Predicting Prostate Cancer’s Future Behavior

BY MARK SCHOLZ, MD


Developing an accurate prognosis, i.e., predicting how a man’s cancer is likely to behave in the future, is the first and most important step toward optimal care. Future predictions are often looked at with some suspicion. With prostate cancer, however, our power to anticipate future cancer behavior is quite accurate unless there is a lack of thoroughness in gathering information.

The Size of the Tumor
Tumor size is a universally important prognostic sign for almost all types of cancer including prostate cancer. The method for incorporating tumor size into the Anthony D’Amico’s staging system relies on the degree of PSA elevation, the tumor grade and on how the prostate "feels" with the finger of a trained practitioner. These indicators are useful but don’t incorporate information from modern imaging. Imaging provides accurate information about tumor size and the presence or absence of extracapsular extension. These are very powerful prognostic predictors and it would be foolish to disregard their importance. As things stand presently these indicators are often used to divide the low, intermediate and high risk categories into "favorable" and "unfavorable" subcategories, each with a different spectrum of recommended treatment options.


Knowing Past Treatments Tells Something about Future Prognosis
Historically, since the total number of available treatments is relatively limited, practitioners have used a sequential "trial and error" treatment methodology that administers the standard treatment options in a fairly predictable sequence. For example, it is not uncommon for men to start with surgery or radiation. When a relapse occurs, standard hormone therapy (Lupron) is often started and given intermittently or continuously. Hormone therapy usually controls the disease for an average of 10 years. When Lupron stops working, immunotherapy with Provenge is usually follows. After Provenge, more potent hormone therapy with Xtandi or Zytiga is started. If these two agents prove ineffective, chemotherapy with Taxotere or radiation with Xofigo would be considered next.

The whole point of presenting the treatment sequence described in the previous paragraph is to convey the idea that the number of previous treatments communicates important information about that patients’ future prognosis. Having "failed" Lupron, for example, bespeaks of a much more worrisome prognosis compared to the situation where Lupron continues to be effective.


Response to Lupron, The Mother of All Metrics
The quality of the "response" to Lupron is actually one of the most powerful prognostic metrics available. The degree of PSA decline after Lupron is incredibly important. How low the PSA drops after starting Lupron is called the "PSA nadir." The specific PSA threshold used to determine a "good response" is less than 0.1. Believe it or not, there is a huge difference in prognosis between a man on Lupron for six months who has a PSA of 0.1 versus a man whose PSA levels off at 1.0.

An Established History is also a Prognostic Indicator
Another somewhat obvious prognostic indicator that is often overlooked and almost never discussed in textbooks has to do with the prognosis of men who have been diagnosed years ago -- over time it is apparent that things are turning out much better than what might have been expected based on their initial indicators. For example, take the case of a man who started off with a panoply of bad indicators—tumor is in the lymph nodes and Gleason 10—but after aggressive treatment remains in remission for 5 years. The fact that things have gone well for five years counts bigtime in his favor going forward. Remember, the original prognostic predictors of a Gleason 10 were just that, predictors. No predictor is 100% accurate. Five years of established history is a stronger predictor than the original Gleason score. The fact that things have gone well for five years, strongly indicates that the future is for that individual is bright. Such individuals have "beaten the odds."

The Location of the Tumor in the Body
Another extremely important indicator of prognosis, something that even laypeople anticipate by simple common sense, is the location of the cancer in the body. Location says volumes about how things are likely to progress in the future. For example, consider the following sequence of progressively more serious cancer sites:

•Contained within the prostate
•Extended into the seminal vesicle
•Spread to the lymph nodes
•Bone metastases
•Liver metastasis

Each of these locations is very important for determining prognosis.

This short blog is just an introduction to some of the "profiling" methods utilized in generating an accurate prognosis. Space limitations preclude discussion here about other known prognostic factors such as the size of the prostate gland (discussed in a previous blog), genetic tests and PSA doubling time. The D’Amico risk categories constitute the backbone of useful prognostic information. However, the additional prognostic information beyond the D’Amico risk categories that are discussed in this blog, provide additional useful information necessary for determining an accurate prognosis. An accurate prognosis is the starting point for accurate selection of treatment.

Androgen Deprivation Therapy for Prostate Cancer Causes Alzheimer’s Disease?

BY MARK SCHOLZ, MD


Dr.Kevin Nead authored an article published in the Journal of Clinical Oncology this month.  It created a media sensation and generated multiple calls to the PCRI Helpline.  Last week, three separate articles about this topic were posted on the Yahoo home page at the same time.


It’s no surprise that an article on this topic generates wide-spread interest. About 500,000 thousand men in the United States are undergoing prostate cancer treatment with androgen deprivation therapy (ADT). This treatment works by blocking the male hormone levels delivering notable anticancer efficacy and also proven to prolong life in men with prostate cancer. Despite it’s known effectiveness, a variety of side effects can occur, including memory problems.  The previously reported studies evaluating this phenomenon seem to indicate that when memory deficits occur, they usually reverse after ADT is stopped.
The research published in the Journal of Clinical Oncology, relied on a new method of searching through patient’s medical charts with computers.  No human review of these medical charts were performed. The computer software searched the medical records in an attempt to determine if men on ADT had a higher incidence of Alzheimer’s. The authors report that this new computer searching methodology in detecting a specific medical diagnosis is 74% accurate.


