Happy New Year

We will be back next week!

Merry Christmas and Happy New Year!

We're taking the holidays to gear up for 2014. We'll be back on 7 January. Here is a recap of the 2013 year in review - new social media launches.

THE PROSTATE VANGUARD  An email list for those interested in Active Surveillance and Imaging.  Learn more about it from Dr. Scholz http://www.youtube.com/watch?v=3c8lZPyOv04  and you may subscribe here: http://www.prostateoncology.com/contact/subscribe

KEEP MY PROSTATE  Stay tuned for a new web site launch in 2014
http://www.keepmyprostate.com/

GOOGLE+ DR. SCHOLZ and PROSTATE ONCOLOGY  Keep up on local events and news
google.com/+Prostateoncology
 
GOOGLE+ HANGOUTS with Prostate Cancer Live discussing The Overtreatment of Prostate Cancer https://plus.google.com/#s/%23hangoutsonair
 

CLINICAL TRIALS Current trials open for recruitment at Prostate Oncology Specialists

http://www.prostateoncology.com/clinical_trials

 

Wishing you and your loved ones a wonderful holiday season.

PSA Screening for Prostate Cancer

BY MARK SCHOLZ, MD

Most elderly men already have prostate cancer—they just don’t know they have it.  And they might be better off remaining ignorant. Newly-diagnosed men are thrown into an eight-billion-per-year medical world that extols radical treatment. Over-treatment is so out-of-control that a New England Journal of Medicine study estimates that forty-eight men are getting unnecessary surgery or radiation for each individual who truly benefits from them.

Random Biopsy, Not PSA is the Real Problem
When PSA is elevated, primary care physicians usually refer to a urologist for an immediate 12-core random prostate biopsy. One million men are biopsied annually in the United States. Few people realize that even when the PSA is normal, the biopsy will be positive 20% of the time. The problem is that a diagnosis of any prostate cancer, even the Low-Risk type, almost invariably leads to surgery or radiation.

Biopsies Are Not Benign
Over-diagnosing Low-Risk prostate cancer, and the attendant risk of over-treatment, is not the only problem caused by random biopsy. Consider the emotional devastation caused by a cancer diagnosis. Men are literally frightened to death by the discovery of prostate cancer: The first week after diagnosis, the risk of suicide and heart attacks jumps dramatically. In addition, 3% of men suffer biopsy-induced infections resulting in hospitalization. Fatal infections are estimated to occur in approximately one-thousand men undergoing random biopsy per year.

Stop PSA Screening?
Due to all these mounting negatives, the US Preventative Services Task Force now recommends that routine PSA testing cease altogether. The Task Force’s conclusion was that unnecessary treatment to over a hundred thousand men annually is too big a price to pay even though PSA screening saves lives. The Task Force fails to understand that overtreatment isn’t caused by PSA, it’s what physicians do with the information PSA provides—they automatically refer every patient for immediate random biopsy.

PSA Is Heavily Influenced by Prostate Size
Most PSA originates from the prostate gland, not from cancer. Therefore, when the cancer is relatively small, PSA is a reflection prostate gland size. In a man without cancer, PSA normally averages one-tenth of the prostate volume. For example, the average PSA for a 30cc prostate is 3; five for a 50cc prostate and 10 for a 100cc prostate with size determined by ultrasound or MRI.

Therefore, PSA can only be termed “abnormal” if it’s 50% higher than expected, based on a man’s prostate size. For example, an abnormal PSA for a 30cc prostate is 4.5, a 50cc prostate, 7.5 and a 100cc prostate, 15. Additional extraneous factors such as low-grade infections, lab variations and recent sexual activity can also cause PSA to vary.  Repeat testing helps average out these variations so the “real” PSA can be determined.

Primary Care Doctors Are the Source for Balanced Counsel
Only the primary care physicians can stop the mindless rush to random biopsy. Instead of referring for random biopsy they can send their patients with elevated PSA for prostate imaging with multiparametric MRI or Color Doppler Ultrasound. Imaging can put the PSA elevation into context by determining the prostate size. Also, in the hands of an experienced radiologist, using state-of-the-art, three-Tesla MRI, high-grade cancer can be ruled out with 95 to 98% accuracy.

If imaging detects a high-grade lesion, primary physicians can then counsel their patients about whether a targeted biopsy directed at the abnormal lesion should be performed. Alternatively they can recommend simple monitoring with a repeat imaging study six to twelve months down the road to determine if the lesion is growing. Lastly, if a targeted biopsy shows cancer, rather than being guided by a urologist, who is, after all, a surgeon, patients can obtain counsel from their primary physician, a non-surgeon who can provide unbiased assistance in selecting the best treatment.

Estimating Cancer Risk
If men are concerned about the risk of forgoing an immediate random biopsy they can estimate the percentage likelihood of harboring low-grade or high-grade disease with an online calculator by googling, “risk of biopsy-detectable prostate cancer.”

