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.
Showing posts with label IMRT. Show all posts
Showing posts with label IMRT. Show all posts
Tuesday, November 10, 2015
Tuesday, July 7, 2015
Active Surveillance for Men with Intermediate Risk Prostate Cancer
BY MARK SCHOLZ, MD
People
are starting to become familiar with the modern way of conceptualizing prostate
cancer. When men are newly diagnosed,
they are split into three broad categories: Low-Risk,
Intermediate-Risk and High-Risk. This system, which was
invented by Dr. Anthony D’Amico, is helpful for the proper selection of optimal
treatment; men with more favorable types of prostate cancer can receive milder
therapy and still maintain normal survival rates.
As
far as treatment selection is concerned, as a general rule of thumb, men with Low-Risk disease are encouraged to
simply monitor the disease, withholding therapy altogether unless tumor growth
is detected on subsequent testing. At the
other extreme, men with High-Risk
disease typically undergo combination treatment with three forms of therapy:
seed radiation, IMRT and hormone therapy, which is continued for a year and a
half.
Treatment
recommendations for men with Intermediate-Risk
range widely from surgery, to the many types of radiation—IMRT, seed implants,
SBRT and Proton therapy to focal therapy, as well as the alternative of simply
giving hormone therapy by itself. This wide variety of treatment options is not
merely a result of physician bias. It
turns out that the types of cancer that occur in the Intermediate-Risk category also vary widely. At the “good” end of the spectrum, men with
the favorable type of Intermediate-Risk disease have a
condition that behaves more like Low-Risk
while cancers men at the unfavorable
end of the Intermediate-Risk spectrum
have a condition that behaves more like High-Risk.
The
indicators that define an unfavorable
type of Intermediate-Risk disease are
multiple intermediate characteristics
rather than having a single Intermediate-Risk
factor. For example, it is considered
unfavorable when the PSA is over ten and
the Gleason is 4 + 3 (instead of 3 + 4) and
there are more than 50% of the biopsy cores containing cancer. At the other extreme are men with the favorable type of Intermediate-Risk disease. These men are characterized by having
all the Low-Risk factors in
combination with only a single Intermediate-Risk
factor.
Making
a proper distinction between the favorable and unfavorable types of
intermediate risk disease can be monumentally important as it relates to
treatment selection. Studies show that men with favorable Intermediate-Risk disease are potential candidates for active
surveillance. A recently published
report at this year’s Genitourinary ASCO meeting bears directly on this issue:
In
Abstract #82 from the meeting, authored by Ann Caroline Raldow from Harvard, 6500
newly-diagnosed men treated with radiation and hormone therapy at the Chicago
Prostate Cancer Center between 1997 and 2013 were evaluated. Dr. Raldow calculated their survival rate
after treatment based on their risk category: low, favorable-intermediate,
unfavorable-intermediate, and high. Eight years after treatment 820 men had died,
72 of them from prostate cancer. Men in the favorable Intermediate-Risk category had the same survival rates as men in
the Low-Risk category. Men in either the High-Risk category or in the unfavorable Intermediate-Risk category demonstrated an increased mortality rate
from prostate cancer.
Bottom
line, the cancer of men with the favorable type of Intermediate-Risk prostate cancer behaves the same as Low-Risk.
Dr. Raldow’s analysis provides further clinical evidence that men
with the favorable type of Intermediate-Risk
prostate cancer can forgo immediate radical therapy and embark on active
surveillance.
Tuesday, January 20, 2015
Who Asked You for Your Opinion Anyway?
BY RALPH BLUM
Unsolicited Advice from Survivors for the Newly Diagnosed
Unsolicited Advice from Survivors for the Newly Diagnosed
In 2014, approximately 233,000 men in the U.S. were
told they had prostate cancer and to many of them it sounded at best, like the
end of their sex life, and at worst like a death threat. In reality, the
majority of them turned out to have an indolent form of the disease that was
not life threatening and could safely be monitored without any immediate
treatment.
Having said that, a diagnosis of prostate cancer is
not a walk in the park. Just when you are most vulnerable you are obliged to
confront so much complex and conflicting information that to say it leaves you
reeling would be an understatement. So your first and most important decision
is not to make a pressured decision, not to rush the treatment selection
process or allow anyone else—including any doctors you consult—to rush you into
undergoing an irreversible treatment until the shock has worn off and you have
had time to carefully analyze all the data that applies to your particular
case.
The first step after being diagnosed is to understand
the concepts of staging and grading. The grade of your cancer will tell you how
aggressive the cancer cells are. The stage tells you how extensive or advanced
the cancer is. This information, together with your PSA level, will help
determine your prostate cancer’s risk factor—whether you are in the low-risk,
intermediate-risk, or high-risk category.
If your cancer is low-risk it can be safely monitored
with “active surveillance” and does not require any immediate treatment.
If you are in the intermediate-risk category, you have many treatment choices,
and in order to make the best decision you will need to get opinions from
specialists with state-of-the-art knowledge.
You will already have seen a urologist who, if you are
a candidate for surgery, is likely to have recommended a prostatectomy. If this
is the case, it is essential to ask him the tough questions: What are the
risks? How many prostatectomies has he performed overall and how many has he
done in the past twelve months? Does he perform nerve-sparing surgery, and if
so what is his success rate with preservation of potency and continence? And if
you are over seventy, please consider prioritizing almost any other treatment option ahead of going through a major surgical procedure.
Before making a treatment decision you should consult
a radiation oncologist about brachytherapy (radioactive seed implantation), and
IMRT (Intensity Modulated Radiation Therapy), a precisely targeted type of
radiation that delivers high doses to the prostate without damaging surrounding
organs. In my opinion both these options are at least as effective as surgery
at curing the disease and both are associated with significantly lower risk of
long-term toxicity.
You should also consult a medical oncologist about
hormone therapy, a treatment that blocks the male hormone testosterone and
significantly slows the spread of the cancer, often for years. Hormone therapy
does not promise a cure, but it is a viable, non-invasive alternative to
surgery, an effective delaying action. A medical oncologist is a good doctor to
consult with as they have no vested interest in either surgery or radiation and
can often be helpful in sorting out the conflicting opinions you likely have
heard.
