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Cancer: Prostate Message Board

Cancer: Prostate Board Index

[QUOTE=sbear1102;3998152]... It will be extremely helpful to us we consider all the options. ... I had a question for you about your dx. You mentioned that all your pre-clinical testing showed that the prostate cancer had not spread and was localized. Did you have a lymph node biopsy? or x-rays? My husband's urologist didn't think it was necessary for him to get further testing, and based on the pathology findings, felt that it is localized. I am wondering whether he should undergo additional work-up to r/o the possibility of metastatis. I feel pretty good that it hasn't, but I guess I'm being extra cautious. I'm sure I will have more questions for you, I will think of them as I discuss this further with my husband. Stay strong.[/QUOTE]

Hi sbear,

I too would like to welcome you and your husband to this board that all of us would have liked to have been an area of no concern and irrelevant in our lives. :) :wave:

kcon has written such a fine post, from the mind as well as from the heart, covering so much of what needs to be said. He also has the perspective of a young patient.

There is one comment in his response where the radiation doctors could probably make a convincing argument in their favor. It's where kcon wrote: "One of my considerations for radiation was that it doesn't remove the delays progression; it slows the cancer down. I learned that taking the radiation approach in my 40's would probably lead to having to deal with it again later in life. " Research for [U]more recent[/U] radiation technology can claim to destroy the cancer potential of the tissue it attacks with an adequate dose, though the tissue itself is not destroyed (in contrast to a technology like cryo therapy). If all the cancer is in the range of the radiation, and if an adequate dose is given, research very strongly indicates that that cancer is gone and will not be a further problem. One of the reasons for what kcon said is that there was a problem with [U]earlier[/U] external beam radiation as a dose around 60 Gy would not always kill all the cancer even when it was on target, though it would slow it down as kcon said. Now, radiation doctors know that higher doses are needed to assure that targeted cancer in the prostate is killed, and now it is a rare prostate cancer indeed that can escape an appropriate dose of properly delivered radiation, if that cancer is all in the range of the radiation. (You may also hear about a newcomer - CyberKnife with Stereotactic Body Radiotherapy (SBRT) dosing; that uses a much lower dose, about 37 Gy, but it is delivered more intensely in five sessions, which seems to make it about as effective as conventional radiation.)

By the way, "more recent" does not mean "yesterday." Dr. Dattoli now has follow-up results in the 14 to 20 year range, and many years of successful followup data are available from other researchers too. Much of the radiation research has survival and recurrence tables with a very nice characteristic: while the rates of success decline a bit as years pass, (similar to rates for any other therapy), the patterns tend strongly to flatten out after a certain number of years have passed. In other words, you see very few additional failures after those times. That's a strong indicator of success over the long-term, over the rest of our lives. :D

There are a number of good books on radiation that make this point effectively based on published studies. The one I know best is by Dr. Michael Dattoli and his co-authors, "Surviving Prostate Cancer Without Surgery - The New Gold Standard Treatment That Can Save Your Life and Lifestyle." The two books kcon recommended are great for an overview and orientation on key empowering aspects for all therapies and decision making (the Primer) and for surgery (the Walsh book, also covers aspects beyond surgery), but a good book by a radiation doctor like Dattoli would give you key information about radiation.

You mentioned that you were still looking at all the options; do you know that cryo therapy is another option that is now established? Dr. Gary Onik, one of the world's experts in cryo, and Dr. Centeno wrote a book that covers cryo well.

You asked about whether to strive for more information about the nature and extent of your husband's cancer. Dr. Strum, medical co-author of the Primer, represents the physicians who like to get as much information as they can in order to do the optimal tailoring of the therapy to the patient. For instance, he would like all new patients to have a PAP (not the one you know, rather Prostatic Acid Phosphatase) test run. (It's a simple blood test, like a PSA test, and the needed vial of blood can be drawn when blood is drawn for other tests with the same needle stick.) He cites research behind his recommendation in the Primer. Dr. Dattoli also feels that test is important for indicating whether radiation will be successful. (Other research shows that it helps predict the success of surgery too.) I believe Drs. Strum and Dattoli. On the other hand, I respect other doctors who feel that the PAP test does not add information that is independent of what you get from other tests. This is typical of the issues that are judgement calls, though calls informed by research, experience and reason.

