First Impressions Can Really Harm You

BY MARK SCHOLZ, MD

The human mind is constantly, searching, analyzing and processing our environs, attempting to make sense of the fluidly shifting situations that surround us. This mental process is healthy, designed to keep us in touch with reality.  “First impressions” are a good example of the powerful and rapid insights provided by these formidable processors we call our brains.  However, while first impressions are for the most part quite accurate, we all have learned at some point that they can also be misleading.

After interviewing thousands of newly-diagnosed prostate cancer patients, I have found that the first impressions of most patients about prostate cancer are almost always wrong.  Why?  There are several reasons.

First, there is no single type of prostate cancer. It is a condition that behaves quite variably. Therefore, it is hard to get your brain around the idea “I have prostate cancer,” and sum it up as a single sound-bite. Even though the word “cancer” would seem to be saying it all, the analogy of the three blind men touching different parts of the elephant works well here.

Second, despite the many variations of prostate cancer, none of these variations are similar to any other type of cancer. You cannot simply point to some other disease and say, “Just think of _____ . . .” (fill in some another cancer type here) and you’ve got it.  Prostate cancer is, arguably, unique among cancers. It has an exceptionally slow growth rate, a pattern of spread that uniquely spares critical organs like brain, lung and liver; it responds to a distinctive method of treatment, hormonal therapy, which commonly induces remission lasting more than ten years.  Moreover, prostate cancer is the only cancer that can be monitored with a one-of-a-kind blood test called PSA.

Third, while surgery is probably the best treatment for most other types of cancers, it is probably the worst (with occasional exceptions) for prostate cancer. And strangest of all, prostate cancer is the only common type of cancer that is exclusively managed by surgeons, rather than by medical oncologists).

As a result of all these one-of-a-kind characteristics, the way that men with newly-diagnosed prostate cancer manage their first impressions has a major impact on the treatment they will receive. Initially, men logically assume that prostate cancer is imminently life-threatening, just like other types of cancer. And for most cancers, surgery is best way to go about getting cured. 

The majority of urologists still tend to repeat their favorite mantra—“Surgery is the Gold Standard”—and to urge men to undergo ill-advised surgery. However though advances in seed implant and radiation therapy technology, the mantra is now outdated.  Newly-diagnosed men can avoid any regrets if they take time and truly investigate their options. “Don’t Rush!” should be their mantra. Men need time to calm their over-stimulated minds, time to regain their emotional bearings, so they can do the research necessary to make an informed decision.

How to Find the Right Specialist

BY RALPH BLUM

When your primary care physician suspects that you have prostate cancer, your first, and arguably most important task, is to find a specialist who is skilled at diagnosing and treating the disease, and with whom you have a good rapport. Meaning, you feel comfortable with that doctor.

Usually your primary care doctor will refer you to an urologist for a definite diagnosis, but before you take this step you need to be aware that all urologists are not created equal. Most urologists—aka surgeons— have a medical practice at least half of which involves treating problems like impotence, incontinence, infections, and kidney stones. The majority perform only a handful of prostate surgeries annually. So ask your primary care doctor if he can recommend an experienced urologist in your area who specializes in treating urologic cancers.

If you are uncertain about your doctor’s referral or want to go beyond your local area to find a urological specialist—perhaps in a larger hospital or major medical center—just remember that you have time. It’s a good idea to take several weeks to network with friends who’ve been through it and support groups.

By all means, do research on the Internet. Make sure that you select a specialist with extensive experience. By consulting “Dr. Google” you can locate the best prostate cancer web sites and doctors. And under the heading “Resources” on the Prostate Cancer Research Institute web site, pcri.org you will see a section called “Finding expert physicians.”

The kind of urologists you want will thoroughly discuss all appropriate treatment options with you—radiation, seed implants, different kinds of surgery available—in an even-handed manner. If board certified, they are obligated by law to do so. And if, for example, you express interest in radiation, they will refer you to a radiation therapist to discuss that option.  But unless your age or physical condition make it inappropriate, most urologists likely to recommend surgery. Surgery is, after all, their specialty.

Regarding radiation, the latest studies (although not perfect) indicate that for most men, either permanently implanted radioactive seeds or intensity modulated radiation therapy (IMRT) are at least as effective as surgery, with similar cure rates, and are, in most cases, performed without the risks associated with a major surgical procedure.

You should also, if you can locate one, consult with a medical oncologist who specializes in treating prostate cancer. Not being directly involved in either surgery or radiation, these specialists are not as likely to have any bias in their recommendation.

Whichever specialist you consult there are a few basic questions it’s a good idea to ask:

•  How long have you been treating prostate cancer patients with this treatment?

•  How many prostate patients have you treated? How many radical prostatectomies and robotic procedures have you performed?

•  Why do you recommend this particular treatment for me?

•  What are the possible side effects of this treatment?

•  What are your success rates for patients with a diagnosis similar to mine?

The following questions which, since they all relate to surgery, apply only to a urologist:

•  How many prostatectomies do you perform each year?
•  What is your success rate with the preservation of sexual potency
•  What about urinary continence?  How frequent is it? How do you deal with it?

•  Do you perform nerve-sparing surgery? (Nowadays most surgeons do.)

•  Do you perform robotic surgery? If so, how many robotic procedures have you performed to date? (Anywhere up to 150 procedures, and you are still part of a surgeon’s learning curve.)

•  What percentage of your patients are approximately my age?

This last question is important because if you are in your 50s and most of the doctor’s patients have been over 70, he may be less knowledgeable about preserving your potency and continence than a doctor who treats more men of your age.