If your cancer is in
the high-risk category you will usually need two or more different kinds of
treatment—probably hormone therapy plus radiation. Some centers even may
mention chemotherapy such as commonly done for patients with colon cancer or
for women with breast cancer. And there
are many new treatment methods in the pipeline, so even if your cancer is
aggressive, you are not looking at an imminent death threat.
So do your research
and take your choice. And always remember: Prostate cancer is about the best
possible cancer to deal with.
Tuesday, December 16, 2014
The Importance of Good Communication
RALPH BLUM
You know how frightening it was for you to hear that you have prostate cancer, but in your state of shock you may not realize it is just as devastating for your partner. Although you are the one with the cancer, and the one who has to struggle to cope with selecting the best treatment, your partner is likely experiencing the same emotional distress. The diagnosis inevitably brings up a whole lot of fear for both of you--fear of what’s going to happen, the unthinkable fear (but one you can’t avoid thinking about) that you might die, fear about how sick you will get, fear about what effect your treatment will have on you, fear of how this will change your life together.
The most important thing you can do to deal with these fears and emotions, both yours and your partner’s, is to maintain good communication. The problem I have seen is that some men react to a diagnosis of prostate cancer by pretending that everything’s going to be fine. They don’t want to talk about it. They think asking for help is unmanly, and they want to protect their partner. And most of all they don’t want to talk about their feelings and fears. But putting on a brave front and shutting out your partner is not a good strategy.
I struggled through this experience with my partner, Jeanne. After almost a quarter of a century of doing active surveillance my PSA spiked to a troubling level without any obvious medical evidence as to why. This change in my condition really upset Jeanne. I sought to reduce her fears (and mine) by explaining to her - my belief that my cancer was no more aggressive, but rather because I of my advancing in age my immune system was no longer the faithful bulwark it had been when I was younger. I told her that as a result I was going to get treatment--which treatment, and why.
Basically, I settled on Intensity-Modulated Radiation Therapy (IMRT). So I took some time explaining my reasons. My decision was the result of two "benign" characterisrtics of IMRT. First, the beams were very unlikely to damage to the healthy tissue they traversed, targeting only cancer cells. Second, the process of apoptosis or cell death, would continue unassisted, for up to 18 months following termination of the IMRT procedure.
It is vital that you communicate with your partner openly and honestly. You need to talk about the possible problems that may occur, about how this disease will affect both of you, how you feel about what is happening, or not happening, in the bedroom. You need to share with your partner all the information you have because it can help alleviate fears and concerns. And whenever possible enlist your partner’s help in gathering information about prostate cancer treatments and analyzing which treatments may have the best results.
Make sure your partner understands up front that although prostate cancer is a major problem it is highly treatable and, in most cases, not life-threatening. Above all, resist hiding your feelings because you don’t want to add to your partner’s already heavy burden. It’s one thing to be positive when you can, but you are not doing any favors to the person you love by pretending that you are not afraid or not depressed. You are in this together. Blessed be!
You know how frightening it was for you to hear that you have prostate cancer, but in your state of shock you may not realize it is just as devastating for your partner. Although you are the one with the cancer, and the one who has to struggle to cope with selecting the best treatment, your partner is likely experiencing the same emotional distress. The diagnosis inevitably brings up a whole lot of fear for both of you--fear of what’s going to happen, the unthinkable fear (but one you can’t avoid thinking about) that you might die, fear about how sick you will get, fear about what effect your treatment will have on you, fear of how this will change your life together.
The most important thing you can do to deal with these fears and emotions, both yours and your partner’s, is to maintain good communication. The problem I have seen is that some men react to a diagnosis of prostate cancer by pretending that everything’s going to be fine. They don’t want to talk about it. They think asking for help is unmanly, and they want to protect their partner. And most of all they don’t want to talk about their feelings and fears. But putting on a brave front and shutting out your partner is not a good strategy.
I struggled through this experience with my partner, Jeanne. After almost a quarter of a century of doing active surveillance my PSA spiked to a troubling level without any obvious medical evidence as to why. This change in my condition really upset Jeanne. I sought to reduce her fears (and mine) by explaining to her - my belief that my cancer was no more aggressive, but rather because I of my advancing in age my immune system was no longer the faithful bulwark it had been when I was younger. I told her that as a result I was going to get treatment--which treatment, and why.
Basically, I settled on Intensity-Modulated Radiation Therapy (IMRT). So I took some time explaining my reasons. My decision was the result of two "benign" characterisrtics of IMRT. First, the beams were very unlikely to damage to the healthy tissue they traversed, targeting only cancer cells. Second, the process of apoptosis or cell death, would continue unassisted, for up to 18 months following termination of the IMRT procedure.
It is vital that you communicate with your partner openly and honestly. You need to talk about the possible problems that may occur, about how this disease will affect both of you, how you feel about what is happening, or not happening, in the bedroom. You need to share with your partner all the information you have because it can help alleviate fears and concerns. And whenever possible enlist your partner’s help in gathering information about prostate cancer treatments and analyzing which treatments may have the best results.
Make sure your partner understands up front that although prostate cancer is a major problem it is highly treatable and, in most cases, not life-threatening. Above all, resist hiding your feelings because you don’t want to add to your partner’s already heavy burden. It’s one thing to be positive when you can, but you are not doing any favors to the person you love by pretending that you are not afraid or not depressed. You are in this together. Blessed be!
Tuesday, December 9, 2014
Radiation for PSA-Relapsed Prostate Cancer, an Alternative to Lifelong Lupron
BY MARK SCHOLZ, MD
About 60,000 men a year relapse after surgery or radiation with a rising PSA. In the old days, a rising PSA after surgery was treated with radiation to the prostate fossa, the area of the body where the prostate was previously located. One-fourth of the time these treatments cause durable lowering of PSA levels, essentially a cure. The other three-fourths of the time the PSA keeps rising and the men are relegated to lifelong hormone therapy with Lupron shots. This article is about what to do for the three-fourths whose PSA keeps rising despite undergoing radiation to the prostate fossa.