Imaging Rather than Biopsy
Prior to PSA screening men should be informed that if PSA is high, the first step should be imaging rather than random biopsy. Random biopsy can cause serious infections. It also diagnoses Low-Risk prostate cancer, a harmless condition that nevertheless, often leads to unnecessary treatment. PSA screening, while saving lives by detecting High-Risk cancer at an early stage, can also, if handled improperly, lead to unnecessary treatment with many lifelong side effects.   

Detoxing for Jocks

BY RALPH BLUM

Recently my friend Michael Crocker—who is 59, a serious athlete (He calls himself “an over-the-hill jock”) and, because of his family history, at risk for prostate cancer—decided that he was not paying half enough attention to the  his diet. He was exercising and getting regular PSA evaluations, but he was eating as he always had, gaining weight and feeling that something in his diet was causing him bloating  and discomfort. He decided he might be having an inflammation reaction from foods that, while not allergy based, created a food intolerance that might be irritating his gut, leaving him depressed—and adding undesirable calories/weight. He put himself on what the profession calls “a food restriction diet.”

Michael made a list of what he called possible “food triggers” and going one week at a time, began eliminating them from his diet—and watching for improvement like decline in acid reflux, better sleep, more energy.

Here is Michael’s list of foods removed from his detoxing diet. He began by subtracting soy, then moved on to wheat and dairy and shellfish, He severely limited his sugar intake, cut out artificial sweeteners entirely, allowing himself honey in small amounts.

After about eight weeks, Michael told me, “I’m eating lean and clean, and probably eating more vegetables and fruit than I ever have before in my life.”

He started reading labels, something he had never done before. (“Jocks don’t read labels. Or at least they didn’t use to.”) He discovered that the FDA had called for labeling of “food allergens” in any packaged food (most of his items) and that even if items like soy were not specifically branded, they must be labeled somewhere on the package.

By the end of three months, Michael was eating limited amounts of lean meats, concentrating more on vegetables and fruits, and adding a side order of brown rice or sweet potato when he craved carbs. He rarely felt hungry on this diet. He dealt with his craving for snacks by carrying a bag of “Trail Mix” in his briefcase.

Here is a menu he found from Dr. Amy Shah on “RiseEarth”. As Dr. Shah writes in mindbodygreen

 A typical day may look like this:

 •    When you wake up: 1 glass green juice

•    Breakfast: Chocolate Cherry (Green) Smoothie: spinach, raw cacao, frozen organic cherries, chia seeds, coconut milk

•    Snack: Herbal tea

•    Lunch: Large salad with avocado, olive oil, balsamic dressing, and tomato soup

•    Dinner: 3 to 5 Black bean burgers (no bun) with guacamole, and salsa. (Optional: sweet potatoes, veggies, and kale chips)

 

•    Dessert: 1 serving of dark chocolate (my favorite is Green and Black's 85% dark)

Michael found that he was never hungry on this type of diet, and that while he wasn’t sure exactly which of “the usual culprits” had been causing his discomfort, he was happy to live with the results (including significant weight loss) of what he calls “The Aging Jock’s Anti-Inflammatory Detox Diet.” Aka AJAIDD.

Another Milestone at Prostate Oncology, Father Joe Gets his First Apartment

BY MARK SCHOLZ, MD

Father Joe Johnson has been with Prostate OncologySpecialists since its inception. Twenty years ago, after he retired from parish work, he started pursuing his lifelong interest in medicine and computers by volunteering to do internet searches to help find new treatments for our cancer patients. Doing an internet search does not sound like a big deal today, but back in the early 1990s there was no Internet Explorer (or Netscape Navigator for that matter). Getting online required substantial computer expertise and information could only be accessed through medical libraries by payment of an annual licensing fee. Father Joe was well equipped for his radical career change out of parish work. He had previously spent a number of years as a chemistry teacher at Loyola University.

A few years later, when searching the internet became a more straight-forward proposition, Father Joe asked if he could help out in some other capacity. Our practice had a large database of early-stage prostate cancer patients who were treated with hormone therapy, but we lacked the statistical skills to analyze the results. I knew of Father Joe’s lifelong interest in mathematics, and wondered if he would consider tackling medical statistics on our behalf.

For those of you who don’t know, qualified statisticians are rarer than diamonds and far more expensive and difficult to come by. To make a very long story brief, Father Joe subsequently mastered medical statistics and has coauthored all the scientific publications at Prostate Oncology.

Throughout all the years of unsung service volunteering in our office—which as you probably know, focuses exclusively on the treatment of prostate cancer—Father Joe has been a constant and immovable rock of steadfast optimism and hope, visiting with patients and keeping them company while the doctors and nurses rush around trying to stay on schedule. Sure, after entering an exam room and introducing himself as a Catholic Priest he has to good-naturedly endure innumerable bad jokes about his being there to give last rites. But almost invariably people quickly warm up to his friendly presence. I strongly suspect that some of our long-term patients are only willing to suffer the terrible Marina del Rey traffic because of the pleasure of visiting with Father Joe.