Choosing the right specialist is a decision that will have a significant effect the rest of your life. So I repeat, take your time. And make sure that the doctor you choose gives you confidence that the treatment he recommends will be successful.

MDV-3100—An Embarrassment of Blessings

BY MARK SCHOLZ

Every day in the office, as a practicing prostate oncologist, I confront serious problems:  PSA levels that are rising, treatments causing too many side effects, patients desperately worried about their future. And sometimes, given our limited tools, the solutions we can offer are only partial. However, every time the FDA approves a new treatment there is an excitement akin to opening gifts on Christmas morning. All of a sudden we have a shiny new tool in the tool chest to help us do a better job.

I’ve repeatedly gone on record criticizing the FDA for the inflexible format they use to approve any new drug.  They insist on survival as the only important measure of effectiveness. There has to be a better way to study new drugs than giving a placebo—an inert substance containing no active ingredient—to unfortunate people who already have a life-threatening illness. But this is the format our government demands—forcing pharmaceutical companies to prove that their new anti-cancer drug works by comparing them with sugar pills. And so the human sacrifices continue.

However, back to the good news, the spirit of Christmas morning. Medivation, the manufacturer of MDV-3100, a new drug that is estimated to be twenty times more potent than Casodex, recently reported a significant survival advantage in their study comparing MDV to  the of unfortunate souls who got placebos. In other words, Medivation cleanly jumped over the bar set by the FDA. Since MDV-3100 was not associated with any unexpected side effects, the FDA will be essentially forced to hold up its end of the bargain and release it soon for commercial use.

Some are saying that MDV is just a copycat of Zytiga, one more expensive testosterone blocking pill in an already busy marketplace. I disagree completely:

1.       Since MDV has few side effects, it can be easily combined with other popular treatments like Provenge and Taxotere.

2.       Since the mechanism of testosterone blockade is completely different from Zytiga, it’s possibly that the anticancer effects of Zytiga and MDV will multiplied if they are given together.

3.       Due to its ease of use, it will be popular with the urologists, the surgeons who are charged with managing most men with prostate cancer.

My “Christmases” seem to get better every year.  Last year the tool chest was expanded to include Zytiga, Provenge and Jevtana. And there are also some amazing new drugs waiting in the wings—Ipilimumab, Dasatinib, XL-184, Revlimid and more. We finally seem to be entering a new, hopeful era for prostate oncologists—and, most important, for their patients.

In Praise of Life in the Libido Free Zone

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Hormone Blockade Effectively Controls Prostate Cancer

BY MARK SCHOLZ

Ralph Blum, my coauthor of Invasion of the Prostate Snatchers, monitored his prostate cancer for 14 years before starting treatment in 2004.  Prior to meeting me, Ralph had been living in Hawaii and managing his own case.  However, when his PSA rose above 10 he came to Marina del Rey for a consult. I advised him to start treatment with either IMRT or Testosterone Inactivating Pharmaceuticals (TIP).  Ralph, after considerable uncertainty and discussion, embarked on TIP for 12 months.  So far he has required no additional therapy.

At Prostate Oncology Specialists, back in the 1990s, when radiation was more prone to burn than cure, we commonly treated men with TIP followed by active surveillance. Our first published report on the feasibility of intermittent TIP was presented at the annual meeting of the American Society of Clinical Oncology in 1997¹ and later published in The Oncologist in 2000.² In 2006 we updated our experience with intermittent TIP in the Journal of Urology and reported that Proscar (finasteride) extends the time-off period” after TIP is stopped.³

This December Clinical Genitourinary Cancer will publish our long-term outcome of 73 men treated at Prostate Oncology Specialists with TIP and monitored for a median of 12 years after treatment. A preprint of the article is available on our "publication" webpage found at prostateoncology.com. Here are the take-home messages we reported in the article about using TIP as first line treatment:

1.     Almost a third, 21 men, have not required any further treatment.

2.     One third, 24 men, have kept their PSA less than 5 with further cycles of TIP. 

3.     After an average of 5.5 years, slightly more than a third, 28 men, underwent delayed local therapy (surgery, seeds, IMRT or cryotherapy). After an additional six years observation, three men have developed a rising PSA (PSA relapse).

4.     Local treatment was administered much more frequently to younger men (whose testosterone recovered more quickly when TIP was stopped)—and to men with D’Amico High-Risk category disease (PSA > 20 or Gleason 8,9,10)—compared to older men and to men who were in the D’Amico Low-Risk or Intermediate-Risk categories.

5.     Mortality from prostate cancer was low.  After twelve years only three men (4%) died of prostate cancer, and none of the remaining 70 men developed metastatic disease. This result compares favorably to a group of 350 men with similar-stage prostate cancer treated with immediate surgery whose ten-year outcome was reported in the New England Journal of Medicine in 2005.⁴ In this group fifteen percent developed metastases and an additional ten percent died of prostate cancer. 

Unfortunately TIP, like all forms of prostate cancer treatment, is associated with a number of undesirable side effects including weight gain, muscle weakness, absent sex drive and hot flashes. However, for most men these side effects are either treatable⁵ or reversible.  Even so, as we have reported in the summary above, many men treated with TIP will, at some point, require further treatment, either with additional TIP or some form of local therapy.

All this not withstanding, in my mind there is no doubt that Testosterone Inactivating Pharmaceuticals (TIP), when appropriate and applied in a timely manner, acts effectively to control prostate cancer.

References:  Copies of all the articles referenced in this blog are available at our webpage  http://prostateoncology.com/education/publications

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