While hormone therapy is the standard approach because it effectively suppresses PSA for over ten years, the quality of life on long term Lupron is often poor, because Lupron causes hot flashes, tiredness, joint aches, muscle atrophy and loss of sex drive.
In the old days crude attempts to improve cure rates were made by extending the radiation field outside the prostate to cover the pelvic lymph nodes. (The lymph nodes are the first jumping off place for prostate cancer when it metastasizes outside the gland.) As might be expected the closely surrounding intestines often are caught in the radiation crossfire, creating nasty digestive disturbances such as chronic diarrhea and intestinal bleeding. However, due to an amazing breakthrough in radiation technology, that occurred in the mid-1990s— intensity modulated radiation (IMRT)—now the radiation beam can be sculpted to target the nodes and miss the intestines.
Excitement about the potential for this new technology ramped up even further with the advent of new cancer scans such as Combidex and C11 PET scans that can accurately detect which lymph nodes are diseased.
Let me recount the story of a PSA-relapsed gentleman who has now passed his fifth anniversary off Lupron, with this revolutionary approach. Initially, in 1992, he underwent a prostatectomy, but by April of 2003 his PSA had risen to 0.07. He was treated with standard radiation to the prostate fossa. His PSA briefly dropped, but by February 2007 it was back up to 1.83 and in May 2008 his PSA was 7.3. A Combidex scan showed cancerous lymph nodes extending from the pelvis up through the abdomen all the way to the diaphragm. He started Lupron and Casodex and underwent another Combidex scan in June 2009 that showed substantial improvement but incomplete resolution of the cancerous nodes. He started IMRT directed at all the cancerous nodes in late July 2009. The Lupron was stopped in June 2009. At his last visit to my office in November 2014, testosterone was normal at 433 and PSA was 0.040.
Sometimes a “breakthrough” in medical care simply results from a new application of existing technology. This case illustrates how the results of targeted treatment with IMRT can be further enhanced with optimal scanning technology to achieve durable remission and freedom from lifelong dependency on hormonal therapy.
Tuesday, November 4, 2014
Finding a Skilled Specialist
BY RALPH BLUM
Your number one priority when you have an elevated PSA and prostate cancer is suspected, is to take the time to find the very best urologist in your area. What you need now is an experienced urologist who specializes in treating prostate cancer, a urologist who is up on all the latest medical knowledge and surgical techniques, and who will thoroughly discuss all viable treatment options with you in an even-handed manner.
Your options might include nerve-sparing prostatectomy, radiation (IMRT and seed implants), cryosurgery, proton beam therapy, hormone therapy, and Active Surveillance. All prostate cancer treatments have their risks and benefits, and sometimes your best decision is no immediate treatment. I strongly suggest that you take the time to do some Internet research so that when you see the urologist you have some knowledge of the various treatments and their side effects, and know what questions to ask.
Before making any treatment decision you should also talk with a medical oncologist. Urologists are surgeons, so if the cancer is contained within the gland, it’s not surprising that their treatment of choice would be surgery. But if you have done your homework, you will know that a prostatectomy is a complex procedure that can leave you with considerable collateral damage. Similarly, radiation therapists will likely recommend one of the targeted radiation options. However, a medical oncologist has no vested interest in either approach and is familiar with all the treatment options, so he is uniquely qualified to help you decide which treatment to select.
Your primary care doctor usually knows the names of the best local urologists and oncologists in your area. But you may want to go beyond your local area to find a specialist, in which case you can network--ask your friends if they know of any good doctors for treating prostate cancer. Search prostate cancer Web sites. Ask any doctors you have ever consulted who they would see if they had the disease. And most states have prostate cancer support groups that provide excellent advice.
Before making a final treatment decision, it is critically important to get a second opinion, preferably from a highly trained urologist, medical oncologist or radiation oncologist at one of the major cancer centers. Second opinion consultations are standard procedure; your doctor makes such referrals all the time, and a second opinion is reimbursed by most insurance programs. One other thing, be sure to take a complete transcript of your medical records with you.
Above all, don’t rush to make any pivotal decision that could influence the rest of your life while you are still in shock from the diagnosis. You have plenty of time to make sure you are selecting an experienced doctor, and one with whom you feel comfortable, and who gives you confidence.
Tuesday, August 5, 2014
Dealing with Unnecessary Worry
BY RALPH BLUM
Two favorable characteristics of IMRT caused me to go for the
procedure. First, the fact that the radiation does not interfere with normal
tissue it traverses but only affects targeted cancerous cells. Second, the fact
that the process of cell death or apoptosis continues for a year-and-a-half to two
years after IMRT is completed.
In the just over a year (June 27, 2013) since I finished the 45 sessions treatment, I have watched my PSA fall from around 26 to—at last reading three months ago—a PSA of 2.81, an impressive drop to a level I haven't seen in a quarter of a century.
A week ago I went in to doctor's office for another PSA. I have not heard the result, which is unusual since I usually get the results in a day or two. So when a week had passed, and still no word, I began to worry. Is he holding back because the results were not favorable? By all counts, the PSA ought to have dropped below two. Has it actually gone up?
I found myself growing more and more anxious with each passing day. I remembered what Lisa Chaikin, MD, an admirable and patient teacher, who is in charge of St. Johns Hospital’s IMRT program, had told me: that the cancer cells turn over slowly. More and more die off with the passage of time. The impact of the radiation, the damage, is done. But the process takes time.
In my anxiety, I called Dr. Chaikin and told her about my new concern. She told me, “The cancerous cells try to reproduce, their radiation-damaged DNA blocks their reproduction. So the rise is expected to slowly decline over a period of a year or two. However, the PSA does not decline in a straight line. It can bounce up and down a bit before it stabilizes. So even if the PSA has gone up a little there is no reason to worry. It's the long term trend matters."
So being made aware of the possibility of a PSA bounce relieved my mind. Took the worry away. Enabled me to wait without concern.