Perhaps it’s reasonable to expect patients to put up with the terrible traffic since they only have to endure it on a periodic basis. But what about me? Back when I lived in Long Beach I used to suffer the traffic daily. Being a problem solver by nature, I began considering the purchase of a limousine. My plan was to black out all the passenger windows and don a cap every morning so that I could pretend I was chauffeuring a passenger and drive in the diamond lane. However, it was Father Joe who rescued me from my law-breaking soul.

One evening, after a long day at the office while bemoaning my own tiresome commute home, I discovered that Father Joe was on the lookout for a new place to live. Once our mutual need was discovered it led to a quick solution. Father Joe had lived in trailers off and on throughout his life. And my home in Long Beach had a huge, unused backyard easily accessible through an alley behind the property. After a quick search of the classified ads, we made a phone call. That same evening we purchased Father Joe’s new home and had it delivered to my back yard. For the next five years Father Joe’s calm and loving presence helped me fight the good fight on the 405 freeway morning and evening.

The privilege of taking the diamond lane was definitely a huge improvement. But in 2003 I got the opportunity to purchase a home ten minutes from the office. The problem was that the backyard of the new house was a hillside, with no place for a trailer. What about Father Joe? My initial calls around the Marina were very discouraging: all I was encountered were ten-year wait lists. But the problem was solved when we found out that a relative of one of our patients owned the marina across the street from the office. Father Joe has been living happily in a boat ever since. Clearly he has friends in high places.

Father Joe’s odyssey of volunteering at Prostate Oncology began twenty years ago when he was a young man. But now at age 82, what the heck is he doing living on a boat? Thank God he has not slipped on the wet dock or fallen into the water off his rocking boat. Last night I showed him a new apartment located a mere three-minute walk from the office but he ended up asking me to take him back to sleep on his beloved boat. After a lifetime spent in the small spaces of boat and trailers, to Father Joe, the one-bedroom apartment is gargantuan. I’ll take another run at getting him to stay at the apartment tonight. If that doesn’t succeed I may have to sink the boat.

Active Surveillance: Knowing the Players, Betting the Odds

BY RALPH BLUM

Prostate cancer screening has led to the diagnosis and treatment of many cancers that would not have become life threatening during a man’s lifetime. Since Mark and I published our book, Invasion of the Prostate Snatchers, stressing the over-treatment of prostate cancer, the ascent of Active Surveillance has become the most game-changing factor in the management of this disease. And yet with the popularity of robotic surgery both doctors and patients are still opting for cutting out prostate with low-grade cancer unnecessarily.

Johns Hopkins was way ahead of the curve with their Active Surveillance program. In 2011, Hopkins published the results of a study involving 769 patients with low-risk prostate cancer who had been deemed eligible for the program. After seven years, only about 50 percent of the men had been treated with surgery or radiation. This meant some 385 men got a pass on one or another of life’s more risky and unpleasant procedures. Furthermore, it must be noted that not a single patient enrolled in the Hopkins’ Active Surveillance program died of prostate cancer.

The best prostate surgeons operate on an extremely small percentage of men over the age of 70, even though they meet the criteria for low risk disease. In fact, Hopkins only intervenes surgically in about 1 percent of those men. On the other hand, nationally, more like 80 percent are undergoing surgery or radiation. More than 90 percent of men over 65 with low to intermediate risk disease undergo treatment even though it is unlikely to extend their lifespan.

Active Surveillance reduces this radical over-treatment of low-risk, indolent cancers while allowing for curative intervention if and when the cancer progresses. Yet despite the obvious virtues of Active Surveillance, the dominant view in prostate care is that everyone who gets diagnosed gets treated in a one-size-fits-all approach regardless of their age, or the grade and stage of their cancer. Which means prostates are continuing to come out at a record pace, even though there is no benefit from the procedure. Senior urologists at top academic medical centers blame a host of reasons, not the least being the pressures on for-profit private hospitals to boost the volume of procedures in order to maintain their annual profit margins. Unfortunately, there are always financial issues involved.

While evidence is mounting that for men with low-risk disease Active Surveillance is both sensible and safe, the challenge is to further refine the protocols for separating out low-risk men from the men facing uncommonly aggressive tumors. In this regard there are some new genetic tests called Prolaris and Oncotype that help detect prostate cancer’s bad actors.

Meanwhile, if your prostate cancer has been diagnosed as low-risk (which has been defined as a Gleason Grade less than 7, a PSA less than 10), and your doctor is recommending immediate radical treatment, my advice to you is to get a second opinion from a doctor who has experience in treating patients with an Active Surveillance protocol. And if the time comes when you do trade Active Surveillance for surgery, never—repeat never—hesitate to ask the surgeon you are considering employing how many radical prostaectomies he performed this year. And last year. And the year before. I have been astonished to learn that hundreds of well-regarded urologists have performed fewer than ten a year. Last time I heard, between 150 and 200 procedures qualified you as “expert.” At that pace, you’d need to be a medically trained vampire to qualify. As for robotic surgery, it makes no great difference: I still want you closing in on 200 procedures, of whatever kind, before you get access to the prostate of any of my friends!