Review of all the charts at Stanford and Mount Sinai hospital unearthed 16,888 prostate cancer patients of which 2,397 were treated with ADT.  After the fancy computer analysis, designed to compensate for multiple factors such as patient age and underlying heart disease (both of which lead to Alzheimer’s more frequently), the conclusion was that the ADT-treated men were twice as likely to have developed Alzheimer’s. A total of about 9 cases would have been expected from normal causes, but 18 were actually detected.  If these conclusions are accepted as gospel truth, an additional 9 out of 2,397 men treated with ADT would equate to an increased risk of less than half of 1%.


The conclusion that there is tiny increase risk of Alzheimer’s with ADT, needs to be put in context based on what we already know about prostate cancer. First, is it possible that these men have reversible memory problems while still taking ADT? There was no attempt in the study made to determine if the “Alzheimer’s” patients were still on ADT when the diagnosis of Alzheimer’s was made. Second, men treated with ADT are substantially sicker than men who don’t need ADT.  There is no way for the computer analysis to compensate for how this may have impacted mental performance. Third, patients getting ADT receive closer medical surveillance and visit physicians more frequently than men who are not receiving ADT.  As such, memory problems are more likely to come to medical attention and be diagnosed when men are on ADT.  Fourth, general anesthesia (from surgery) is known to cause long-term memory problems.  This study did not perform any analysis to determine if surgery was performed with equal frequency in both groups.


In summary, it is not clear from this JCO article whether the men labeled having Alzheimer’s disease had memory problems while still receiving ADT or whether they had true Alzheimer’s, i.e., long-term irreversible memory problems continuing after the ADT was stopped. There is one thing, however, this study does show: At worst, memory problems serious enough to be labeled as “Alzheimer’s” occur in in less than one out of every 200 men treated with ADT.

Sir Spheres for Liver Metastases from Prostate Cancer

BY MARK SCHOLZ, MD

Cancer that spreads outside the prostate gland is what makes prostate cancer dangerous. Metastatic prostate cancer cells cause malfunction by impeding normal function. Some organs, like lymph nodes for example, continue to function quite nicely, even if the degree of cancer spread is extensive.  Lymph node spread, therefore, is the least dangerous form of prostate cancer metastases.  At the other end of the spectrum is the liver, which is far less tolerant.  The seriousness of bone metastases, the most common site of prostate cancer spread, lies about half way between that of node metastases and liver metastases.


The earliest stages of metastases are microscopic and therefore invisible even with the best available technology. To be detected with the best available PET scan technology, small tumors must measure more than 1/8 of an inch across. For detection with standard CT scans and MRI scans, more than a half-inch sized tumor is necessary. Since the presence of metastases is such a defining issue when describing a cancer’s character, men who are newly-diagnosed are labeled as low, intermediate or high-risk depending on their estimated likelihood of micro-metastatic disease. Liver metastases are extremely rare at the time of initial diagnosis of prostate cancer. When they occur it is usually after many years of ongoing treatment for known metastatic disease in the bone.


Prophylactic treatment with hormone therapy, chemotherapy or radiation to treat the possibility of micro-metastases is common for high-risk prostate cancer and occurs maybe half the time in intermediate-risk prostate cancer. The goal is to cure the micro-metastases at an early stage when they are most susceptible to eradication, thus preventing the future development of detectable metastases which is what makes cancer life threatening.


When talking about prostate cancer, even though this is a blog about metastases, it should always be remembered that many common types of prostate cancer never spread. These low grade “cancers” are genetically distinct and represent a totally different category of disease.  However, when discussing the type of prostate cancer that is capable of metastasis, the following factors impact how dangerous it is:

1. The site of spread.
2. The extent of spread
3. The tumor cell growth rate
4. The efficacy of available treatment

As noted above, the liver is far less tolerant to metastatic invasion than bone or lymph nodes.  In addition, because liver metastases tend to occur in men with advanced disease, tumor growth rates tend to be brisk. Also, the most commonly administered treatments, hormone therapies and chemotherapy, have often already been tried before liver metastases first develop. The advent of liver metastases, therefore, usually represents a very serious and life threatening issue.


Liver metastases may first be suspected when standard blood tests such as ALT, AST or ALP which are components of a hepatic panel blood test, register outside the normal range. Investigation into their cause often leads to doing a CT scan or MRI scan of the abdomen and pelvis to confirm the presence of disease in the liver. Alternatively, a scan may detect abnormal spots in the liver during routine periodic scanning that is being performed as regular surveillance.


Hormone therapy with Lupron, Zytiga and Xtandi, or chemotherapy with Taxotere, Jevtana and Carboplatin, is the standard approach to treatment for liver metastasis.  However, these treatments may have already been tried or may no longer be effective.  Since liver failure is tantamount to death, prostate cancer growth in the liver needs to be stopped immediately, regardless of how the disease is faring in the bones or nodes.


Much that has been learned about the treatment of liver metastases comes from reviewing common methods for managing metastatic colon cancer. The liver is the cancer’s preferred site of metastatic spread for colon cancer.  Treatments that have been employed include surgery, radiation and blockage of the blood supply to the liver by embolization of the arteries, all with variable success.  More recently, radioactive microspheres injected directly into the tumor, called SIR-Spheres, have shown notable efficacy with very tolerable side effects.


Prostate cancer and colon cancer are similar in that they are both adenocarcinomas which means they are derived from glands. Therefore, they are likely to have similar susceptibility to radiation.  As such, we have been administering SIR-Spheres to a limited number of prostate cancer patients with liver metastases.  Results have been encouraging with a notable improvement of survival compared to our historical experience treatment patients with liver metastases without SIR-Spheres.  Our preliminary results using SIR-Spheres in six patients is being presented at the 2016 Genitourinary Cancers Symposium - San Francisco in January 2016.