When the PSA report finally came in: 3.0, a bare rise and no reason for concern. And I had already given up worrying. A big step! Waiting for test results is always a difficult time. Even if the results are not what you want to hear, knowing in advance what to expect makes the uncertainties easier to deal with.
In the just over a year (June 27, 2013) since I finished the 45 sessions treatment, I have watched my PSA fall from around 26 to—at last reading three months ago—a PSA of 2.81, an impressive drop to a level I haven't seen in a quarter of a century.
A week ago I went in to doctor's office for another PSA. I have not heard the result, which is unusual since I usually get the results in a day or two. So when a week had passed, and still no word, I began to worry. Is he holding back because the results were not favorable? By all counts, the PSA ought to have dropped below two. Has it actually gone up?
I found myself growing more and more anxious with each passing day. I remembered what Lisa Chaikin, MD, an admirable and patient teacher, who is in charge of St. Johns Hospital’s IMRT program, had told me: that the cancer cells turn over slowly. More and more die off with the passage of time. The impact of the radiation, the damage, is done. But the process takes time.
In my anxiety, I called Dr. Chaikin and told her about my new concern. She told me, “The cancerous cells try to reproduce, their radiation-damaged DNA blocks their reproduction. So the rise is expected to slowly decline over a period of a year or two. However, the PSA does not decline in a straight line. It can bounce up and down a bit before it stabilizes. So even if the PSA has gone up a little there is no reason to worry. It's the long term trend matters."
So being made aware of the possibility of a PSA bounce relieved my mind. Took the worry away. Enabled me to wait without concern.
When the PSA report finally came in: 3.0, a bare rise and no reason for concern. And I had already given up worrying. A big step! Waiting for test results is always a difficult time. Even if the results are not what you want to hear, knowing in advance what to expect makes the uncertainties easier to deal with.
Tuesday, July 15, 2014
INDIGO: Relapsed Prostate Cancer
MARK SCHOLZ, MD
Those dreaded words, “relapsed cancer,” shake you to the core. They mean that surgery or radiation has failed to “get it all.” However, while with most cancers “relapse” is a fatal pronouncement. However, prostate cancer has its own distinct reality. Most men who relapse don’t die from the disease. The outlook is good because relapses are usually detected by a rising PSA when the cancer is still microscopic. Visible, scan-detected metastases may not appear for ten or more years after the PSA relapse occurs.
Multiple Treatment Options for a Rising PSA
The list of potential treatment options for INDIGO is extensive: observation, radiation, hormone therapy with Lupron and Casodex, salvage seed implant, salvage cryotherapy, Zytiga, Xtandi and Taxotere. However, combinations of these treatments are most commonly employed. Some of these combinations are listed below in order of increasing treatment intensity:
Just as PSA, cancer grade, scan findings and stage were instrumental for assigning a SHADE in newly-diagnosed men; SHADES are important for putting a relapsed in perspective. Ultimately, how to treat INDIGO is guided by a combination of four factors— the SHADE before treatment, the PSA doubling time, individual patient factors such as age, sexual functionality and urinary control, and last, but not least, the cancer location.
The Original Shade before Treatment
In general, treatment should be more aggressive (combined therapy with Lupron and pelvic lymph node radiation) if the original SHADE was unfavorable (AZURE for example). Treatment should lean toward a less aggressive approach—cryotherapy alone, seed implant alone or Casodex alone—if the original SHADE was SKY.
The PSA Doubling Time
Treatment is heavily influenced by the rate of PSA rise. For example, if the PSA is doubling in less than six months, aggressive combination treatment with Lupron and Casodex plus radiation (or cryosurgery in men previously treated with radiation) is probably required. If the PSA doubling rate is between six and twelve months, a less aggressive treatment approach with radiation alone, cryosurgery alone or intermittent Lupron and Casodex is reasonable. When more than a year is required for the PSA to double, observation without immediate treatment may be considered.
Patient Factors that Affect Treatment Selection
A patient’s age needs to be factored into the treatment decision-making process. Men who are more elderly can “step down” the intensity of their treatment by temporizing with milder hormone therapy such as Casodex with Avodart. Younger men, who, prior to relapse, were in the High-Risk (AZURE) category may want to consider upgrading the intensity of treatment by using prophylactic pelvic lymph node radiation plus a more intensive hormone therapy such as Zytiga or Xtandi and/or chemotherapy with Taxotere.
Searching for the Location of the Cancer
Men with rising PSA should undergo standard imaging studies (listed below) in an attempt to determine the location of the cancer. Unfortunately, these scans are often unable detect recurrent cancer unless the PSA is over 20. However, improved PET scans that utilize C11 choline or acetate have the potential to detect recurrent disease with much lower PSA levels. Unfortunately, the PET scans are so new that insurance coverage is often limited.
Sometime even the best scans can’t detect where the cancer is. When this occurs after surgery, particularly when the PSA doubling time is slow, residual cancer in prostate fossa is often suspected and radiation to the prostate fosse is often administered. Cure rates are better when radiation is initiated at a lower level of PSA.
Standard Imaging Studies for INDIGO
Those dreaded words, “relapsed cancer,” shake you to the core. They mean that surgery or radiation has failed to “get it all.” However, while with most cancers “relapse” is a fatal pronouncement. However, prostate cancer has its own distinct reality. Most men who relapse don’t die from the disease. The outlook is good because relapses are usually detected by a rising PSA when the cancer is still microscopic. Visible, scan-detected metastases may not appear for ten or more years after the PSA relapse occurs.
Multiple Treatment Options for a Rising PSA
The list of potential treatment options for INDIGO is extensive: observation, radiation, hormone therapy with Lupron and Casodex, salvage seed implant, salvage cryotherapy, Zytiga, Xtandi and Taxotere. However, combinations of these treatments are most commonly employed. Some of these combinations are listed below in order of increasing treatment intensity:
1.
Observation
2.
Mild
hormone therapy consisting of continuous or intermittent Casodex
3.
Monotherapy
with fossa radiation, seed implant or cryotherapy for persistent local disease
4.
Combination
hormone therapy with Lupron and Casodex given intermittently
5.