The ROYAL Shade of Blue

BY MARK SCHOLZ, MD

Men in the ROYAL shade have metastatic prostate cancer that has spread to bone, or, to lymph nodes outside the pelvis, or, they have a PSA over 100, or, they have a rising PSA with a low testosterone level. Metastases are typically detected by doing a body scan or a bone scan.

Men with advanced prostate cancer tend to live longer than men with other types of cancer. One major reason is because prostate cancer doesn’t usually spread to critical organs like the brain, the liver or lungs.  Another reason is the availability of so many effective treatments. Standard hormonal treatment with Lupron and Casodex, for example, can induce long remissions. And just recently, the FDA approved two new types of hormone therapy—Xtandi and Zytiga. These medications are so powerful they can induce remissions in men who have become resistant to Lupron and Casodex. In addition to Xtandi and Zytiga, two non-hormonal treatments—Provenge and Xofigo—have also been recently approved by the FDA.

Since so many effective treatments are available, wasting time on a treatment that has stopped working is a terrible crime. Therefore, after initiating a new treatment close monitoring of disease status is essential. Monthly blood tests and PET scans with sodium fluoride or carbon 11 acetate help to determine when a specific treatment stops working. Ineffective treatment should be stopped as soon as disease progression occurs so that a more effective therapy can be started in a timely fashion.

Treatment for ROYAL
Men in the ROYAL category who have never had hormone therapy should start testosterone inactivating pharmaceuticals (TIP).  The standard approach is to begin with Lupron and Casodex in combination.

Men who have become resistant to Lupron, but have fewer metastases and a slower PSA doubling time, should take Provenge to boost their immune system. Studies show that Provenge works better when treatment is started earlier. Preliminary research has also suggested that Provenge might be more potent if it is combined with spot radiation directed at a site of metastatic cancer. Studies to evaluate this possibility are ongoing.

With or without Provenge, radiation to cancer metastases has historically been reserved for controlling bone pain, a use for which it is quite effective. However, newer thinking suggests that radiation directed to all known sites of metastases—when the numbers of metastases is relatively small, say less than five—may occasionally lead to longer remissions.

Potent medications to strengthen the bones—Xgeva and Zometa—are routinely recommended when bone metastases are present. These medications have three potential benefits: They inhibit cancer growth in the bones; they reduce bone pain; and they help counteract calcium loss that hormonal therapies commonly cause.

If men in ROYAL have the type of prostate cancer that progress quickly while on Lupron and Casodex, the first step should be to stop Casodex and start one of the following three options:

1.    Second-line TIP such as Zytiga or Xtandi

2.    Chemotherapy with Taxotere or Jevtana

3.     Xofigo, a form of injectable radiation

Three additional treatment options can be considered if these first three options are no longer effective in controlling the disease:

1.       Combination chemotherapy using Carboplatin or Xeloda with a Taxane or the combination of both Revlimid and Avastin added to a Taxane. 

2.       The “off-label” use of Cabozantinib (XL-184), a medication being researched for prostate cancer but already FDA-approved to treat thyroid cancer

3.       Other investigational medications

Investigational trials represent an opportunity for patients to get medications prior to FDA approval.  A patient’s enthusiasm for embarking on a study that uses an investigational medication, however, needs to be tempered by what is actually known about the effectiveness of the specific medication.  Some medications are so new that even the investigators performing the trial don’t know if they are going to work or not.

While on treatment men need to have their blood monitored monthly by checking PSA, PAP, ALP and CTC levels. Medication side effects and cancer-related problems also need to be screened for with monthly blood tests such as CBC, a metabolic panel and a hepatic panel.  A periodic bone scan and body scan should be performed to track the disease status.  Two to three months after starting a new treatment, if the blood markers are not improving, a change in therapy needs to be considered.    

Reducing the Side Effects of Treatment
Fatigue is one of the biggest challenges faced by men in ROYAL. First, both chemotherapy and radiation can cause tiredness. Second, muscle loss is a frequent occurrence from TIP-induced, low testosterone.  Stimulants such as Provigil or Nuvigil may be helpful, but the most important priority is to counteract muscle loss with consistent, diligent exercise. Resistance training with weight lifting is only known effective method for restoring muscle mass.

Xgeva and Zometa cause gum recession and infections of the jaw bone, a condition called osteonecrosis.  This phenomenon is much more likely to occur after a tooth extraction so men on this therapy are advised to avoid extractions as much as possible.  Osteonecrosis, when it occurs, generally resolves, albeit slowly, after Xgeva or Zometa are stopped.

A variety of different medications can be useful for reducing side effects from hormone therapy. Low-dose estrogen skin patches can control hot flashes. Excessive mood swings can be stabilized with low doses of antidepressant pills. Breast enlargement can be prevented with Femara. 

Final Thoughts

In this blog I have outlined a traditional, sequential approach to treatment selection.  Strong consideration, however, should be given to using these active new agents in combination and at an early stage.  Men in ROYAL have a potentially life-threatening type of prostate cancer. An aggressive and imaginative treatment plan should be designed that has the specific goal of attaining and maintaining a complete remission, i.e. a PSA less than 0.1. In my opinion, the standard “one treatment at a time” approach that is so popular at academic centers, it is a grave disservice to the men fighting aggressive prostate cancer. 

