether or not Epididymitis can raise the score. I'll take whatever input I can get here. Thanks.[/QUOTE]

[COLOR="DarkGreen"]I covered this above under BPH and the amount of healthy PSA associated with each cc of prostate. I took a look at " PSA AND epididymitis " in PubMed and got six hits, most only tangentially related to the question. I looked at all the abstracts, and none gave a clear-cut answer. However, prostatitis, basically infection of the prostate, is caused by infection, and infection is a frequent cause of epididymitis from what I just learned. That makes it seem reasonable that a patient with epididymitis could be at substantially higher risk of prostate infection, and such an infection could explain the elevated PSA. Urologists can do workups that often but far from always can pin down the existence and cause of prostatits; fairly often they can come up with a drug that will cure the infection. (Part of the problem with that is bacterial resistance to antibiotics.)

Here are a couple other alternatives to a biopsy for getting a handle on whether you have prostate cancer. One is the Color Doppler Ultrasound exam. The CDU is often used to guide a biopsy, but it can be used as just an imaging technique. In addition to the normal ultrasound clue of a low-echo area in the image, suggesting cancer, the CDU's doppler feature allows new blood vessel growth to be highlighted in red in the image. Such new growth typically accompanies a growing tumor. One tactic for you would be to go to one of the approximately half dozen US sites with the technology and expertise for just a CDU exam, with the understanding that the doctor would add the biopsy if he saw the tell-tale red imaging.

Another tactic is to do a "finasteride challenge" or "Avodart challenge". That technique puts you on either drug to see if your PSA will drop by about 50% in six months as the drug shrinks your prostate, eliminating or minimizing BPH. If the PSA drops substantially less than 50%, that's a sign of the possible presence of cancer. Finasteride also has some proven anti-cancer usefulness, though it is fairly mild, and results expected this spring will probably prove Avodart to be even more effective. That means you get three benefits: suppressing BPH, helping determine the presence of prostate cancer, and helping to counter any prostate cancer that is present.

[B][I][U]The PCA3Plus test[/U][/I][/B] A final thought - really saving the best for last. There is a new urine test that has been out a few years now, known as the PCA3Plus test. (That's about the third generation of the original uPM3 test; PCA3Plus is trade marked by Bostwick Laboratories and is available from that commercial firm; the uPM3 test is trademarked by a different company from Quebec but is also still available, I believe.) The tests are based on prostate cells that are shed into the urine following an "attentive" DRE, which lasts about a minute - in effect a massage, after which the urine is collected and a sample sent to a remote lab. That test is not affected by BPH or infection. The test detects a gene that is highly associated with prostate cancer but is not associated with any other human tissue. These tests are the first genetic tests for prostate cancer. A value of 35 or higher on the PCA3Plus test indicates a high likelihood of prostate cancer. In contrast, significantly lower values indicate that prostate cancer is unlikely.

PCA3Plus is strong where PSA is weak and vice versa; therefore, having both tests gives a far more complete picture. In essence, the PSA test is quite sensitive for prostate cancer - unlikely to miss it if it is there using a threshold of 4.0 or higher, but it is also sensitive for BPH, prostatic infection, and for some other causes. That means there are a lot of false alarms at a PSA of 4.0 or higher but not exceeding 10.

In contrast, PCA3Plus is not that sensitive - my impression is that the signal from the results is not strong enough to detect anywhere near as many cancers as PSA. However, if the PCA3Plus result is 35 or greater, it is highly likely the patient has prostate cancer - very few false alarms.

Here is a table published by Bostwick Laboratories comparing the two tests:

PCA3Plus with a.........................Sensitivity.....Specificity
result of 35 or higher:......................57%.............75%

PSA with a result of
4.0 or higher....................................83%.............17%

The bottom line: if I were you, I would get a PCA3Plus test done before I signed up for a biopsy. If the result was well under 35, I would defer that biopsy, relax a lot but not totally, and just keep monitoring periodically for possible prostate cancer while adopting some of the lifestyle tactics to counter any possible cancer. If the result was close to 35 or higher, I would get that biopsy.

To me, getting the PCA3Plus makes a lot more sense than going straight to a biopsy that is likely to be negative at this point because of your circumstances even if there is cancer; that's because the dozen or so samplec cores, each approximately 12 mm in length and as wide as a pin, are not that likely to be the spots where there is cancer, even with the aid of Trans Rectal Ultrasound (TRUS), which does help some in targeting more promising areas of the prostate.

My impression is that the PCA3Plus test is often used after a patient with clues that are quite suspicious for prostate cancer has one or more negative biopsies. However, doesn't it make sense to use it up front where you have a low-likelihood of a postive biopsy but want some assurance that you are not overlooking a small but aggressive cancer? I'm not sure what I'm suggesting is best for your case, but it's worth a thought. I'm glad I don't have to make this decision myself.

Take care and keep cool,

Jim[/COLOR]
[COLOR="DarkGreen"]Hi Irvin,

You're welcome. That's what we are all here for - to help each other. :) I'm giving some more comments in green. Jim[/COLOR]

[QUOTE=Irvino;3964176]Hey, Jim. Thanks so much for your information and ideas. You gave me enough imput to make my head spin, while doing some new research. I'm glad to hear that there are alternatives to having a biopsy. I thought there might be, but until now I didn't know.