Same
as #4 but with the addition of pelvic radiation and 4 months of hormone therapy
6.
Same
as #5 but with hormone therapy extended for 18 months
7.
Same
as #6 but with the addition of Taxotere or Zytiga or Xtandi
Defining
Different Types of RelapsesJust as PSA, cancer grade, scan findings and stage were instrumental for assigning a SHADE in newly-diagnosed men; SHADES are important for putting a relapsed in perspective. Ultimately, how to treat INDIGO is guided by a combination of four factors— the SHADE before treatment, the PSA doubling time, individual patient factors such as age, sexual functionality and urinary control, and last, but not least, the cancer location.
The Original Shade before Treatment
In general, treatment should be more aggressive (combined therapy with Lupron and pelvic lymph node radiation) if the original SHADE was unfavorable (AZURE for example). Treatment should lean toward a less aggressive approach—cryotherapy alone, seed implant alone or Casodex alone—if the original SHADE was SKY.
The PSA Doubling Time
Treatment is heavily influenced by the rate of PSA rise. For example, if the PSA is doubling in less than six months, aggressive combination treatment with Lupron and Casodex plus radiation (or cryosurgery in men previously treated with radiation) is probably required. If the PSA doubling rate is between six and twelve months, a less aggressive treatment approach with radiation alone, cryosurgery alone or intermittent Lupron and Casodex is reasonable. When more than a year is required for the PSA to double, observation without immediate treatment may be considered.
Patient Factors that Affect Treatment Selection
A patient’s age needs to be factored into the treatment decision-making process. Men who are more elderly can “step down” the intensity of their treatment by temporizing with milder hormone therapy such as Casodex with Avodart. Younger men, who, prior to relapse, were in the High-Risk (AZURE) category may want to consider upgrading the intensity of treatment by using prophylactic pelvic lymph node radiation plus a more intensive hormone therapy such as Zytiga or Xtandi and/or chemotherapy with Taxotere.
Searching for the Location of the Cancer
Men with rising PSA should undergo standard imaging studies (listed below) in an attempt to determine the location of the cancer. Unfortunately, these scans are often unable detect recurrent cancer unless the PSA is over 20. However, improved PET scans that utilize C11 choline or acetate have the potential to detect recurrent disease with much lower PSA levels. Unfortunately, the PET scans are so new that insurance coverage is often limited.
Sometime even the best scans can’t detect where the cancer is. When this occurs after surgery, particularly when the PSA doubling time is slow, residual cancer in prostate fossa is often suspected and radiation to the prostate fosse is often administered. Cure rates are better when radiation is initiated at a lower level of PSA.
Standard Imaging Studies for INDIGO
- Color Doppler Ultrasound or Multiparametric 3 Tesla MRI can be used to look for residual cancer in the surgical fossa or in the prostate gland in men previously treated with radiation.
- Pelvic MRI or CT scans are used to check for spread to pelvic lymph nodes. (Carbon 11 acetate PET scan, however, is far more accurate than CT or MRI but some centers still consider them investigational/experimental)
- Technetium bone scans are standard. New F18 PET bone scans, however, are preferable because they can detect much smaller cancers than technetium bone scans.
Scans done in a man with a rising PSA after radiation that indicate a recurrence localized inside the prostate, may be curable with cryosurgery alone or possibly with a seed implant alone. Similarly, an isolated local relapse in the prostate fossa after surgery may be curable with radiation alone. Even though scans show no metastases outside the prostate or the fossa, microscopic metastases in the pelvic nodes may be present, especially in men who have fast PSA doubling times or whose SHADE was originally AZURE. In these higher risk situations, the addition of prophylactic pelvic lymph node radiation with intensity modulated radiation (IMRT) combined with hormone therapy may be advisable.
Regional Spread to Lymph Nodes
When cancerous nodes are
detected in the pelvis, the idea of doing node-directed IMRT is even more
compelling. Since overt cancer in the lymph nodes is an indication of
potentially life threatening disease, an extended course of hormone therapy,
possibly with the addition of second generation hormones such as Zytiga or Xtandi, can be contemplated. Taxotere chemotherapy is an additional
consideration.
Hormone Therapy Alone
When the location of
the relapse is unclear, or if the risks of side effects from radiation appear
too high, relapsed disease can be effectively suppressed for many years with hormone
therapy alone. The side effects of hormone therapy tend to increase with longer
use so intermittent therapy is very
popular. A typical intermittent protocol is to begin with an initial course of
treatment for six to twelve month followed by treatment holiday. After hormone therapy is stopped, testosterone starts to
recover and the PSA begins to rise. Treatment is restarted when the PSA rises
back to the original PSA baseline, or up to five, whichever is lower.
Putting It All Together
Treatment selection
for INDIGO can be complex. Constructing a cancer “profile” using the original
SHADE, the PSA doubling time, and scan finding, is the first step. Unfortunately,
the location of the recurrent cancer may remain uncertain, even after doing the
best scans. When this is the case the
extent of disease may require a professional “guesstimate” based on the PSA
doubling time and the original SHADE. Despite
all these difficulties and uncertainties, the good news is that a wide variety
of treatment options are available and treatment is usually very effective. For
the majority of men the disease can be controlled on a long-term basis, and some
cases it can even cured.
CALENDAR ALERT TO THOSE WHO LIVE AROUND LONG BEACH, CA Learn more about prostate cancer treatments as Mark Scholz, MD, discusses treating PSA relapsed disease at UsTOO Long Beach Prostate Cancer Support Group July 22, 2014 - 6:30 PM to 8:30 PM, at Long Beach Memorial Medical Center. For more information follow this link: http://goo.gl/HMojNV
Tuesday, May 6, 2014
Selecting Prostate Cancer Treatment
BY MARK SCHOLZ, MD
"You mean you have never heard of diffusion-weighted imaging” Exclaimed a recently-diagnosed prostate cancer patient to his doctor. How could his doctor be unacquainted with this important aspect of modern prostate imaging? It’s shocking when a patient realizes he possesses more medical information than the “expert.”
