Newly-Diagnosed Prostate Cancer

BY MARK SCHOLZ

Now that prostate cancer has become a treatable disease—like hypertension or diabetes for example—new problems have surfaced. Selecting effective treatment has become complicated by plethora of different treatment options you are presented. Here is a very brief introduction to the types of therapy available for men with newly-diagnosed prostate cancer.

No Treatment

It is now becoming clear that thousands of men undergo aggressive treatment every year for a type of prostate cancer that will never be life-threatening. Active Surveillance, which means that treatment is only administered if the cancer continues to grow, is becoming more and more popular for men with the Low-Risk type of prostate cancer.

Local treatment

Surgery, radioactive seed implantation, targeted beam radiation and cryosurgery are all local treatments, which when administered by experts, can be expected to eradicate the cancer within the prostate with a high degree of consistency.  There are two potential drawbacks with all of these options.  First, these treatments can cause irreversible side effects to adjoining structures such as nerves that control erections, urinary, and rectal function.  Second, if the cancer has already spread outside the prostate the treatment may not cure the cancer.

Systemic treatment

Other options are designed to treat cancer both in the prostate and throughout the rest of the body.  These options include herbal, hormonal, immune and chemotherapy treatments.  The disadvantage of systemic treatments is that while they suppress the cancer, they usually fail to eradicate it completely. Systemic treatment aims to convert prostate cancer into a chronic, non-progressive condition and keep it stable for many years. Each type of systemic treatment is associated with its own unique spectrum of side effects. 

Combinations

This approach—systemic plus local treatment—is used for selected patients with aggressive prostate cancer who have a high risk of relapse with local therapy alone. Combination treatment offers the best chance for cure in patients with disease that has already spread or metastasized outside the prostate.

Selecting Treatment

The aggressiveness of each individual’s cancer is determined by typing.  The extent and grade of the cancer can be estimated with blood tests, biopsy information and scan results. For more details about “typing” your cancer see the brochure titled What’s Your Type available at pcri.org. 

Prostate cancer patients are more involved in treatment selection than those diagnosed with any other type of cancer. This is because with early-stage disease the best choice is based on quality of life considerations, not merely with survival.  Therefore only by examining the potential side effects of each treatment option, and comparing it with the other choices, can important distinctions and decisions be made among the alternatives.

Even though patient involvement in the treatment selection process is an absolute requirement, there are potential pitfalls. Clear and objective reasoning may be difficult during a time of shock and grief brought on by the diagnosis of cancer.  Strong emotions are also stirred up as one is forced to face the possibility of treatment-related, life-altering side effects that impact sexual, rectal, and urinary function. Patients can be prone to hurried treatment decisions instead of waiting until they have a full understanding of all the information. Despite reassurances, it is hard for patients to escape the lingering fear that unless they act swiftly, the cancer will grow and spread.  

Specific Recommendations for Selecting Treatment

1. Don’t rush into immediate treatment!
2. Obtain thorough and proper staging to determine the likelihood that the cancer has spread to a location in the body distant to the prostate.
3. Educate yourself thoroughly about this disease via sources such as the Internet, books, and support groups focused on prostate cancer.
4. Whenever possible, seek advice and treatment from doctors who specialize in treating prostate cancer. 

The Screening Paradox? Or Is It Just a Dilemma?

BY RALPH BLUM

Maybe it’s shabby of me to immediately think: It’s all about money. The pot of gold at the end of the prostate cancer rainbow. Well, the first dip into that pot is billing for all those PSA tests, DREs and biopsies. Standard screening procedures, right? Only it’s not that clear cut. More and more these days, I tend to consult with Dr. Google. Turns out there is disagreement in high places.

The American Board of Family Practice regards screening as less than effective; they don’t recommend it for prostate cancer. Meanwhile the American Urological Association staunchly maintains that screening saves a lot of lives—even if, as one urologist told me, “Thanks to screening, I may end up doing 38 unnecessary radical prostatectomies to save one life.”  When you get a specialty board at odds with a family practice group, it makes you think.

Then you have both the American Urological Society and the American Cancer Society discouraging screening for men whose life expectancy is 10 years or less. Why? Because the cancer, in most cases, is so slow growing that it can take that long for screening to prove useful. And besides, those men will probably die with it, not from it. Gina Kolata, science reporter for the New York Times, published an article “Screening Prostates at Any Age.” The piece opened with the question: “When, if ever, are people just too old to benefit from cancer screening?” Apparently never.