Did You Know: Stress Comes in Three Shades

BY RALPH BLUM

Our central nervous system, endocrine and immune systems communicate constantly with each other to maintain homeostasis—a healthy balance that promotes health and healing. Then at moments of perceived threat, these systems respond almost instantaneously with a chain of physical responses commonly known as fight-or-flight.

Originally evolved to protect us from acute physical danger—like an attack from a wild animal—the fight-or-flight system is a brilliant mechanism for handling acute, concrete threats, and then returning to homeostasis when the threat has passed. However, this emergency response system was not designed to be continuously activated, and when it receives a threat message for which there is no swift resolution, the result is chronically elevated levels of stress hormones that repress the action of the immune system. In fact, according to Bruce Lipton, Ph.D. stress hormones are so effective at curtailing immune function that doctors provide them to recipients of transplants so that their immune systems wouldn’t reject the foreign tissues.

In today’s world, the challenges most of us face have shifted from immediate physical threats to unending or chronic emotional ones. The term “stress” has become a generic term that we commonly use instead of specifically describing feelings as varied as frustration, exhaustion, anxiety, worry, grief, fear and despair. Yet these emotions, generated by stress, can trigger the same flight-or-fight response system that our body deploys to survive a close encounter with a lion, without, however, the release of escaping from that encounter and restoring homeostasis.

There are three distinct categories of stress which, taking my cue from Dr. Scholz’s Blue Shades of prostate cancer, I have designated GREEN, BLINKING YELLOW and FLASHING RED to indicate the different stress levels.

It is important to point out that not all stress is harmful. Brief episodes of stress heighten our alertness, sharpen our senses and actually improve immune function. It is what the flight-or-fight response was designed for and I consider them as GREEN stress responses.

The second category—BLINKING YELLOW—is referred to by researchers as “tolerable stress.” This is stress that could become harmful, however we have the capacity to recover though relationships, and through practices like regular exercise, meditation, healthy eating and adequate sleep. Though we are still disturbed by episodes of BLINKING YELLOW stress, if we recognize and respond to them at their onset, we are able to regain and restore internal balance.

Prolonged or toxic stress is the FLASHING RED variety.  In the grip of toxic stress, we don’t fully regain our equilibrium because the healing relationships and practices that may have worked with tolerable stress are insufficient and thus no longer successful. If it accumulates in our bodies, toxic stress “dysregulates” the systems that protect health and healing.

Some wags have suggested that a few large margaritas or smoking dope might help! But the hard fact is: When the BLINKING YELLOW occurs you need to act, to use available remedies so you do not progress to the toxic, FLASHING RED degree of stress. Strange to say (And I found it a pleasant surprise) activities like meditation and yoga seem to do the most to reestablish homeostatic balance. 

The INDIGO Shade of Blue

BY MARK SCHOLZ, MD

Prostate cancer is a vast and complicated field. To make it more manageable, PCRI breaks it down into five separate Shades of Blue. Men with recurrent disease after surgery or radiation are in the INDIGO shade. The outlook for men with INDIGO is optimistic.  Some men can still be cured. For those who can’t, the vast majority will be able to keep their disease in check with treatment.

A rising PSA confirmed on sequential measurements is the most common sign of a relapse.

Less common signs of relapse are:

a.     A positive biopsy from the prostate fossa. The “fossa” is where the prostate gland used to be prior to surgery (also, a nodule may or may not be felt on digital rectal examination)

b.    Persistent prostate cancer detected in the gland after radiation by needle biopsy, or by scans or by digital rectal examination

c.     Prostate cancer that has been detected in the pelvic lymph nodes by a scan.

 

People need to be aware that a PSA elevation after surgery or radiation can occur for noncancerous reasons, including incomplete removal of the prostate gland after surgery, prostate tissue “left behind” in the fossa, results in low but persistent levels of detectable PSA.

After radiation, the prostate gland remains in place. Therefore, in men who have been recently treated with radiation combined with testosterone inactivating pharmaceuticals (TIP), discontinuing TIP will lead to testosterone recovery which causes PSA levels to rise. Also, radiation-induced inflammatory reactions can occur in residual prostate gland cause a PSA rise. This rather common phenomenon is called the “PSA Bump.”  It’s essential to be aware of the noncancerous causes of PSA elevation so that well-intentioned but unnecessary treatment can be avoided.  

INDIGO men will require imaging studies to determine the extent of the disease.

1.     Color Doppler or MRI is used to look for residual cancer located in the surgical fossa or in the prostate gland in men previously treated with radiation. 

2.     Pelvic MRI or CT scans are used to look for spread to pelvic lymph nodes. (Carbon 11 acetate PET scan is more accurate than CT or MRI but is still considered to be under investigation)

3.     CT or MRI of the abdomen and bone scans are used to detect the presence of more distant spread to lymph nodes outside the pelvis or to the bones. Scan-detected disease outside the pelvis or in the bones changes the shade to ROYAL. 