No One Can Be an Expert in Everything
Actually, in this modern era, this situation is being encountered more and more frequently. It’s not so surprising when considering the explosive growth rate of new medical information. It’s humanly impossible for anyone to stay abreast of every new medical development. For example, even though urologists “specialize” in diseases of the urinary system, their area of responsibility demands expertise in a wide variety of unrelated but important areas such as urinary infections, prostate enlargement, prostate infections, sexual dysfunction and kidney stones. They also have to be expert at the surgical treatment of such problems as congenital defects, bladder cancer, testicular cancer and kidney cancer… just to name a few.
Prostate Cancer by Itself is Quite Complex
Prostate cancer alone is intricate enough to keep a specialist occupied full time. For example, simply staging prostate cancer is complicated. Prostate cancer staging uses a multimodality profiling system that estimates the likelihood of microscopic metastases outside the prostate using PSA, Gleason grade, and a percentage of cancer-containing biopsy cores. Now, new imaging techniques are providing further information about the size and location of the cancer within the prostate gland. And even more recently molecular profiling has become commercially available. Staging prostate cancer properly has become a continually developing art form.
Seeking Advice—Delivered from a Level Playing Field
Equally important is the need to seek out unbiased treatment advice. Unfortunately, the process of rendering advice about treatment options is usually very slanted. Urologists (who are surgeons) usually recommend surgery. Radiation therapists usually recommend radiation. This is not to imply that these physicians have less than the best intentions. Over time they just become convinced that what they do is the best option for their patients who are consulting them.
What You Don’t Know Can Hurt You
The number of treatments available for men with newly-diagnosed disease is rapidly expanding. For example, what was previously known simply as “radiation” now includes IMRT, Proton therapy, Cyberknife, two types of Brachytherapy as well as various combinations of these different radiation modalities. Hormone therapy options have now expanded beyond traditional Casodex and Lupron to include Zytiga and Xtandi. The management of the potential side effects of hormone therapy requires special training in diet physical fitness, bone integrity and sexual health to limit the risk of lingering damage after treatment is completed. These days, relapsed or advanced prostate cancer requires physicians who are conversant in genetic typing, modern PET scans, immunotherapy and injectable radiation.
Every Journey Begins with a Single Step
So newly diagnosed prostate cancer patients are faced with daunting situation. Clearly there is no simple answer to this tangle of complicated issues. However, the newly diagnosed cancer patient is far from helpless. He has two overriding responsibilities. First, he must learn as many facts as possible by getting thoroughly educated about the different treatments for his specific type of prostate cancer. Second, he must use discernment in the selection of which physicians to consult.
There is Time to Learn
With prostate cancer there is rarely a need to rush into making a treatment decision because it is usually slow growing. There is plenty of time for the shock of diagnosis to wear off, giving you enough time to get educated about the scientific facts. Published studies comparing outcomes are available. The PCRI in particular publishes articles that translate scientific information into a patient-friendly format. Ultimately, all claims about treatment should be supported by references published in the scientific literature. Selecting treatment for prostate cancer is a high stakes proposition, potentially risking sexual function, urinary function, even life itself. I want to encourage patients to take a leadership role in the treatment-selection process.
"You mean you have never heard of diffusion-weighted imaging” Exclaimed a recently-diagnosed prostate cancer patient to his doctor. How could his doctor be unacquainted with this important aspect of modern prostate imaging? It’s shocking when a patient realizes he possesses more medical information than the “expert.”
No One Can Be an Expert in Everything
Actually, in this modern era, this situation is being encountered more and more frequently. It’s not so surprising when considering the explosive growth rate of new medical information. It’s humanly impossible for anyone to stay abreast of every new medical development. For example, even though urologists “specialize” in diseases of the urinary system, their area of responsibility demands expertise in a wide variety of unrelated but important areas such as urinary infections, prostate enlargement, prostate infections, sexual dysfunction and kidney stones. They also have to be expert at the surgical treatment of such problems as congenital defects, bladder cancer, testicular cancer and kidney cancer… just to name a few.
Prostate Cancer by Itself is Quite Complex
Prostate cancer alone is intricate enough to keep a specialist occupied full time. For example, simply staging prostate cancer is complicated. Prostate cancer staging uses a multimodality profiling system that estimates the likelihood of microscopic metastases outside the prostate using PSA, Gleason grade, and a percentage of cancer-containing biopsy cores. Now, new imaging techniques are providing further information about the size and location of the cancer within the prostate gland. And even more recently molecular profiling has become commercially available. Staging prostate cancer properly has become a continually developing art form.
Seeking Advice—Delivered from a Level Playing Field
Equally important is the need to seek out unbiased treatment advice. Unfortunately, the process of rendering advice about treatment options is usually very slanted. Urologists (who are surgeons) usually recommend surgery. Radiation therapists usually recommend radiation. This is not to imply that these physicians have less than the best intentions. Over time they just become convinced that what they do is the best option for their patients who are consulting them.
What You Don’t Know Can Hurt You
The number of treatments available for men with newly-diagnosed disease is rapidly expanding. For example, what was previously known simply as “radiation” now includes IMRT, Proton therapy, Cyberknife, two types of Brachytherapy as well as various combinations of these different radiation modalities. Hormone therapy options have now expanded beyond traditional Casodex and Lupron to include Zytiga and Xtandi. The management of the potential side effects of hormone therapy requires special training in diet physical fitness, bone integrity and sexual health to limit the risk of lingering damage after treatment is completed. These days, relapsed or advanced prostate cancer requires physicians who are conversant in genetic typing, modern PET scans, immunotherapy and injectable radiation.
Every Journey Begins with a Single Step
So newly diagnosed prostate cancer patients are faced with daunting situation. Clearly there is no simple answer to this tangle of complicated issues. However, the newly diagnosed cancer patient is far from helpless. He has two overriding responsibilities. First, he must learn as many facts as possible by getting thoroughly educated about the different treatments for his specific type of prostate cancer. Second, he must use discernment in the selection of which physicians to consult.