Bone and CT scans, though, are on Dr. Strum's bad list if patients have low-risk case characteristics, and it appears your doctor has not recommended them, which is a good thing in my layman's opinion. (I'm a now savvy survivor in my tenth year with a challenging case, so I've learned a lot, but I've had no enrolled medical education.) Fortunately, the respected American Urological Association (AUA) has weighed in on the issue, also recommending that they add little or no value for men with low risk cases. You can see a recently updated thread about these tests.

As far as sampling lymph nodes, either in advance or at the time of surgery, the AUA has weighed in on that too, also advising that neither be done for low-risk men. These AUA recommendations are available to us in an 82 page document entitled: "Prostate-Specific Antigen Best Practice Statement." You are in luck as they update this document about every ten years, and they just updated it last month.

Your husband's case statistics look good, but there are at least a couple of steps you both could take. What seems like the most important is to make sure that Gleason Score was developed by a pathologist who specializes in prostate cancer, as contrasted with a general pathologist who handles tissue samples from boys and men, girls and women, for cancer and all other comers. If not, then it is really wise and important to get that sample reviewed by a lab that is expert in prostate cancer pathology. The Primer makes recommendations.

A second step is a low-chance-of-reward but high-payoff-if-successful tactic: a leading-edge-of-the-art Combidex scan of lymph nodes. That scan is excellent at finding metastasis to lymph nodes - far superior to surgical sampling of nodes. On the other hand, (1) it's unlikely that nodes will have metastases for low risk cases, and (2) competent Combidex scanning is now only available in the Netherlands. I'm not sure whether insurance would cover the expense for a case that appears so far to be low risk. One of us vets should start a thread about Combidex. Till that happens, you can get great information from the Prostate Cancer Research Institute, a non-profit organization, which devoted much of a recent issue of its newsletter (free, but they depend on voluntary contributions) to Combidex.

Be sure to checkout some of the posts on lifestyle tactics to help counter PC on this board. These tactics involve nutrition, supplements, diet, exercise (aerobic and strength) and stress reduction.

Take care, and I hope you don't have too bad a case of information overload :dizzy:! ;)

Jim :wave:
[COLOR="DarkGreen"]Hi again sbear,

kcon has already done a great job of responding to your concerns in this post, so I'll just add some comments to an excerpt of your post #13 in green where you might be helped by other thoughts or for emphasis of what he said. Jim[/COLOR]

[QUOTE=sbear1102;4005709]... I'm thinking of having him get a PAP test,

[COLOR="darkgreen"]Great plan! I have had one, but it was well into my therapy, and it might have been reassuring if I had had one near the start back in 1999. The PAP at "baseline" is a very handy piece of information to have! :cool:[/COLOR]

bone scan, and pelvic scan

[COLOR="darkgreen"]kcon (response to your #13) and I are both really doubtful about the value of these in your husband's case. Here's some information you probably do not know yet: neither scan is much good at catching very small metastases, which is highly likely to be the worst case now for your husband, with the normal case being no mets at all! :D The bone scan is more sensitive than the CT scan, but it still takes about 10% of cancer in an area of bone for it to show up as possible cancer in the scan. If you have 8% cancer in that area, for example, it is likely not to show up at all. The CT scan takes a rather large tumor in the lymph nodes, typically, to show up at all. That means you can have a fair amount of cancer in a node, but it won't show up on the scan unless it is large enough. Again, that's really unlikely in your husband's case.

Another aspect of deciding about the worth of these scans in your husband's case is what difference results would make in decision making. If your husband and you would want some kind of local therapy even if the scans were positive, with the reasonable objective, for instance, of "debulking" the cancer, then that diminishes the potential impact of positive scan results. On the other hand, if you both would reject surgery but turn to radiation if one of the scans were positive, that outcome of a positive scan, though highly unlikely, would enhance the worth of the scan results.