A recent study published in The Journal of Clinical Oncology reported that men in their 70s are being screened at almost twice the rate of men in their 50s. What’s that all about, given the life expectancy at that age? The study also found that men from 80 to 85 are screened as often as men in their 50s. Can you hear the chorus of clanging cash registers in the background?

Perhaps there is a more tolerant way to look at what, at first glance, appears to be blatant over-screening. Is it possible, Kolata wonders in her Times article, that late and continued screening provides a psychological “boost” for older men? A kind of placebo effect in the form of “evidence that death is not waiting in the wings?” (Some kind of Botox treatment for us sagging old geezers?) Obviously the cancer industry profits handsomely from that “delusive obsession.”

Fact: Some 50-year-olds do not require screening; some 75-year-olds may benefit from it. Certain prostate cancers are highly aggressive but do not produce much PSA. At the same time, since prostate cancer is usually asymptomatic until well advanced, plenty of doctors I respect consider it  dereliction of duty not to screen for and detect it when it is still curable. Hard to argue with that logic. The burden is on the doctor to prove the guy doesn’t have cancer. Which is why he orders the screening tests just like he orders a cholesterol test or CBC (Complete Blood Count) for anyone over 50. And then there are all the “diagnostic tests. . .” Still, as the saying goes, ‘Better safe than sorry’.” Your doc doesn’t want to hear from the lawyer for your estate.

As my departed friend, NBC White Paper producer Fred Freed never tired of saying, “There are no easy answers.” To confirm the truth of that dictum for this cancer, you ought to attend a monthly meeting of the Prostate Cancer Club at Michael Milken’s Santa Monica Headquarters, and listen to 30 or more of LA’s top urologists, prostate and radiation oncologists and diagnostic radiologists arguing over a dozen or so current papers on all aspects of prostate cancer, none of which command widespread consensus.

Why should screening be an exception? Keep it simple: If you have reason to think you may be at risk for prostate cancer, get screened. If not, go fishing. Or buy yourself a new putter. If you’re rising 80 and off having fun with your sweetie, ignorance may not be bliss, but it sure can contribute to your quality of life.

Avodart & Proscar for Men on Active Surveillance

BY MARK SCHOLZ

More and more men are embarking on active surveillance—close monitoring of their prostate cancer—rather than implementing immediate radical therapy. Of course, only individuals with carefully selected low-grade prostate cancer are eligible for this approach. During the extended observation period many men enquire if there are nontoxic interventions to improve their odds that the cancer will stay dormant. The important issue of diet often arises though that is not the subject of today’s topic. Hormonal treatment, on the other hand, is a treatment that calls for further discussion.

Targeted Hormone Blockade

Blocking testosterone production with testosterone inactivating pharmaceuticals (TIP) is an amazingly effective anticancer maneuver unique to prostate cancer. However, TIP is generally reserved for treating the more aggressive types of prostate cancer since it has potentially unpleasant side effects like impotence, weight gain and reduced muscle strength.  However, there is a way that hormonal therapy can be targeted to specifically block testosterone activity inside the prostate while sparing the rest of the body from negative side effects. Proscar and Avodart—both FDA-approved medications to shrink the prostate gland function by this very mechanism. They block a special form of testosterone called dihydrotestosterone (DHT) that only occurs inside the gland.  The general public is familiar with these medications due to their ability to reduce the size of the prostate gland and ameliorate a common problem familiar to aging men:  the need to get up frequently at night to urinate.  Yet thanks to their lowering effect on DHT, these drugs also have anti-cancer effects.   

The Benefits of Proscar and Avodart for Fighting Prostate Cancer

The effect of Proscar and Avodart against cancer have been evaluated in several double blind placebo controlled trials.  In one trial 18,000 men¹ were treated with Proscar or placebo for seven years. Ten thousand of these men then underwent a prostate biopsy. The Proscar treated men were 25% less likely to be diagnosed with prostate cancer, compared to the men treated with placebo. In two other double blind placebo controlled trials, Avodart was also shown to reduce the risk of a prostate cancer diagnosis by about 22%.^2,3

More recently, in a study reported in abstract form at the American Society of Clinical Oncology in March this year, 302 men on active surveillance were given either Avodart or placebo for 3 years. As is typically the case with men on active surveillance, repeat prostate biopsies were performed 18 and 36 months after the initial diagnosis to determine if the cancer was progressing.  Men who received Avodart had a progression rate that was 38% less than the men on placebo.