There is Time to Learn
With prostate cancer there is rarely a need to rush into making a treatment decision because it is usually slow growing. There is plenty of time for the shock of diagnosis to wear off, giving you enough time to get educated about the scientific facts. Published studies comparing outcomes are available. The PCRI in particular publishes articles that translate scientific information into a patient-friendly format. Ultimately, all claims about treatment should be supported by references published in the scientific literature. Selecting treatment for prostate cancer is a high stakes proposition, potentially risking sexual function, urinary function, even life itself. I want to encourage patients to take a leadership role in the treatment-selection process.
Tuesday, April 1, 2014
IMRT: The Gift that Keeps on Giving
BY RALPH BLUM
By 2013, I had lived with prostate cancer for almost 25 years without submitting to any form of radical treatment. I was fortunate that my cancer was the non-aggressive, slow moving variety. And over the years I became a strong advocate of a “Die with it not from it” policy.
I learned early on that a “Whatever you say, doc,” attitude can be dangerous, and I knew that the longer I could simply monitor the cancer and use the time to educate myself about the disease, the better off I would be. However, the main reason I resisted radical treatment was the book Mark Scholz and I wrote with the sub-title: “No More Unnecessary Biopsies, Radical Treatment or Loss ofSexual Potency.” I reckoned I’d better practice what I preached.
Then, a little over a year ago, when my PSA suddenly spiked to 26 for no reason I could determine (like BPH or an infection), I figured the cancer was finally on the move. And maybe, after all these years, my immune system was no longer the staunch ally it had been. Mark was reassuring. My cancer hadn’t changed—it was still the non-aggressive type. Which meant the odds of surviving were pretty much in my favor if I decided not to submit to treatment. Still, “To treat or not to treat” remained the question.
After determining that the cancer hadn’t spread to my lymph system or to my bones (big relief there!), I couldn’t help wondering if perhaps I was pushing my luck by sticking to my credo. And to tell the truth, I was getting tired of living with cancer. So as I am no fan of surgery, and anyway at my age (81) it was not an option, I decided to go for a cure with IMRT, Intensity Modulated Radiation Therapy.
It is now almost five months since I completed 45 sessions of IMRT, and I could not be more pleased with the results. At first, I was dismayed to see a rather snail-slow descent of my PSA. Then I learned—and this is the really big news—that cell death, or apoptosis, continues after treatment for another year to a year and a half. According to Lisa Chaiken, MD, an admirable and patient teacher, who is in charge of St. Johns Hospital’s IMRT program, “The cancer cells turn over slowly. More and more die off with the passage of time. There is an immediate impact of the radiation—the damage, is done—but the process takes time."
And get this: the cells only die when the time comes for them to divide! In trying to participate in the creative process of replication, cell death, apoptosis, is the result. The cancerous cells are actually committing suicide: How’s that for irony?
To confirm with visual evidence what is taking place, I’ve been to see radiologist Duke Bahn, MD and compared his various ultrasound images of my prostate: the multiple red tributaries indicating angiogenesis (the flow of new blood to the tumor), once as thick as a busy river delta, are now reduced to a scattered few!
An unexpected bonus for me from undergoing IMRT is a new understanding of PSA function, about which I was always uncertain in the past. Now that I understand the process, the behavior of my PSA—post-treatment—makes total sense: As the cancerous cells die off, the PSA falls. I am now almost five months post treatment, and my PSA has dropped from 26 to 17 to 7.8 and a week ago, in the most recent PSA, to a gratifying 2.8! A level I haven’t seen in a quarter of a century!
Technically speaking, I still have prostate cancer. But my cancer is terminally feeble, itself waiting for the final cut by the Grim Reaper of cancers.
IMRT is truly the gift that keeps on giving!
By 2013, I had lived with prostate cancer for almost 25 years without submitting to any form of radical treatment. I was fortunate that my cancer was the non-aggressive, slow moving variety. And over the years I became a strong advocate of a “Die with it not from it” policy.
I learned early on that a “Whatever you say, doc,” attitude can be dangerous, and I knew that the longer I could simply monitor the cancer and use the time to educate myself about the disease, the better off I would be. However, the main reason I resisted radical treatment was the book Mark Scholz and I wrote with the sub-title: “No More Unnecessary Biopsies, Radical Treatment or Loss ofSexual Potency.” I reckoned I’d better practice what I preached.
Then, a little over a year ago, when my PSA suddenly spiked to 26 for no reason I could determine (like BPH or an infection), I figured the cancer was finally on the move. And maybe, after all these years, my immune system was no longer the staunch ally it had been. Mark was reassuring. My cancer hadn’t changed—it was still the non-aggressive type. Which meant the odds of surviving were pretty much in my favor if I decided not to submit to treatment. Still, “To treat or not to treat” remained the question.
After determining that the cancer hadn’t spread to my lymph system or to my bones (big relief there!), I couldn’t help wondering if perhaps I was pushing my luck by sticking to my credo. And to tell the truth, I was getting tired of living with cancer. So as I am no fan of surgery, and anyway at my age (81) it was not an option, I decided to go for a cure with IMRT, Intensity Modulated Radiation Therapy.
It is now almost five months since I completed 45 sessions of IMRT, and I could not be more pleased with the results. At first, I was dismayed to see a rather snail-slow descent of my PSA. Then I learned—and this is the really big news—that cell death, or apoptosis, continues after treatment for another year to a year and a half. According to Lisa Chaiken, MD, an admirable and patient teacher, who is in charge of St. Johns Hospital’s IMRT program, “The cancer cells turn over slowly. More and more die off with the passage of time. There is an immediate impact of the radiation—the damage, is done—but the process takes time."
And get this: the cells only die when the time comes for them to divide! In trying to participate in the creative process of replication, cell death, apoptosis, is the result. The cancerous cells are actually committing suicide: How’s that for irony?
To confirm with visual evidence what is taking place, I’ve been to see radiologist Duke Bahn, MD and compared his various ultrasound images of my prostate: the multiple red tributaries indicating angiogenesis (the flow of new blood to the tumor), once as thick as a busy river delta, are now reduced to a scattered few!
