Important News on Active Surveillance

BY MARK SCHOLZ, MD

For men with prostate cancer on active surveillance or (“watchful waiting,” as it is often known), new and compelling data from a large study called the “PIVOT  Trial” was presented at the annual meeting of the American Society of Urology this May. In this trial, which started in 1994, 731 men volunteered to get either watchful waiting or immediate surgery based on a coin flip. The goal of the trial was to determine if immediate surgery prolongs life compared to watchful waiting.

The men in the study had a median PSA of 7.8. One strength of the study was the fact that 75% of the men were diagnosed after biopsy for a rising PSA (as opposed to feeling a lump on the prostate).  This means that these study results can be more easily compared to the situation men face in this modern era. The weakness of previously published watchful waiting studies was that they were done on men with more advanced disease, cancer that was diagnosed by feeling an abnormality on the prostate gland during a digital rectal exam (DRE)—so called palpable disease, a situation that is far less common these days. 

The breakdown of the risk categories of the men participating in the study was similar to what is commonly reported in men with newly-diagnosed prostate cancer in the modern era:

·         43% Low-Risk

·         36% Intermediate–Risk

·         20% High-Risk

The surprising finding, after 12 years, was that there was no difference in survival between surgery and watchful waiting in the Low-Risk or in the Intermediate -Risk group.  On the other hand, men who were in the High-Risk category did benefit with improved 12-year survival when treated with immediate surgery compared to the men with High-Risk disease who did watchful waiting.

The results of the Pivot Trial are very important because up till now only men with Low-Risk prostate cancer were thought to be safe candidates to do watchful waiting.  

We eagerly await the final publication of all the data from the PIVOT trial since expanding the recommendation for watchful waiting to men with Intermediate-Risk disease would essentially double the number of men in the United States who would be eligible for monitoring. Additionally, this new discovery that men with Intermediate-Risk prostate can be safely monitored provides even stronger assurance to men with Low-Risk disease who have been experiencing trepidation about forgoing immediate treatment.

The Diagnosis: Eight Basic Rules for Coping with Unwelcome News

BY RALPH BLUM

There is no easy way to receive the news that you have cancer, but it is important to realize that prostate cancer is typically not a death sentence. In fact the vast majority of men diagnosed with prostate cancer have the low-risk form of the disease, and will live a normal life span. Even those men diagnosed with the more aggressive kind of prostate cancer have effective treatment options available to them today.

Nevertheless, the psychological impact of receiving a cancer diagnosis can leave you reeling. You’re in shock, disoriented, and filled with fear. As one urologist told me, “Once a patient hears the word ‘cancer,’ most of what I tell him after that won’t be absorbed.”  So when it comes to being an informed patient, here are some basic rules:      

Rule #1: It is critically important to understand clearly your diagnosis and proposed treatment options. So always have your spouse or a friend accompany you to your appointment with the urologist, to take notes and to ask the crucial questions which, in your state of shock, may not occur to you at the time.

Rule #2: Recognize and resist your natural desire to rush into treatment. A combination of the urologist’s preference for surgery and most men’s terrified “just get it out” attitude, leads to tens of thousands of unnecessary radical prostatectomies every year—unnecessary because all of these men would have lived just as long without surgery, without the risk of losing both potency and normal urinary function and greatly compromising their quality of life.

Rule #3: Do not to waste your energy asking yourself, “How did this happen? Did I bring this on myself?” Regardless of your eating habits, exercise regime, or anything else that might contribute to getting this disease—you did not cause it. Prostate cancer is incredibly common. Like diminished sight and hearing, for many of us it comes with advancing age.  In the words of one well-known prostate oncologist, “If you are over seventy, and you don’t have prostate cancer, chances are you’re a woman.”

Rule #4: Be proactive. The days of the passive patient with a “Whatever-you-say-Doc” attitude are over. When it comes to obtaining the best care and treatment, the single most influential decision maker is you.  Do your own research, and become totally involved with your doctor in the decision-making process. And remember: this is the tortoise of all cancers. In most cases, time is on your side. So take whatever time you need to educate yourself. Learn what questions to ask your doctor about all your treatment options. Make sure you are aware of their short-term and long-term side effects.