[COLOR="darkgreen"]Don't feel lonely about not being aware of alternatives. I'll bet the vast majority of us are in that boat, including many doctors. However, I've talked to a number of doctors who are keeping up and are using these alternatives with our patients.[/COLOR]

... I eat a lot of salmon and sardines for omega-3, as well as omega-3 eggs, walnuts and fish oil supplements.

[COLOR="darkgreen"]All of that is fine, I consume all of those too, except for the walnuts. Most nuts are fine for us - many beneficial, but there is controversy with walnuts - some evidence good, other evidence unfavorable. I did a quick search but could not find information on the negative side; I know it exists.[/COLOR]

... I have only recently read about the positive effects of Vitamin D on preventing and treating PC. I wish I had known this before. I thought that one shouldn't exceed the recommended 400 IU dosage, but it's now reported that 1500 IU is allowable.

[COLOR="darkgreen"]Actually, much higher doses than 1500 IU are now being used by many people, including many prostate cancer patients. Toxicity has been studied, and it appears that most of us will avoid trouble if we stay below 10,000 IU per day. However, for those with severe deficiency, there is an FDA approved dose of 50,000 IU, I presume for a short period until the level builds up. The key is to get that 25-hydroxy vitamin D test, as individual needs vary a lot. While many of my survivor friends were doing fine with doses of 5,000 to 6,000 IU/day, I scored at nearly the "vitamin D intoxication" level (141 for me) using about 4,000 IU/day in supplements, no doubt getting more with daily herring for lunch and 4,000 IU of fish oil daily. I reduced the supplementation and got my level down to a better range. I try for around 60 to 100 as my target test result range. Two of the major researchers are Dr. Reinhold Vieth from Canada and Dr. Holick from Boston, if you want to check out the research with www.pubmed.gov; I got 86 hits with this search string " vieth r [au] AND vitamin D " and 300 hits with " holick mf [au] AND vitamin D ".[/COLOR]

Actually, the sun is supposed to be the most effective way to get your Vitamin D requirement, and I do a pretty good job of getting that.

[COLOR="darkgreen"]The sun is best for younger folks, provided they don't have to worry about skin cancer. However, as we age, our skin's ability to make vitamin D decreases substantially. Also, higher lattitudes mean the sunlight is more filtered, so our skin does not have as much to work with. In the winter months, sun in the northern US is inadequate even for the young; many of us dig deep into our store of vitamin D during the winter unless we get it from diet. Dr. Charles "Snuffy" Myers has a lot of favorable things to say about vitamin D in his book "Beating Prostate Cancer: Hormonal Therapy & Diet." On page 149 of the original edition he wrote: "I'm starting this discussion with, and devoting most of the segment to, vitamin D because I think it is by and large the most important supplement for prostate cancer treatment." Here's another line, from page 151: "Also, as we age, our skin becomes much less effective at manufacturing vitamin D during sun exposure. As a result of skin aging and reduced sun exposure, vitamin D deficiency is quite common in those over age 80.... But how much vitamin D should you take if you never get any sun? The best current estimates are 4 to 5,000 IU a day. The best estimate for those of us with routine sun exposure would be 2,000 IU." However, in his newsletter on prostate cancer and talks he emphasizes the importance of getting the 25-hydroxy vitamin D test so we can tailor the level to our personal needs.[/COLOR]

By the way, I read that Afro Americans have a very high rate of PC. I wonder if that's because dark skin doesn't absorb UV rays as well as lighter skin does, therefore causing a low Vitamin D intake.

[COLOR="darkgreen"]That theory appears sound and is getting a lot of research attention as one of the causes of higher PC among African Americans. If you want to look into this yourself, try this PubMed search string: " prostate cancer AND vitamin D AND (African American OR black) ".[/COLOR]

Well, I have a lot of reading to do, thanks to you.

Thanks again for your help.

Irvin

Ps. I forgot to mention that I've been taking Saw Palmetto for many years, and I just added Pygeum extract, which is widely used in Europe for BPH, and the prevention and treatment of PC.[/QUOTE]

[COLOR="darkgreen"]
Research supports the worth of high quality saw palmetto (many brands are low in quality) for BPH, but it does not seem to help for prostate cancer. It is a mild "5-alpha reductase inhibitor" (5-ARI); you can get stronger 5-ARI action from the drugs finasteride and Avodart. However, while finasteride has been proven to have anti-cancer action, and while we expect proof soon for Avodart, saw palmetto acts in a somewhat different way biologically, and research indicates it lacks anti-cancer activity despite all the commercial hype. If you want to look at the research, try this search string, which results in 9 hits: " prostate cancer AND saw palmetto AND 5-alpha reductase ". Be sure to check the Hill paper. Also, as is common with researchers who focus just on a particular area and who are not expert in other areas, at least one of the papers mistakenly advocates saw palmetto over the drugs because it does not affect PSA, thinking that it therefore does not invalidate PSA readings but that the drugs do. This is not so, though the PSA baseline is reset for those men taking the drugs and the thresholds need different interpretation.

Take care,

Jim[/COLOR]





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