By the way, both these scans are excellent staging tools for cases with high risks of metastases, like my own case. However, even though I started with a PSA of 113.6 (flared to 125), a Gleason 4+3=7, all biopsy cores positive and most 100% cancer, perineural invasion, and stage 3 with suspected involvement of the seminal vesicles, both my bone and CT scans were negative. That's not that unusual, even in high risk cases. :D [/COLOR]

as well as another PSA test (I've seen on here and elsewhere that it can spike in a matter of weeks).

[COLOR="darkgreen"]PSAs are not a big deal to do and not expensive, and one now would help confirm what appears to be a fairly low-risk trajectory or, if a clear increase occurred, call for added urgency. The test should be done at the same lab with the same kind of test, and your husband should follow the usual preparation routine. However, a spike in a matter of weeks would be highly unusual in view of the reasonably low PSAV to date. Also, spikes are usually due to infection. Spikes due to prostate cancer, such as can sometimes be associated with PSA doubling times as short as a couple of weeks, are rare.

Unlike breast cancer patients who have no equivalent of the PSA, we prostate cancer patients have this wonderful blood test that is an excellent indicator of the status of the disease once we are diagnosed, provided our Gleason Score is not in the 8 to 10 range. (In very unusual cases, it can be unreliable with a lower Gleason, and my impression is that fairly often it is still fairly useful in the higher 8 - 10 range.) This is worth repeating: while PSA is not all that great a sign of prostate cancer since it doubles in brass in detecting BPH and infection, PSA is really good as a marker once we have the disease. All this means it is quite unlikely that aggressive prostate cancer is going to be able to make a big move on us that is undetected along the way. :cool:

Your husband could also add the PAP test at the same time as well as a 25-hydroxy vitamin D test. It's unlikely he's deficient in vitamin D at his age, but it's worth checking in my opinion because so many of us prostate cancer patients are deficient in vitamin D.[/COLOR]

... An appointment for a second opinion is scheduled with a specialist at the end of this month. My husband thinks it is ok to delay treatment for awhile, until at least beginning of next year but I feel like, to refer to another thread on this board "he is carrying a rattlesnake in his pocket".

[COLOR="darkgreen"]I'll just underline kcon's response about the rattlesnake for emphasis. IF you both decide to hold off on treatment, or even if you decide to go ahead, he would be very likely to increase his odds of success by implementing lifestyle tactics involving nutrition/diet/supplements, exercise and stress reduction - the last no easy task with all you both have on your plate at this time.

While the evidence is not yet conclusive for these tactics, it is pretty persuasive, enough to have motivated many of us to radically change our diets, to start popping a few pills, to pump some iron, and to log some miles on the treadmill or at the track. For a quick orientation take a look at the thread I started on 3/6/2008, "Nutrition & lifestyle tactics - books, resources, and a quick summary." I've also initiated threads on some elements of a lifestyle program including lycopene &/versus soy (12/8/2007), soy (12/15/2007), selenium (1/17/2008), pomegranate juice and extract (4/22/2008), selenium (SELECT Trial - 10/28/2008), soy and pomegranate (1/25/2009), a long response about vitamin D in a thread on calcium and vitamin D (5/23/2009), exercise (3/5/2009), and chondroitin (TO AVOID! - 3/7/2009).

Has your husband cut out red meat, pork, and flaxseed (or canola) oil yet, all of which look like bad bets for prostate cancer patients? (As you may know, flaxseed oil may well be helpful for women and for people with cardiovascular issues, but the evidence looks bad for consuming it if you are a prostate cancer patient. :() Unlike many cancers, for prostate cancer sugar does not seem to be a significant adverse factor in our diets, unless we have very aggressive cases. That's probably why many studies show that diets with ample fruit and some red wine appear to be beneficial to prostate cancer patients. :D Saturated fat appears to be the culprit that provides most of the energy for prostate cancer. :(

Is your husband taking a statin drug? Apparently there are very few significant muscle problems for those taking those drugs, and they appear to substantially reduce the risk of lethal prostate cancer, especially when taken for at least three years, as well as giving the well-known cardiovascular benefit, of course. :angel: Taking 50 mg of Co Q 10 helps eliminate a minor side effect when taking a statin.