Another study published in European Urology retrospectively evaluated 288 men on active surveillance who received Avodart or Proscar that were compared to men who received neither.  After three years of observation, the biopsy progression rate was 50% lower—18% for the men on treatment vs. 36% for the men on no treatment.⁴

Is There a Downside Risk?

Given that Avodart and Proscar lower PSA by about 50%, the question becomes: “Are they masking the capacity of PSA to detect cancer progression?”  The answer is no.  PSA still rises in men with progressive disease.  In fact, studies show that Avodart and Proscar improve the accuracy of the PSA monitoring process, enhancing the likelihood of detecting High-Risk cancer.⁵  The standard approach in our practice is to offer Avodart or Proscar to all our patients on active surveillance. 

When taking these pills, about one out of five men will notice a modest reduction in their sex drive.  This reduction in libido may fade away after a few months with continued treatment.  Even so, if a reduction in libido occurs, we often simply advise stopping the medication since these medications are not essential to the active surveillance approach but rather an optional enhancement.

References

1. Ian Thompson, The influence of finasteride on the development of prostate cancer. The New England Journal of Medicine, July 2003.
2. Gerald Andriole, Effect of dutasteride on the detection of prostate cancer in men with benign prostatic hyperplasia. UROLOGY, 2004.
3. Gerald Andriole, Further analysis from the REDUCE prostate cancer risk reduction trial. The Journal of Urology, April 2009.
4. Antonio Finelli, Impact of 5-Alpha-Reductace inhibitors on men followed by active surveillance for prostate cancer.  European Urology, Vol. 59; 509.
5. Ian Thompson, Effect of finasteride on the sensitivity of PSA for detecting prostate cancer. Journal of the National Cancer Institute, August 2006.

Wanted: Safe Places Where Women Whose Men Have Prostate Cancer Can Talk About What Really Matters

BY RALPH BLUM

Fact of life: The presence of even a single man in any support group changes the nature of the conversation about prostate cancer.

As one woman told me, “When the men aren’t there, we talk much more freely about how the disease is affecting both of us psychologically—our worries, our fears, our need to put on a brave face. And how we feel about everything that is happening— or not happening—in the bedroom.”

I assumed that support groups for women whose partners have prostate cancer were plentiful—meetings where women can talk openly about the things men won’t talk about. As it turns out, in the entire United States, there is not one prostate cancer support group for women only.

At first, I couldn’t believe it, so I consulted Dr. Google, plugging in “Prostate Cancer” and “Women” and “Support Groups.” Nothing. I scanned the American Cancer Society, CancerCare, National Cancer Institute, Women Against Prostate Cancer (WAPC). More nothing. I checked out UsToo International, with its over 300 support groups nationwide, and came up with a handful of groups tagged “For Women Only.” To my dismay, I learned that those meetings served as preludes to regular family support groups, and that they only lasted half an hour!

A Light in the Darkness

Then my remarkable friend, Celestia Higano, MD, a prostate oncologist at the Seattle Cancer Care Alliance, put me in touch with Sylvie Aubin, Ph.D., who had created just what I was looking for: a support group that focused on the psychosocial issues that impact both men and their partners following a diagnosis of prostate cancer. She called it a “Spousal Support Group.”

According to Dr. Aubin, only in a Spousal Support Group, with no men present, are women able to talk unashamedly about their sadness and their fears. When a man is diagnosed with prostate cancer, woman must face the question: How will this change our lives? A big concern is financial survival, true enough. But they are actually more fearful of losing his emotional support—the agonizing possibility of life without him, without his companionship. Women need to hear from other women about how they how they are coping—what they are going, through and how they have survived.

“At home,” Dr. Aubin told me, “women always feel the need to put on a brave face, to contain their emotions, to become—like their men—solution oriented. That’s why the Spousal Support Groups are so desperately important. Men’s support groups are very focused on treatment options. My women’s group is entirely about the experience and the challenges. Men are uncomfortable looking at or dealing with intimacy issues. They’re socialized to ‘fix the broken chair.’ It’s almost impossible to get them to open up about how they feel. They seem to think that if they talk about their emotions, people will think, ‘Oh, so he probably can’t perform.’”