Rule #5: Attend prostate cancer support groups. The leaders of many of these groups have dedicated countless hours to research; they are a fund of valuable information about different treatment options. Equally important, they are a trustworthy resource for locating the best doctors in your area. It can also be helpful to talk with men who have successfully navigated the medical minefield of prostate cancer. Never forget: every cancer case is different; what worked for other men may not be the right treatment for you.                                                          

Rule #6: Stay calm, be cool. Beware of terrifying yourself by thinking that every negative aspect of this disease applies to you. The very process of gathering the information you need to make an informed decision can be scary as hell. Do not be panicked by all the numerical tables, statistics, and graphs. Statistics measure populations; they do not apply to individuals. Statistics and pathology reports only tell part of the story. What is missing is the influence exerted by all the variables and intangibles that make you an individual.

Rule #7: Prostate cancer is a complex disease with many treatment options. So be prepared to take conflicting opinions from reputable experts in your stride. I have yet to encounter two urologists who agreed on everything. Which is why you need to trust your own instincts in determining which doctor and, if called for, which treatment is right for you.

Rule #8: Get a second opinion. Even if you are satisfied with your urologist, it is vitally important to get a second opinion, preferably from an independent board-certified medical oncologist—a cancer specialist—and if possible, an oncologist with a specialty in prostate cancer. Obtaining a second opinion doesn’t imply that you don’t trust your doctor. On a decision this important, you owe yourself the benefit of more than one person’s thinking.

Finding an oncologist is a cinch. Finding the right oncologist may require traveling to a major cancer center to talk with a leading edge specialist. Insurance will almost always cover the cost of a second opinion. You will need to take with you a complete transcript of your medical records, including all pathology reports and slides. And in order to get the best out of your appointment, take a written list of questions. And a friend. And a tape reorder.

Finally, I have to say it again: If you have just been diagnosed with prostate cancer, resist the impulse to rush into radical treatment that is quite possibly unnecessary and almost guaranteed to adversely affect the quality of the rest of your life. But if you do decide that your cancer calls for immediate treatment, have absolute belief in the effectiveness of the treatment you choose.

Screening for Prostate Cancer Can Be Risky Business

BY MARK SCHOLZ

PSA Screening is Defensible and Essential

The majority of radical treatment decisions are made on the basis and results of PSA testing. PSA or Prostate-Specific Antigen, is a protein produced by cells of the prostate gland. The PSA test measures the level of PSA in the blood. Due to the dangers of overtreatment some experts have proposed forgoing PSA  testing altogether. However, this attitude is like throwing the baby out with the bathwater, since early diagnosis and treatment of high-grade prostate cancer unquestionably improves survival and quality of life.  

Too Many Biopsies and Too Much Treatment

In a perfect world the diagnostic process would detect all high-grade disease early and ignore all low-grade disease. Is such a goal attainable? The way things stand, it is unlikely. The present system relies on an immediate prostate biopsy when the PSA passes a specific threshold. Unfortunately, when cancer is diagnosed, regardless of the grade or risk level, immediate surgery or radiation usually follows.  

Primary Care MD’s to the Rescue

Primary care physicians can alter this landscape in two ways: First, by taking a more measured and insightful approach to selecting men for biopsy (see below). Second, by not delegating the treatment selection process to urologists after a biopsy shows cancer.  Urologists and radiation therapists do not always provide unbiased advice. An overview of how to select treatment has been published in a brochure available at the PCRI, entitled, Treatment for Newly-Diagnosed Prostate Cancer.

Estimating Risk of High-Grade Disease Starts with Prostate Size

PSA is only “normal” in relation to prostate size.  Prostate volume in cubic centimeters is measured with ultrasound or with MRI. A normal PSA  reading is one-tenth of the prostate volume.  Abnormal PSA is when the reading is 50% above normal.  For example, an abnormal PSA for a 30cc prostate is 4.5, for a 50cc prostate, it is 7.5 and for a 100cc prostate, 15 is considered abnormal. 