Active Surveillance: Follow-Up Essential

BY RALPH BLUM

 

A recent UCLA study found that a significant percentage of men diagnosed with low-risk prostate cancer who chose "active surveillance," rather than aggressive treatment in order to avoid the debilitating side effects of surgery or radiation, don't follow up with the required tests and office visits.

 

This is an alarming finding, because not being monitored appropriately puts them in danger of the cancer progressing or metastasizing without their knowledge. Before patients decide on active surveillance as a management option for prostate cancer they should agree with their physician on a strict follow-up schedule to closely monitor the cancer.

 

There is no doubt in my mind that active surveillance is the smart treatment option for low-risk prostate cancer.  With other cancers, or if the prostate cancer is aggressive, the main issue is survival. But with low-risk prostate cancer, since long survival is the norm, the most important consideration is quality of life. Having said that, with active surveillance regular check-ups are essential, because when men are watched closely, treatment can be started at the first sign of cancer progression.

 

So what does active surveillance require? How exactly is it carried out?

 

Different centers have different requirements. At a 2007 Active Surveillance Conference, attended by over 200 of the world's leading prostate cancer experts, the attendees recommended a biopsy after one year, subsequently repeating it every two to three years. But as I have often said, I am not a fan of biopsies. So I prefer to recommend doing a repeat targeted biopsy only on the basis of a PSA and prostate imaging with either color Doppler ultrasound or 3T multi-parametric MRI.

 

Here is an Active Surveillance Protocol that Dr. Mark Scholz recommends:

 

• PSA every three months
• Rectal examination every 12 months
• Color Doppler ultrasound annually
• Multi-parametric MRI annually

Whatever protocol your urologist recommends you need to be committed to following it. It may be inconvenient or uncomfortable but the alternative is aggressive treatment that has the potential to leave you with erectile and urinary dysfunction.

 

There is always the consideration to just treat the cancer and be rid of it. But having lived with this disease for over two decades, with my prostate intact, I am a firm believer in avoiding radical treatment and preserving quality of life as long as possible. And if you have low-risk prostate cancer, bear in mind that the longer you can wait before you submit to radical treatment, the better the odds are that research in the field will have advanced, and treatment will have become more effective and less toxic.                                                                

What’s Going On at the Prostate Cancer Research Institute

BY MARK SCHOLZ, MD
In 2016, the PCRI will celebrate its 20^th anniversary.  The PCRI, founded in 1996 by Dr. Stephen Strum and I, was originally funded by a generous grant from the Daniel Freeman Medical Foundation.  This initial grant was spent on hiring Harry Pinchot, aka Helpline Harry. The helpline format adopted at the PCRI was modeled after the work of Lloyd Ney, the founder of PAACT.  PCRI’s helpline presently has four counselors: Jonathan Levy, Silvia Cooper, Bob Each and Charles Kokaska, all who provide unbiased prostate-cancer-related information, free of charge to the public.


PCRI started doing patient-focused conferences in 2006. Since 2006 this has become an annual meeting. The conference has grown in stature through the years by attracting world-renowned prostate cancer experts who are invited to present the latest information on optimal diagnosis and therapy. DVDs of the presentations are distributed throughout the world.  Partly due to the wonderful moderating presence of Dr. Mark Moyad, the conference has grown to be the largest patient-orientated prostate cancer conference in the world.


PCRI makes its biggest impact via its online presence by providing articles and blogs authored by prostate cancer experts from every specialty. But more importantly, PCRI is presently in entering into a new phase, the development of the SHADEs of Blue organizational format, a methodology to help patients sort through the overwhelming amount of information by reducing it into a more manageable bite-sized format.  As we all know, the internet has solved the problem of getting access to information.  Now the biggest problem patients face is information overload. How does one sort through the deluge of unfiltered information?


The development of the SHADES of Blue program will address this problem of information overload by segregating prostate cancer information into five large categories. Three are for the newly-diagnosed, Low, Intermediate and High-Risk, and two are for men with either relapsed disease or metastatic, hormone-resistant disease. The SHADES program is a big undertaking for a small organization like the PCRI, especially considering that we have expanded our conference schedule by now doing two conferences annually with the addition of the Mid-Year Update in March.


Looking to the immediate future, I never been more excited by the PCRI’s potential for making a positive impact in the lives of men with prostate cancer.   If my suspicious are correct, PCRI’s visibility is truly on the verge of taking a big jump.

Photons or Protons? You Choose

BY RALPH BLUM


Following in the footsteps of robotic surgeons, prostate cancer continues to go high-tech. Radiation, for instance, is no longer just radiation. There are now numerous different ways to deliver it. But the two methods I want to write about here are Intensity Modulated Radiation Therapy (IMRT), and Proton Beam Therapy (PBT).


The predominant method in the U.S. for the past decade is IMRT, a complex procedure that precisely targets the prostate gland with multiple beams of high energy light (photons) at different angles and intensities while significantly lowering the risk of damage to the surrounding tissues and organs.  This greater accuracy in targeting also allows the therapist to maximize the radiation dose to the tumor.  IMRT has at least as effective a cure rate as surgery, and without the risks and side effects of a major surgical procedure.


Having said that, I have recently been checking out Proton Beam Therapy, a form of radiation that targets the tumor with charged particles called protons. Several decades ago, Loma Linda University in California was the first to begin administering PBT. At that time, I had a friend who, at 55, developed prostate cancer and was one of the first patients at Loma Linda when proton therapy was at a very early stage.  Bill has been free of cancer for over twenty years, and only recently had a rise in PSA and is discussing further treatment.