It is possible that the green tea, pomegranate juice or extract, vitamin D3 etc. will be enough to counteract your husband's prostate cancer, slowing it down, or stabilizing it, or even decreasing it. His response to a lifestyle program in fact has value in assessing the seriousness of the case, helping indicate whether the case is mild or not. It's quite possible that your husband's PSA may decline! This is like what the allergists do when they "challenge" a patient with various possible allergens to see how the patient responds. In this case, the challenge is to see what happens to the PSA. However, while the lifestyle tactics probably help almost all of us, many of us will need something more. Also, patients do not have to do all the tactics in the lifestyle programs; the more they can do, the better.

Taking finasteride or Avodart is another option. Finasteride has mild proven effectiveness against prostate cancer, and it is highly likely that Avodart will also be proven to have similar impact. We should know within the next few weeks or months as two major clinical trials are due to report. For most of us, these drugs are virtually without negative side effects, unless you count growing more hair in male-pattern baldness areas as negative, which most of us don't. ;) In the quite unusual case that a patient does experience diminished libido, erectile function or breast irritation, these are apparently all highly reversible when the medication is stopped. Because both drugs reduce the size of the prostate by about a third, ejaculate will be somewhat reduced. Because of this and possible other affects on trying to have a baby, the leading doctors I follow advise men to bank sperm if they and their wives want more children.

He is so busy with work, we were planning on moving, and a baby due in October, everything all at once.

[COLOR="darkgreen"]This probably sounds nuts, but do you think you both could work in a short period of meditation each day? It could help.[/COLOR]

...I'm trying to be as optimistic as possible, while still considering it serious enough to not delay treatment. I'm worried that waiting until after October is risky. His urologist told him it is a slow growing cancer,

[COLOR="DarkGreen"]My layman's estimate is that your husband's cancer would not grow much in the next few months and would be quite unlikely to cross any key thresholds. As related above, you may even find that lifestyle tactics are able to knock the cancer back a bit or halt it in its tracks.[/COLOR]

however, he has a Gleason of 6, 4 out of 6 cores were positive for cancer, ranging from 15%- 30%, and his last PSA reading from April was 5.03. The reading before that was 3.7 in july of 2007.

[COLOR="darkgreen"]Those exact PSA scores are even better than what I had indicated as the likely worst case earlier - an increase of just 1.33 in about two years. I really think you would find some reassurance if you would take a look at the Dattoli groups' papers on a PSA velocity of up to 2.0 or greater in the year before diagnosis. While 2.0 turned out to be the most productive "cut point" in the studies, the lower the better, and your husband's annual PSAV appears to be fairly low, near the 0.5 per year mark.

The Gleason Score is on the encouraging side, as are the percentages of cancer in each core. While having more than 50% of the cores positive is a concern, it's quite possible that no more cores would have been positive if 8, 10, 12 or more cores had been sampled. With 6 cores sampled, just one positive core is making the difference between higher than 50% positive (4 of 6) and 50% positive (3 of 6). Usually, there seems to be less concern by doctors at the 50% point. You have good reason to be concerned and motivated, but you do not have to rush wildly into this.

I know you are not a physician,

[COLOR="darkgreen"]"NOT" for me and most of us, unless you count degrees from the School of Hard Knocks. ;) [/COLOR]

but are there any recommendations you can give as far as his upcoming appointment with his urologist? things to mention, request, etc. Thanks kcon.[/QUOTE]

[COLOR="darkgreen"]I believe daff recommended this before, but its worth making sure the urologist will use numbing agents and other anesthetics, and also that he will give a drug to prevent infection, such as a few Cipro pills. You might also want to ask about the advisability of taking finasteride or Avodart, especially if one or both of the Avodart trials for prostate cancer have been reported. If either of you is still interested in a bone or CT scan, you might want to ask the odds of a positive result for a case lie his (probably less than 1 in 200, as I recall) and how either negative or positive results would affect decision making in your husband's circumstances.

Take care,

Jim [/COLOR]

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