The PSA Test Is Not Perfect

Infections, lab errors and recent sexual activity can all cause an elevated PSA, If there is an infection, a course of antibiotics will bring the PSA down. However a false reading can be ruled out  with repeat testing.   Recently, a new urine test called PCA-3 became commercially available. Studies show that the amount of PCA-3 in the urine increases in proportion to both the size of the tumor and the aggressiveness of the cancer. Unlike PSA, PCA-3 is unaffected by the size of the prostate. 

Imaging

Prostate imaging with endorectal MRI or color Doppler ultrasound is improving rapidly. These imaging techniques are useful for measuring prostate size and for detecting high-grade prostate cancer. While imaging is not 100% reliable, studies indicate that larger amounts of high-grade cancer can be detected fairly consistently.  In situations where the need to do a biopsy is debatable, a high quality ultrasound or MRI study may provide additional assurance that a biopsy can be safely delayed. 

Look Carefully Before You Leap

Rather than rushing into a biopsy at the first sign of an elevated PSA, screening should be seen as diagnostic process combined with an ongoing dialogue with the patient. As information is gathered by repeat PSA testing, PCA-3 levels and prostate imaging, the likelihood of a biopsy diagnosing either low-grade or high-grade prostate cancer can be presented to the patient and compared with the risks of a biopsy.  

There are many mistaken fears about prostate cancer. These unwarranted concerns need to be addressed before diagnosis, before the word cancer becomes personal, and a man’s  capacity for rational thought is impaired.  

Most elderly men have prostate cancer and don’t know it.  And most are better off not knowing. Diagnosing low-grade prostate cancer can be a curse. Frightened patients are ill-prepared to navigate a powerful medical system predisposed to over-treatment. How bad is it? One New England Journal of Medicine study estimates that our system is so skewed that 48 men receive unnecessary treatment for each individual who truly benefits. 

Part 2. Self-Hexing

BY RALPH BLUM

There is only one other form of abuse that approaches medical hexing for its pernicious influence, and that is self-hexing.  When you are diagnosed with any type of cancer it’s natural to ask, “Why did this happen to me?” Or “Could I have prevented it?” Or most pernicious, “Did I do something to bring this on myself?”

To some extent we are all responsible for maintaining our own health—for watching our diet, exercising regularly, and avoiding, to the best of our ability, the emotional stressors that negatively impact our immune system. But there are those who cross the line from responsibility into the zone of guilt and self-blame, who believe it is their fault they got cancer.

While no evidence exists to indicate that prostate cancer is some kind of “retribution” for sexual misconduct, I have met intelligent, rational men who, although they rarely discussed it, genuinely believe that they had brought on their cancer by being “bad boys.” After telling me about his promiscuity, one man said ruefully, “I guess I got what I deserved.” Logical? No. But in his mind, the just measure of “let the punishment fit the crime.

This kind of negative and irrational belief causes feelings of guilt and self-blame which, over time, create stress hormones that will weaken the immune system. As I have learned more about our ability to tilt the scales toward either healing or illness with our beliefs, I have become increasingly aware that those who blame themselves for getting cancer are sabotaging their chances of recovery.

Nor is this guilt-driven form of self-hexing exclusive to men. According to psychologist Carolyn Conger, there are women who blame themselves and who feel that they deserve their cancer. After her hysterectomy, one woman told Conger: “I let too many strangers into my body.”

Although I logged many miles as a bad boy myself, I was fortunate that it never occurred to me to connect my prostate cancer to my less than exemplary sexual history. However, I can see now that the way I was living for so many years made me a likely candidate for some life-threatening disease. Simply put, I did not take good care of my health. But instead of feeling guilty and blaming myself, I chose to see the cancer as a serious wake-up call. Rather than dwelling on how I may have participated in getting prostate cancer, I decided to participate in my own healing. I took the cancer as a heads-up, an urgent message from my body that I needed to review and reshape my life on all levels—physical, emotional and spiritual.

So if any of you reading this have impaled yourselves on the punji stakes of mindless old behavior, I say be done with self-hexing. “Reframe” your cancer: See it a catalyst for change. And give yourself a break. Go mountain climbing. Take your sweetie on a road trip. Go out and buy yourself a new putter. Expect a miracle—and talk to guys who have experienced one.

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