Since then, thanks in part to marketing hype, PBT is becoming increasingly popular.  Now, M.D. Anderson, Harvard, and the University of Florida in Jacksonville, are among the major medical centers that have made PBT available. And The Mayo Clinic is building two proton therapy centers (one in Rochester, one in Arizona) at a cost of $380 million. Naturally PBT costs considerably more than IMRT.


When weighing treatment options, patients generally consider two main factors: potential side-effects, and successful outcome. So how do these two therapies measure up? Well, there is considerable controversy in the urologic community. The good news is both therapies have a high cure rate. Studies that have tried to compare IMRT with Proton therapy indicate that the outcomes are quite similar and that the side effects are comparable.  No large randomized trials have been published that directly compare patient outcomes with the different techniques.  So in the end, a treatment decision usually depends on such variables as patient preference and doctor preference.


It is reasonable, therefore, to keep in mind that any medical center that has invested an astronomical amount of money on equipment will end up wanting to use it.

Biopsy, Not PSA, Leads to Prostate Cancer

BY MARK SCHOLZ, MD

Prostate cancer is way over treated, and the problem starts with over diagnosis.  Once men are diagnosed, the fear of cancer naturally drives them toward radical treatment. In 2011 the US Preventive Services Task Force intervened, trying to stop overtreatment, argued that PSA testing causes more harm than good.

Some have questioned the expertise of the panel because of the lack of representation by urologists, radiation therapists or medical oncologists --the types of doctors usually responsible for treating prostate cancer.  Actually, the credentials of the panel constituents appear entirely appropriate to comment on screening, because this is an area of medicine usually handled by primary care doctors.  The panel members consisted of twelve MD’s and four PhD’s trained in primary care, public health and statistics.

The Task Force agrees that PSA screening may save lives. Their judgment, however, was that too few lives are saved to justify thousands of men getting unnecessary radical treatment. One statistic indicates that a thousand men must be screened to save one life within the next 12 years.

Personally, I agree with the panel in regards to over diagnosis is a root cause of over treatment. However, simply discarding PSA is an oversimplification. PSA can detect a variety of problems infection and benign prostate enlargement. Actually, the majority of men with elevated PSA, don’t have prostate cancer.

No, the real problem is after a PSA test rises. Every year, a million men are advised to have a dozen, large-bore needles jabbed into their rectums “Just to be sure there is no cancer.”  Such behavior sounds ridiculous, but really, it is just the survival instinct in action. People will do practically anything when they fear for their lives.

So if not a biopsy to evaluate an elevated PSA, what’s next?

First, the fear must be faced. Ralph Waldo Emerson says “Knowledge is the antidote to fear.” So let’s look at some basic facts:

• One out of 38 men die of prostate cancer
• One out of seven men are diagnosed with prostate cancer
• In men who are “diagnosed”
  • Five-year survival is 100%
  • Ten-year survival is 99%
  • Fifteen-year survival is 94%
    

Considering it is cancer, survival rates are great! At least these numbers should overcome any urge to rush. Clearly there is plenty of time is to study and learn more. Confusion arises because a minority of prostate cancers can indeed be dangerous. Not as dangerous as lung or pancreas cancer which kill within months. However, demise from prostate cancer certainly qualifies as “dangerous,” even if it is rather infrequent and much postponed.

These statistics reveal something else that is quite useful. Prostate management issues are of long-range nature, like saving for college or for retirement. Just as expert financial planners are limited in the ability to make predictions about economic activity ten years in the future, doctors should be equally humble in their pronouncements about the future of prostate cancer. We don’t know for sure, but we strongly suspect there will be substantial breakthroughs in the diagnosis and treatment of prostate cancer in the next ten years.

For the short term, I think the best way to proceed is with imaging the prostate with a 3Tmulti-parametric MRI or color Doppler ultrasound. Scans are about as accurate as a random biopsy for detecting aggressive cancers and they usually fail to detect the harmless low grade types, which is a good thing. However, if there is a worrisome abnormality, a targeted biopsy with just a couple cores is needed.

Over-diagnosis and over-treatment is not due to PSA. It’s the misguided policy of rushing into an immediate random biopsy whenever there is a slight elevation.  .The random biopsy procedure should be abandoned.  PSA abnormalities should be evaluated with prostate imaging A targeted biopsy can be considered in men who have a distinct abnormality detected by imaging.    

Reforming Old Behaviors

BY RALPH BLUM


Back into the mists of time, year after year, in our unending struggle to protect ourselves against sinister and deadly invaders, we expend our energies, our wealth and our physical strength to survive and maintain our health. One mysterious and potent ally is the Anger Response. The Anger Response system is not unique to our bodies. Parallel forms of this “homeland defense” can be identified at all societal levels: of the family, the community, of nations.


However, like any effective and powerful resource, over-reliance is a potential pitfall. Over dependency on the use of anger as a problem-solving-mechanism leads to an angry persona. “As a people thinketh” certainly applies.  So the loose bundle of platitudes and commonplace aphorisms pertaining to sending healing, loving messages, really needs to become SOP, “Standard operating procedure.”


What a daunting privilege! Swing high enough on that swing and you are led, inevitably, inexorably, to thoughts of Our Creator, to the God of our Understanding . . . in whose image we are said to be fashioned.  We have the free choice to send messages of hate and fear or messages of healing and love.  And so we communicate with the rest of the planet. Words come back to me, my mother frustrated and distressed, me about 25, her launching, “Your whole modus operandi is rotten to the core.”  Not even certain she could define modus operandi.  It was a phrase she picked up from my father.