Dr. Aubin also emphasized women’s essential role as providers of accurate information, especially when it relates to a man’s emotional state. “We ask him, ‘Have you been feeling sad or depressed?’ And he goes, ‘No, not at all.’ Then we ask the spouse, and she says, ‘My God! He’s depressed all the time!’ It’s the rare man who feels comfortable bringing up his emotional problems in a group. But then a lot of women are also reluctant to talk openly about their intimate lives, even when it’s just among other women. Which probably explains why groups like mine are practically non-existent. And why, I regret to say, my group no longer meets.”

A Safe Place of Your Own

More than any other cancer, prostate cancer is a family disease. This country needs Spousal Support Groups, meetings exclusively for women and as plentiful, as available as 12 Step meetings. All I can do is urge you, the women who play such a huge role supporting us after we are diagnosed, to create a nationwide array of Spousal Support Groups.

And while you’re at it, you might want to start a Spousal Support Newsletter. And a Spousal Support website. Make the Internet your bush telegraph to put out the word.

Dr.Aubin nailed it when she said, “Believe me, a multitude of men owe their lives to their partners. I’d say to women, Come together and share your experiences. You are going to be his best helper. No urologist will ever love him like you do!” 



Zytiga (abiraterone): A Breakthrough for Men with Prostate Cancer

BY MARK SCHOLZ, MD

One of the unique characteristics of prostate cancer is its responsiveness to the withdrawal of testosterone. This “Achilles Heel” of prostate cancer was discovered in the 1940’s when surgical removal of the testicles was shown to induce cancer remissions. In 1985, Lupron, an injectable medication that works by tricking the testicles into ceasing testosterone production, was FDA approved. Orchiectomy, or surgical removal of the testicles, has been declining in popularity ever since.

Lupron works for an average of 2-6 years in men with metastatic disease, and for more than ten years in men without metastasis. When Lupron stops working, other hormonal agents such as Casodex or Nilutamide are commonly employed.  Their effectiveness is measured by monitoring prostate specific antigen (PSA).  A good response is signaled by a declining level of PSA in the blood.

Controversy has raged in academia about the significance of these PSA responses and whether or not they are an indication of extended survival. Before approving new drugs, the FDA mandates that pharmaceutical manufacturers document improved survival in prospective placebo-controlled trials. A trial of abiraterone (Zytiga) in men with a rising PSA while on Lupron has shown just that—volunteers who received abiraterone lived 33% longer than men who received a placebo.

Zytiga is a designer drug that exploits the relatively recent discovery that cancer progression is a result of prostate cancer cells manufacturing their own testosterone instead of feeding on testosterone originating from the testicles and reaching the prostate cancer cells via the bloodstream. Zytiga works inside the cancer cell by blocking the function of an essential enzyme in the synthetic pathway of testosterone.  On April 28, 2011, the FDA approved Zytiga, a product of Centocor Ortho Biotech which is owned Johnson & Johnson. We have conducted one phase early access protocol (EAP) and two phase III trials of abiraterone in our Marina del Rey office.

Side effects of Zytiga can include changes in potassium levels in the blood and rare cases of liver irritation. Zytiga has to be administered with prednisone, a form of cortisone. Cortisone can be associated with gastric irritation and occasionally stomach ulcers.  People with diabetes may experience higher blood sugar levels.

Since Zytiga will be offered at a cost of $5,000.00 per month, many men will be interested to know that its chemical mechanism of action is very similar to another more affordable medication already on the market—ketoconazole.  And a month’s supply ketoconazole is only $60.00.  However, there has been subdued enthusiasm for ketoconazole due to a very high frequency of adverse interactions with other common medications like Lipitor, Zithromax, Norvasc, Glipizide, Paxil, Prozac, Coumadin, Coreg and antihistamines.  It can also cause side effects such as stomach upset or liver problems. To be used safely, close monitoring on therapy is essential. Even so, if used cautiously, after close to 20 years of experience with ketoconazole, I have found that many men can tolerate it quite well.

For men who can afford it, or at least have insurance to cover the cost, Zytiga will be popular thanks to the much lower incidence of side effects.  Even with the major cost considerations I predict Zytiga will become the standard of treatment for men who are resistant to Lupron.  And just as Lupron is continued indefinitely, even after PSA begins to rise, Zytiga will probably be used indefinitely as well, even if the cancer is progressing.  After all, now that we know that Zytiga can deny the cancer cells the capacity to manufacture their own testosterone, why would we want to stop the medicine and allow those out-of-control cells to start producing testosterone again?