Treatment for INDIGO

Treatment options include observation, radiation, TIP, cryotherapy, or combinations of TIP with radiation or cryotherapy. Treatment selection is guided by four factors—the cancer location, the original Shade, the PSA doubling time and a patient’s age. By incorporating all four factors into the treatment selection process, the risk over-treating, i.e., incurring unnecessary side effects from treatment, is reduced.  Awareness of all four of the factors also helps to avoid another common mistake—under-treating—which reduces the likelihood of achieving durable remission.

An isolated “local” relapse is one that appears to be localized inside the prostate after radiation. Local relapse may be curable with cryosurgery alone.  An isolated “local” relapse in the prostate fossa after surgery may be curable with radiation alone.

When no local disease can be detected and when all the scans are clear—termed a “pure” PSA relapse—treatment selection will be influenced primarily by the rate of PSA rise. For example, if the PSA is doubling in less than six months, aggressive combination treatment with TIP plus radiation or TIP plus cryosurgery may be best.  If the PSA doubling rates is between six and twelve months, a less aggressive treatment approach with radiation alone, cryosurgery alone or intermittent TIP alone, is reasonable.  When the doubling time is greater than 12 months, observation without immediate treatment may be considered.

A patient’s age and the original shade at the time of diagnosis also need to be factored into the treatment decision-making process. Men who are more elderly can “step down” the intensity of their treatment plan by temporizing with mild forms of TIP, such as low-dose Casodex. Younger men, who prior to relapse, were in the High-Risk (AZURE) category may want to consider prophylactic pelvic lymph node radiation, a more intensive type of TIP with Zytiga or Xtandi or even chemotherapy with Taxotere.    

Side Effects of Treatment—INDIGO

The residual prostate gland after radiation is anatomically close to the rectum, urinary bladder, and the nerves that control erections. Therefore treatment with salvage radiation or cryotherapy increases the risk of additional long-term sexual, urinary or rectal dysfunction beyond what has already caused by the original surgery or radiation.

Men who are already struggling with incontinence problems from previous surgery may experience further decline in their urinary control when they undergo radiation directed at the fossa. Men who have cryosurgery for a relapse after radiation almost always become impotent. Incontinence can also occur. Surgery to remove a previously radiated prostate causes very high rates of impotence and incontinence.

Radiation to the pelvic lymph nodes can cause damage to the surrounding intestines with symptoms of cramping, diarrhea or loss of rectal control. Since the advent of intensity modulated radiation (IMRT), however, bowel damage from pelvic radiation is a much less common event.

TIP is a common component of the treatment plan for men in the INDIGO category. The severity of side effects from TIP increases when it is continued for a longer duration. As a result, intermittent TIP is very popular. The intermittent TIP protocol is to continue treatment for six to twelve month after which TIP is stopped and a treatment “holiday” is ensues—assuming the PSA drops below the 0.1/ng threshold. The next cycle of TIP is resumed when the PSA rises back to the original PSA baseline, or up to five, whichever is lower.

The most troublesome side effects from TIP are weight gain and fatigue. Maintaining a careful diet and doing regular exercise is very helpful in offsetting these problems. Low libido, however, only responds to a treatment holiday. Daily Cialis is necessary to reduce the risk of permanent erectile atrophy.

Other side effects of TIP typically respond well to the following medications:  Low-dose estrogen controls hot flashes. Osteoporosis can be prevented by Prolia, Boniva or Actonel. Mood swings stabilize with antidepressants. Breast growth is prevented with nipple radiation or Femara.  Erectile dysfunction can be counteracted with Viagra.

Finding the right type of treatment for men in INDIGO is achieved when the benefit of treatment is weighed carefully against the potential for treatment-related side effects. Fortunately, a wide variety of effective treatment is available for men with INDIGO and the majority will have their disease controlled on a long term basis.

So much for getting “the Blues” when you have prostate cancer!

Fighting Stress: The Amygdala as Super-Hero

BY RALPH BLUM

Writing about “Stress Management” has been a Pandora’s box for me. I am convinced that, along with taking charge of my own recovery, an understanding of stress—it’s nature, how it operates, how to manage it—has served me well in facing the dragon of prostate cancer. Whether you are newly diagnosed or coping with bone metastases, I hope my exploration of stress will serve you—and give you renewed hope.

 

Stress is a poisonous compound of worry, anxiety, exhaustion, regret, fear, despair, and all the other toxic tourniquets that bind us to the wheel of suffering. In most people’s lives, these negative feelings are registering in our bodies chemically and organically much of the time. So let’s take a close look at the factor of stress in our lives, and see how it weighs down and impedes the process of recovery.

 

Really ancient, the word “stress” is a form of the Middle English destresse, which is in turn derived, through Old French, from the Latin stringere, “to draw tight.” Used first in physics to refer to strain on a material body, by the 1920s stress was being applied in medical circles to refer to mental strain, or harmful environmental “agents” that cause illness.