As advice for Rageaholics, I remember various of my elders advising me to “stop and think” before I blasted off.  Well, here are five questions to teach small boys to ask themselves, to determine, or “profile” who they are at any given moment.  Five questions to answer when they can catch themselves in the act of feeling angry:


1) Is it true?
2) Is it helpful?
3) Does it inspire?
4) Is it necessary?

5) Is it kind?

A tremendous communication tool, serves as a referee for our impulses, and allows an opportunity for us to work through a kind of a checklist re. who we want to be—what compliment of qualities would we want present in this moment, qualities that will allow us to operate (and “cooperate” to match our destiny) in most positive and uplifting way.  I have a growing taste for acronyms. Well there’s a good one: The acronym (what a pleasant surprise) is THINK.

Let the Buyer Beware

BY MARK SCHOLZ, MD

It’s time to change our preconceptions about prostate cancer and “reboot” the way we think about what typically is a non-life-threatening disease. Ever since the FDA first approved PSA testing in 1987, prostate cancer has grown into an aggressive multibillion dollar industry. Marketing hype has created the impression that treatments like Proton therapy and robotic surgery are universally desirable, even though well-informed patients know this is hardly the case.  How did the prostate cancer world deviate so far off the originally intended tract of helping patients? And what can be done to set things straight?

Ten years ago the experts believed that immediate curative treatment was needed for every man with prostate cancer.  Today, after 20 years of vigorously detecting and treating every case of prostate cancer, it has become clear that almost half of the 230,000 men diagnosed every year are undergoing radical treatment for a cancer that is incapable of metastasizing.  Now it’s time for the medical community to come to grips with the fact that over a million men in the United States are living with impotence and incontinence for no justifiable reason. This is a disaster of gargantuan proportions.

Shockingly, even though we can now readily identify these harmless cancers, the problem of rampant overtreatment continues. In 2015 another 50,000 men will undergo unnecessary radical treatment. The medical industrial complex that has been gaining momentum for 25 years refuses to confess its tragic errors.  The huge investments in enormously expensive medical equipment need to be paid off.  No one is willing to accept responsibility, make apologies or confess wrongdoing for all the overtreatment.  The existing system is entrenched and the doctors are too comfortable with the status quo.

Reversing the momentum of twenty-five years of recommending unnecessary radical treatments is going to require the patients to protect themselves.  They need to become far more medically sophisticated consumers.  Five years ago, Ralph Blum and I fired the first salvo by writing Invasion of the Prostate Snatchers: No More Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency. In our book, we attempted to defang the poisonous and fear-inducing word cancer by renaming the low-risk type that does not metastasize “The UnCancer.”  Our book has been helpful at revamping the gross misconception that every prostate cancer is potentially deadly.  Invasion provides an excellent introduction to men with newly-diagnosed cancer by presenting the important concept that prostate cancer comes in three broad types: low, intermediate and high-risk.  

One of the important themes introduced by Invasion is a healthy mistrust of physician motives. For protection against patients receiving the wrong treatment, Invasion argues strongly for patient empowerment through education. The term, “prostate cancer” is merely an umbrella term for a broad spectrum of illnesses that behave very differently. The book simplifies the treatment decision making process by clearly identifying the three major subtypes of prostate cancer, low, intermediate and high-risk.  Once patients have gained an accurate understanding of where they fit into this individualized schema, an informed treatment decision can be made.  As a medical oncologist, rather than a surgeon, the information provided in the book is unbiased with clear presentation of all the risks and benefits associated with all the different treatments that are available.

In an era now past, physicians were trained to put their patient’s interests ahead of their own.  Today, patients need to adopt defensive tactics that are realistic about how prostate cancer care has become a highly lucrative business. The patient who assumes that their counseling physician represents his best interests, is on the cusp of making a dangerous mistake. Bluntly, the prostate cancer world has evolved into a sophisticated and well-oiled business and the buyer better be on guard.   

The Faces of Stress

RALPH BLUM

Whether you are newly diagnosed with prostate cancer, or coping with bone metastases, learning about chronic stress and its negative impact on your body is almost as critical to your healing as whatever treatment you choose.

Short-term stress, a single episode of acute stress, generally doesn't cause problems. However, chronic emotional stress, caused by situations or events that last over a period of time, takes a significant toll on the body.  Furthermore, this kind of prolonged stress suppresses the immune system, profoundly affecting its ability to detect defective or cancerous cells and destroy them.

Persistent feelings of fear, anxiety and unrelieved stress trigger the fight-or-flight response system that our ancestors relied upon.  When a threat is recognized, heart rate and blood pressure skyrocket, sugar pours into the blood, muscles tense for quick action, and the whole metabolism goes into survival mode. This is great if you're on the African savannah and you hear a lion growling outside your tent.  However, Nature never intended this "On your mark! Get set! Go!" response to last more than a moment or two.  So when the brain sends a threat message for which there is no swift resolution, the fight-or-flight system stays stuck on "Get set!."  As a result, the immune system is locked into protection mode and is no longer capable of performing the remedial function that is our most powerful defense against cancer.

So when we feel unable to manage or control the changes in our lives caused by prostate cancer, it not only reduces our quality of life, but it is associated with poorer clinical outcomes.  In fact, studies in mice, and in tests in human cancer cells grown in the laboratory have found that prolonged psychological stress can enhance a tumor's ability to grow and spread.