 

In 1926, Harvard Physiologist Walter Cannon used the term “stress” for its clinical significance, describing external factors that disrupted what he called “homeostasis,” a steady state or  equilibrium ideal for our well-being and healing. Moreover, Cannon’s book, The Wisdom of the Body, was the breakthrough in understanding that we actually have a capacity to self-correct from stress, and restore homeostasis.

 

It goes without saying that a potentially life-threatening situation, like cancer creates the kind of stress that persists over time, taking a significant toll on the body and seriously disrupting homeostasis. So what can we do to alleviate chronic stress?

 

While I was looking for fresh ways to manage stress in my life, I came across an exotic “game” created by high school teacher and psychologist, Justin Galusha.  His game asks you to create 17 “Superheroes, Villains and Sidekicks” for "17 areas of the human brain.” In order to “play,” you need a name for the character, a description of that character’s super powers and/or weaknesses, the brain area where the character is found, and what it actually controls in the brain. Among the areas (and characters) he includes Cerebellum, Thalamus, Hippocampus, Temporal Lobe and the Amygdala. Since we’re not playing the game, we don’t have to look at all seventeen,  focusing on just one—the one that coordinates all the others—the amygdala.

 

I was already aware of the power of the amygdala to process emotions and manages stress, particularly when feelings of anxiety or fear are involved. Seated at the center of an exquisitely tuned and coordinated emergency response system, the amygdala is a small almond-shaped structure, buried deep within the temporal lobe, part of the brain’s limbic system.  For his game, Galusha describes the amygdala as “governing emotions related to self-preservation . . . in particular stimuli that are threatening to the organism.” And he means life threatening, So that’s what this is all about—self-preservation.

 

In Galusha’s brain game, here is how the role of the amygdala—dubbed “Amyg’DaMan”—is described:

Blessed with a heightened amygdala thanks to a freak accident in the Vidal Sassoon mouse testing facility, Amyg’DaMan knows when he can win a fight or when he needs to take flight . . . With only his superhuman ability to read facial features and govern emotions, Amyg’DaMan never gets in over his head. He sports a caveman like costume as a shout out to his ancestors. . .  Had it not been for their amygdalas they wouldn’t have known when to run from predatory trolls with extra arms or stay and slaughter innocent docile foes. This one’s for you Amygdala guy—and the quick judgment that saves your life.

The whole idea—including a hairy caricature of his club-wielding caveman hero—made me laugh. And while the conventional fight or flight options described here are not available to a man with newly diagnosed with prostate cancer, the primitive emotions are the same. Stress is the result. Laughter is one antidote. And self-preservation is the objective.

 

I’d say laughing at the vision of Amyg’DaMan whooping those four-armed predatory trolls is good anti-stress activity.

 

In my next blog I will consider stress as three-tiered, one toxic, one tolerable, and one (I was surprised to learn) both positive and useful, capable of improving the function of the immune function.

The AZURE Shade of Blue

BY MARK SCHOLZ, MD

Patients frequently ask their physicians, “Am I stage A, B, C or D,” without realizing that the original purpose of a lettering system was simply to guide urologists in the selection of candidates for surgery. While stage matters, a combination of PSA level and the Gleason grade is a better way to assess disease status. So rather than using stage, it’s best to incorporate all three factors together—PSA, Gleason and stage—to divide prostate cancer into five broad categories or Shades of Blue.

Using standard doctor terminology, the AZURE Shade of Blue is essentially the same thing as “High-Risk” prostate cancer. “Risk” refers to a higher probability of relapse after surgery or radiation compared to men in SKY or TEAL shades. Therefore, men in AZURE are usually treated with combination therapy consisting of IMRT, a seed implant and testosterone inactivating pharmaceuticals (TIP) for 18 months.

 

Here are the specific factors that define AZURE. 

1.     No previous treatment with surgery or radiation.

2.     Bone and body scans without metastasis.

3.     One or more of the following three factors:

a.     PSA above 20 and less than 100, or

b.    Gleason score above 7, or

c.     A prostate tumor felt by digital rectal exam extending across the midline of the gland or outside the capsule.

Men with two or three of these factors are still classified as AZURE. Men with spread to pelvic nodes are classified as INDIGO.  Men with metastasis that has spread to bones or to nodes outside the pelvis are ROYAL. Radiation—rather than surgery—is the preferred treatment for AZURE because of the risk for cancer infiltration outside the prostate. Safe surgical removal is next to impossible when the disease extends into surrounding organs.  Incomplete cancer removal means radiation will be required to “mop up” the residual cancer anyway. Therefore, most experts recommend radiation because the risk of needing both surgery and radiation is so much lower.

Within the AZURE category exist subcategories of men who have a relatively more advanced type of AZURE. For example, some men have larger tumors, higher PSA levels above 40 and Gleason grade 9 or 10.  Men in this situation might want to try to further enhance their cure rates by adding a more potent form of TIP such as Xtandi or Zytiga to their therapeutic plan.  Also, a short course of Taxotere chemotherapy can be considered.

My last blog (about TEAL) reviewed potential side effects from surgery and radiation.  The side effects of TIP become more severe when treatment duration is prolonged. The three most troublesome TIP-related problems are low libido, weight gain and fatigue. However, libido recovers after TIP is stopped.  Weight gain and fatigue can be reduced with diet and exercise. Yet as we all know, maintaining a consistently good diet and getting adequate exercise over long periods of time can be very challenging.  Obtaining professional support from a trainer or a physical therapist is one way to sustain a disciplined program on an ongoing basis. 

 

Other common TIP side effects can be controlled with medications.  Hot flashes regress with a low-dose estrogen patch. Calcium loss from the bones can be prevented with an injection of Prolia every six months, a Fosamax pill weekly or with an Actonel or Boniva pill monthly. Mood swings can be reduced with low-doses of an antidepressant called Effexor.  Effexor also has salutary effects on hot flashes. Breast growth can be prevented with an estrogen-blocking pill called Femara.  When libido is chronically low, men tend not to care about getting erections, so taking daily Cialis should be considered standard for men receiving TIP.

Unfortunately, many doctors have limited knowledge about how to prevent TIP side effects. Patients, therefore, need to protect themselves by getting as much education as possible. Certain side effects, such as breast growth, erectile atrophy and osteoporosis, are preventable with appropriate intervention.  However, once they are allowed to occur, these effects can be permanent.

While side effects are an important consideration, men in the AZURE group have a relatively more dangerous type of prostate cancer compared to men with SKY or TEAL.  The appropriate treatment stance, therefore, is to be aggressive—to get cured.

The good news is that the majority of men with the AZURE stage of prostate cancer will be cured with the treatment approach outlined above.  Studies have shown that the best results come from using IMRT, radioactive seed implantation and testosterone inactivating pharmaceuticals (TIP) in combination with each other. 

So if you do find yourself in the AZURE zone, don’t despair: There is good reason for hope.

A Few Words About Prostate Biopsy by Someone Who Will Go a Long Way to Avoid Having One

BY RALPH BLUM

The large majority of men I meet are not aware that by agreeing to a prostate biopsy they are starting down a slippery slope. The biopsy is a pivotal step—not because it is painful— when expertly performed there should be minimal pain—but because, more often than not, if any of the tissue samples or “cores” taken from different sections of the prostate prove positive for cancer, the whole radical treatment process is set in motion.

Very few men understand that in most cases, prostate cancer is the more common Low-Risk type that is not life threatening and does not require immediate treatment.

So what can be done to prevent this rush to over treatment? Especially the panic to “just cut it out?”

First of all, family doctors need to refrain from recommending a biopsy at the first sign of an elevated PSA. You’d be surprised to learn how often this happens. But a slight increase in PSA does not justify an immediate biopsy. Instead, it should merely result in a risk assessment process to determine what is really going on in the prostate.

 

For instance, an enlarged prostate, the result of Benign Prostatic Hyperplasia (BPH), common in aging men, is often the cause of an artificially elevated PSA reading. Similarly, a random laboratory error, an underlying chronic prostate infection or even recent sexual activity, can cause a rise in PSA. I remember once, about ten years ago, my PSA was unaccountably elevated. Then I remembered I had helped a friend move some heavy carpets from his house to his truck the day before the test. We repeated the test a week later, and my PSA had dropped back again to its previous level. Could it have come from my vigorous exertion?

 

So an obvious first step, when there is an unexplained shift upward, is to make certain that all the above reasons are ruled out and have your doctor repeat the PSA. If on retesting your PSA is still elevated, additional testing with PCA-3, color Doppler ultrasound or mulitparametric MRI should be considered before resorting to a biopsy and starting down that slippery slope to unnecessary radical treatment—treatment that all too often leads to incontinence and loss of sexual potency.

 

If further testing indicates that you should to go ahead with a biopsy, remember that some margin of error is always present. Biopsies fail to spot cancer about 20% of the time, especially in men with enlarged prostates. So even when an initial biopsy comes up free of cancer, you are not off the hook.  Naturally doctors are concerned about missing cancer in their patients, so chances are they will recommend a second or even a third biopsy, and one of these follow-up biopsies is likely to show something that was missed in the first go-around.

 

A better approach is to consider an image-guided, targeted biopsy with MRI or Color Doppler Ultrasound. Not only is high grade disease located more frequently, low-grade disease can be overlooked.

 

However, if this should happen, don’t panic. As Mark pointed out in our book, Low-Risk prostate cancer is so common that the likelihood of the average man harboring some degree of microscopic disease can be estimated by putting a percentage sign after his age. Low-grade disease is a normal part of aging, not something to be frightened of.

 

So if your PSA is only slightly elevated, my advice to you—depending on your age, your life expectancy, your overall health and your family history—is to think very carefully about the risks inherent in radical treatment, and don’t allow yourself to be rushed into getting a biopsy before less invasive diagnostic methods have been explored.

 

In the meantime, put that percentage sign after your age, and know you are in good company. Just remember: The odds are on your side. Time is on your side. For my part, I am doing my best to live up to the sub-title of our book: “No more unnecessary biopsies, radical treatmentor loss of sexual potency.”