There is always the temptation to alleviate the stress overload of a potentially life-threatening diagnosis with risky behaviors such as drinking alcohol in excess, taking drugs, and over-eating. But this kind of "stress management" only further inhibits immune function. However, maintaining a healthy lifestyle—which means eating well and staying physically active--supports the immune system.  As do coping strategies such as relaxation techniques, meditation, yoga, and visualization.  And don't forget laughter—the ultimate antioxidant.

Here's how the Discovery Health Web describes the impact of laughter on the immune system: "When we laugh, natural killer cells which destroy tumors and viruses increase, along with Gamma-interferon (a disease-fighting protein), T cells (important for our immune system) and B cells (which make disease-fighting antibodies).  As well as lowering blood pressure, laughter increases oxygen in the blood, which also encourages healing."

So find out what works for you so that stress does not get the best of you.  If you can’t seem to get a handle on it, laugh your way back to health!

A Midlife Crisis Avoided

BY MARK SCHOLZ, MD

Building up a medical practice and getting a late start with a family, my midlife crisis was delayed past the usual occurrence for men in their early 40s.  However, by the time I hit 50, self-questioning was starting to surface. My life had meaningful pursuits but it was time to take a deep breath and do the traditional life inventory of the “mid-years,” to reassess my goals for the last third of my existence here on planet earth.

After reflection, I realized that I really didn’t have any great ideas to reinvigorate my passion for the last lap. I couldn’t sell my wife on the idea of buying a Lamborghini (I already owned a small boat).  I didn’t have any specific desire to travel.  I had given up on golf due to a terrible and uncorrectable slice.  I have never been successful playing the stock market.  All these considerations were going through my head about ten years ago.  Now ten years later, I turned 60 and I feel revitalized and reinvigorated.  So what turned things around?  

Many of you have come to know Ralph, my coauthor in the Snatchers Blog. He is as a sensible dispenser of advice and knowledge about life and about prostate cancer.  I first met Ralph almost fifteen years ago, first as a patient, subsequently as a writing teacher and now as a writing partner. As I reflect back over the years that we have worked together I am convinced that its Ralph who spared me from my mid-life crisis.  Don’t get me wrong, I have a lovely family.  My wife Juliet is a bulwark of truth.  My children are delightfully sensible, talented and hard-working. I am also blessed with an amazing medical practice with wonderful coworkers and extra-special patients.

Even so, visiting with a dozen men a day, five days a week, year after year, decade after decade can wear you down.  Getting paid less and less every year while the work load steadily increases is hardly inspiring either.  A midlife crisis was in the wings and I had no idea how my passion for the medical profession could be restored.  So back in 2005, I was looking for a new challenge when Ralph first approached me to write a book . I even agreed after he told me the zany title, “Invasion of the Prostate Snatchers.”

Fortunately, when Ralph invited me to be a cowriter, he didn’t give a second thought to the paucity of writing skills.  (Ralph has so much confidence in his own writing skills he believes he could train a monkey to write). Over the next four years we clashed on many occasions. Considering that English was my worst subject in school I have to give myself some credit for having the courage to accept his proposal.

Back then I had little interest I had in developing the craft of writing.  Writing is hard to do.  In addition, with limited free time in a busy medical practice, it’s no surprise that developing writing skills was a low priority to me.  But I was also starting to get upset about the injustice of so many men’s sexual identities being robbed by unnecessary surgery.  The dawning realization, that men, rather than being helped by surgery are actually being tremendously harmed, is what motivated me to finally confront the painful task of developing some writing skills so I could convey my observations to the naïve and unsuspecting patients. Thank God I had Ralph to tutor me along through this long and arduous journey.

Learning to write about topics that matter to me (such as saving men from the loss their sexual identity) has saved me from the “meaningless” philosophical wandering that characterizes a midlife crisis.  And as I get older and further polish my writing skills, I have enjoyed even more satisfaction by helping men to avoid numerous medical pitfalls.  For example, in my next blog I’ll be exposing another incredibly repugnant policy—men on Active Surveillance who have 12 large needles plunged through their rectal wall into the prostate gland every year. Yikes!

In the meantime, let me express my genuine appreciation to Ralph for having the patience and skill to draw me down this totally unexpected pathway.  At this point I am happy to report that I see no hint of an existential crisis looming on the horizon.     

Taking Charge of Your Prostate Cancer Recovery: Fast Forward From the Old Model

BY RALPH BLUM

In the old model of prostate cancer care, you were rushed into radical treatment--usually surgery or radiation--often without fully understanding all your options, or the risks and side effects involved. The entire process was focused on the tumor; minimal attention was given to you as a person, and little effort was made to explore the benefits of healthy lifestyle choices, immune-enhancing treatments, reasonable delays, and emotional support.  

The emerging new model of prostate cancer care recognizes the important role you can, and should, play in your recovery. The emerging model comprehends that simply attacking the cancer is not enough. Greg Anderson, who after surviving "terminal" lung cancer founded the Cancer Recovery Foundation, has said that "Retaining a medical team without doing everything you can to help yourself is like attempting to walk on one stilt."

So what do you need to know in order to take charge of your recovery?

There are three common misperceptions about prostate cancer:

*The assumption that the disease is as dangerous as other cancers.

*The assumption that the urologist who did your biopsy is a prostate cancer expert.
*The assumption that a quick treatment decision is necessary before the cancer spreads.

First of all, prostate cancer is unique among cancers because the mortality rate is so low. Around two hundred thousand men in the U.S. alone are diagnosed with the disease every year, and less than 15% will eventually die from it, usually over a decade down the line, while a majority of men who have the far more common low-risk, slow-growing prostate cancer can anticipate living a normal life span, or dying of something else.

Your local urologist has a busy medical practice that involves treating problems like impotence, infections, incontinence, and kidney stones. He also does biopsies. But the average urologist performs fewer than five prostate removals (prostatectomies) a year--far too few to be considered proficient. He may be a talented doctor, but he is unlikely to be a prostate cancer expert. So once you have your biopsy results, it is best to consult a prostate cancer specialist, either at a major medical center, or at a high-volume prostate cancer clinic.

As for the third misperception, it is essential, before committing to any form of treatment, that you  do your own research, and are convinced the treatment you choose is the right one for you.  Do not let anyone rush you into making a bad decision. Once your category of prostate cancer is identified (Low, Intermediate, or High Risk), get on the Internet and learn about every treatment option--including no treatment whatsoever--for your type of disease.  If you are over 70, and have low-risk disease, my advice to you is to find a doctor who has experience monitoring an active surveillance protocol.

Your role in your recovery, however, doesn't end with choosing your treatment. The emphasis on lifestyle changes has been one of the most significant shifts in cancer care in the last decade. A study at UCSF showed that improving your nutrition, reducing stress and getting more exercise, can lower PSA levels.  And according to a relatively new field of health psychology called "illness representation," your beliefs and expectations also impact the outcome of your disease. So take charge of your recovery, and have faith in your choice of treatment.

Ah, Yes. . .Your Medical Records

BY RALPH BLUM

 

When you are diagnosed with prostate cancer, keeping a folder with all your medical records can be a challenge, especially when you are working with several doctors and addressing different health concerns. But that is also when it is most important, both for your own understanding and safety, and for the use of any specialists you might want to consult for a second opinion.

The following is a list of the variety of information you need to preserve in your medical folder (MMF):

* A Chronological Log of all your PSA tests with dates, and note in the log any general health changes that might impact your PSA.

*  A copy of your urologist's notes that give the results of your Digital Rectal Exam (DRE).

*  A copy of your urologist's Transrectal Ultrasound (TRUS) report that lists the size of your prostate.

*  A copy of your Biopsy Pathology Report. This should provide your Gleason Score, how many cores were positive for cancer, the extent of disease in the cores, and the location of the cancer in the prostate gland.

*  Copies of the radiology reports of any scans (color Doppler ultrasound, bone, CT, MRI), and if available, digital copies of the actual scans.

*  Copies of all information regarding your medical history, including any current (unrelated to the prostate cancer) health problems you may be dealing with, even if they seem minor.

*  A list of all your medications (including the dosages), and a list of any over-the-counter supplements you are taking.

It is also wise to retrieve your biopsy slides from the pathologist and send them to a world-class cancer treatment center, such as MD Anderson, Johns Hopkins, Sloan Kettering, Saint John's, for a second opinion. In fact if you live in a small town or in the country, if possible you should get yourself to a urologist or oncologist specializing in prostate cancer at one of the major centers for a consultation before making a treatment decision.

Keeping this medical record not only gives you a feeling of control, but it is extremely helpful when you consult different specialists. It is also something your partner can help you create. Giving your partner something constructive to do can help her (or him) deal with the worry they inevitably feel over your diagnosis.

I personally feel very strongly about the importance of keeping and organizing all your medical information when dealing with prostate cancer because I didn't do it. And I know how often I and my doctors have found the MMF invaluable support. Truly, we are partners with our oncologists and our urologists. Be an active partner.

 

2015 Conference Recap

BY MARK SCHOLZ, MD

Every year’s Conference presents recurring themes.  This year’s focus was prevention, combination treatment and timeliness were emphasized. We live in an era of exploding technological progress. It is a delightful problem to have a wealth of new treatment options and diagnostic tools.  However, just like buying a new car or a new smart phone, it takes a little time to learn the ropes and fully exploit the complete range and capabilities of the new technology.  A short blog can’t cover everything from a three-day conference.  Here are a few comments.

 

Dr. Dan Margolis, an expert on prostate imaging from UCLA, presented information on 3 Telsa, multi-parametric MRI’s capacity as a substitute for random needle biopsy in men with elevated PSA who have never been previously diagnosed with prostate cancer.  MRI offers the advantage of being equally or more accurate than random biopsy without relying on invasive techniques.

 

Dr. Chuck Drake, from John Hopkins, the preeminent expert in the world on immune therapy for prostate cancer, presented exciting data on how many of the new immune drugs work synergistically when given in combination.  “Synergism” means that when either drug is given by itself the anticancer effect is rather modest.  But when the two drugs are given in combination, the anticancer effect is multiplied.  Provenge has already been FDA approved for prostate cancer.  Hopefully Yervoy will also be an approved indication for prostate cancer in the next six to 12 months.  The combination of these two drugs together offers immense hope for jumpstarting immunologic treatment for prostate cancer.

 

Dr. John Mulhall, the expert in the world on sexuality and prostate cancer from Memorial Sloan Kettering, spent a lot of time emphasizing mindfulness in the selection of treatment. In other words, he was saying that it is better to minimize damage by selecting the least toxic form of prostate cancer treatment than trying to fix an already established problem.

 

Dr. Peter Grimm, sometimes called “The Father of Seed Implant Therapy,” delivered a candid overview of the world of radiation therapy, emphasizing the improved cure rates and reduced toxicity seed implant therapy offers.  He also spoke on how increased financial incentives to do IMRT, Proton therapy and SBRT, distorts the decision making process and slants treatment away from seed implants.

 

This is only the briefest of overviews and no words can express all the fun and games that Dr. Mark Moyad injected into the proceedings. I can only say that initial feedback from the attendees was extremely positive.

2015 PCRI Conference DVDs, which include all the presentations, will be available in six weeks at a suggested donation of $150. For more information, email: info@pcri.org.  In addition, the PCRI will be presenting its second annual Mid-Year Update, March 26, 2016, an afternoon of educational sessions in developments in the prostate cancer world. Laurence Klotz, MD who has been called “The Father of Active Surveillance” will be one of the speakers. Learn more at: www.pcri.org/2016-mid-year-update

Taking Charge of Your Prostate Cancer Recovery:Fast Forward From the Old Model

RALPH BLUM

In the old model of prostate cancer care, you were rushed into radical treatment--usually surgery or radiation--often without fully understanding all your options, or the risks and side effects involved. The entire process was focused on the tumor; minimal attention was given to you as a person, and little effort was made to explore the benefits of healthy lifestyle choices, immune-enhancing treatments, reasonable delays, and emotional support.  

The emerging new model of prostate cancer care recognizes the important role you can, and should, play in your recovery. The emerging model comprehends that simply attacking the cancer is not enough. Greg Anderson, who after surviving "terminal" lung cancer founded the Cancer Recovery Foundation, has said that "Retaining a medical team without doing everything you can to help yourself is like attempting to walk on one stilt."

So what do you need to know in order to take charge of your recovery?

 There are three common misperceptions about prostate cancer:

*The assumption that the disease is as dangerous as other cancers.
*The assumption that the urologist who did your biopsy is a prostate cancer expert.
*The assumption that a quick treatment decision is necessary before the cancer spreads.

First of all, prostate cancer is unique among cancers because the mortality rate is so low. Around two hundred thousand men in the U.S. alone are diagnosed with the disease every year, and less than 3% will eventually die from it, while a majority of men who have the far more common low-risk, slow-growing prostate cancer can anticipate living a normal life span, or dying of something else.

 
Your local urologist has a busy medical practice that involves treating problems like impotence, infections, incontinence, and kidney stones. He also does biopsies. But the average urologist performs fewer than five prostate removals (prostatectomies) a year--far too few to be considered proficient. He may be a talented doctor, but he is unlikely to be a prostate cancer expert. So once you have your biopsy results, it is best to consult a prostate cancer specialist, either at a major medical center, or at a high-volume prostate cancer clinic.

As for the third misperception, it is essential, before committing to any form of treatment, that you do your own research, and are convinced the treatment you choose is the right one for you.  Do not let anyone rush you into making a bad decision. Once your category of prostate cancer is identified (Low, Intermediate, or High Risk), get on the Internet and learn about every treatment option--including no treatment whatsoever--for your type of disease.  If you are over 70, and have low-risk disease, my advice to you is to find a doctor who has experience monitoring an active surveillance protocol.

Your role in your recovery, however, doesn't end with choosing your treatment. The emphasis on lifestyle changes has been one of the most significant shifts in cancer care in the last decade. A study at UCSF showed that improving your nutrition, reducing stress and getting more exercise, can lower PSA levels.  And according to a relatively new field of health psychology called "illness representation," your beliefs and expectations also impact the outcome of your disease. So take charge of your recovery, and have faith in your choice of treatment.

The September Prostate Cancer Conference

BY MARK SCHOLZ, MD

PCRI’s Prostate Cancer Conference for Patients is less than two weeks away.  The Conference is a unique event giving opportunity for patients to interact closely with experts in prostate cancer and leaders in research.  It is also a great venue to establish a connection with other patients who have “been there and done that.” This is a weekend to stay informed about the latest in prostate cancer.

That’s where the invited experts come in - we ask them to present their lectures in a way that can be understood by patients. This year’s program will stress breakthroughs in imaging, immunology, new hormone therapy, expanded roles for chemotherapy and the latest thinking on radiation.  The Saturday program will include:

 

·         Dr. Matthew Cooperberg from UCSF is providing an update on active surveillance .

·         Dr. John Mulhall from Memorial Sloan Kettering  will educate us on the latest methods for maintaining normal sexual function after treatment for prostate cancer.

·         Dr. Peter Grimm, from Prostate Cancer Center of Seattle, a world authority on seed implantation reviewing the latest breakthroughs in the area of radiation therapy.

·         Dr. William Oh from Mount Sinai will discuss breakthroughs in injectable radiation that targets bone metastases and new roles for chemotherapy.

·         Dr. Tomasz Beer from the University of Oregon will provide the latest thinking on the powerful new hormonal agents Xtandi and Zytiga.

·         Dr. Dan Margolis a world-renowned prostate imaging expert from UCLA will explain new used for multiparametric imaging of the prostate.

·         Dr. Charles Drake from Johns Hopkins, the world’s preeminent immune expert in prostate cancer will share the latest breakthroughs in this rapidly advancing field.

Dr. Mark Moyad, our moderator, will also be speaking about supplements and diet and how they can lead to increased survival and better quality of life. 

Cancer care is advancing so rapidly that it takes a team effort between you and your physician to achieve the best care.  For the average patient it is overwhelming to try to stay up to date with the latest clinical studies, journal articles and protocols. Often the best place for information is an event like this that specializes in distributing the latest information in a digestible format. 

On Sunday morning, most of our Saturday speakers will participate in a smaller group setting and review their presented topics.  The conference will end with a speaker roundtable to see what treatment the experts will recommend when confronted with actual patient situations. 

The PCRI Conference is for your empowerment. We want it to give you hope and a new confidence in facing the challenging tasks of making important treatment decisions that will impact you for the rest of your life.  

Sign up online: http://prostate-cancer.org/events-calendar/conference-2014/