An unexpected bonus for me from undergoing IMRT is a new understanding of PSA function, about which I was always uncertain in the past. Now that I understand the process, the behavior of my PSA—post-treatment—makes total sense: As the cancerous cells die off, the PSA falls. I am now almost five months post treatment, and my PSA has dropped from 26 to 17 to 7.8 and a week ago, in the most recent PSA, to a gratifying 2.8! A level I haven’t seen in a quarter of a century!
Technically speaking, I still have prostate cancer. But my cancer is terminally feeble, itself waiting for the final cut by the Grim Reaper of cancers.
IMRT is truly the gift that keeps on giving!
Tuesday, October 8, 2013
The TEAL Shade of Blue
BY MARK SCHOLZ, MD
People assume that the differences in the way prostate cancer behaves—one man develops symptoms and another doesn’t—is because they are seeing different stages of the same illness. What’s overlooked, often with disastrous consequences, is that these differences are also due to the fact that distinct varieties of prostate cancer exist.
Receiving optimal therapy depends on matching an appropriate treatment with both the correct stage and the correct type of prostate cancer. Since blue is the color for prostate cancer, as pink is the color for breast cancer, the PCRI has subdivided prostate cancer into five major Shades of Blue. These shades incorporate both the stage and the type of disease. The five shades are SKY, TEAL, AZURE, INDIGO and ROYAL.
The first three shades, SKY, TEAL and AZURE, represent men who have had no previous surgery or radiation. TEAL is what medical professionals call “Intermediate-Risk.” Men in the TEAL shade have identical characteristics to SKY—PSA under 10, Gleason under 7 and a small nodule (or no nodule) on digital rectal examination. However, in addition, men in TEAL have one of the following: PSA between 10 and 20, or, Gleason of 7, or digital rectal exam with a “biggish” nodule confined to one side of the gland.
Since men in TEAL have a small but real chance of cancer spread, staging scans of the bone and body are needed. In addition, a multiparametric MRI or a Color Doppler Ultrasound should be done to check for spread around the gland just outside the capsule. If extra-capsular disease is seen, the shade changes from TEAL to AZURE.
Treatment for TEAL
The list of treatment options for TEAL is long. While occasionally men are candidates for active surveillance— particularly those who are older—one of the following treatments is usually administered: Robotic surgery, open surgery, intensity modulated radiation, temporary high-dose seed radiation, permanent seed radiation, a combination of seed radiation and IMRT, proton therapy, Cyberknife, focal therapy or testosterone inactivating pharmaceuticals (TIP). Sometimes a short course of TIP is combined with radiation.
Focal therapy “focuses” treatment on the cancer itself rather than the whole gland. Typical tools used for focal therapy are cryotherapy, HIFU or laser. In general, skillfully administered focal therapy is thought to be associated with a lower risk for side effects and only slightly higher risk of future cancer relapse. However, focal therapy is very new and there are relatively few studies accurately describing long-term results.
Another option is to use TIP. TIP causes the cancer to shrivel up. Typically TIP is continued for six to twelve months after which men are placed on active surveillance.
One general principle is that treatment success depends just as much on the skill of the administering doctor as it does on the type of treatment selected.
The second general principle is that cure rates with most of the different treatments are so close that for comparison purposes, they should be considered identical. Of course, the truth of this principle is predicated on the assumption that all treatments are administered by equally skilled experts.
Side Effects of Treatment
The prostate gland is so close to other critical organs it becomes very difficult to target the gland without damaging surrounding structures. The most common side effects, therefore, are persistent difficulties with sexual, urinary or rectal function. For example, after radiation in an average 65-year-old, about 75% of men will recover back to their normal pretreatment level of urinary function. About 50% will recover back to their normal pretreatment level of sexual function. After surgery, about 50% of men have urinary function that is restored but only 20% describe their sexual function as recovering back to baseline.
Predictions about the incidence of side effects after focal treatment are less than certain because this technology is so new. Overall, assuming that the treating physicians are skillful, one would expect somewhat better potency rates and somewhat lower cure rates compared to standard surgery or radiation.
Comparing TIP with others options is even more difficult. Cure rates are certainly much lower. However, the good news is that permanent side effects are rare. The three most troublesome side effects during therapy are low libido, weight gain and fatigue. Weight gain and fatigue are partially counteracted with diligent diet and exercise. Low libido only resolves after TIP is stopped. Other common side effects such as hot flashes, calcium loss from the bones, mood swings, breast growth and erectile dysfunction can be prevented with medication.
Final Thoughts
Men in the TEAL Shade of Blue, compared to men in the other shades, face the biggest challenge—making a therapeutic choice. First, there are so many options. Second, none of the options are attractive. The “best” choice is only relatively better than the others; it’s never something you want to do. Making the best choice for yourself requires good comparison shopping skills, and that requires extensive homework. There are no shortcuts. Third, the biggest differences between the options are not related to the cure rates, it’s the concern about permanent side effects that needs the most attention.
Therefore, my recommendation for selecting treatment is to create a list of all the reasonable choices and study them closely, especially in term of the potential long-term side effects. The “worst” choices should be eliminated one by one. The last option left on the list will probably be the best treatment for you.
People assume that the differences in the way prostate cancer behaves—one man develops symptoms and another doesn’t—is because they are seeing different stages of the same illness. What’s overlooked, often with disastrous consequences, is that these differences are also due to the fact that distinct varieties of prostate cancer exist.
Receiving optimal therapy depends on matching an appropriate treatment with both the correct stage and the correct type of prostate cancer. Since blue is the color for prostate cancer, as pink is the color for breast cancer, the PCRI has subdivided prostate cancer into five major Shades of Blue. These shades incorporate both the stage and the type of disease. The five shades are SKY, TEAL, AZURE, INDIGO and ROYAL.
The first three shades, SKY, TEAL and AZURE, represent men who have had no previous surgery or radiation. TEAL is what medical professionals call “Intermediate-Risk.” Men in the TEAL shade have identical characteristics to SKY—PSA under 10, Gleason under 7 and a small nodule (or no nodule) on digital rectal examination. However, in addition, men in TEAL have one of the following: PSA between 10 and 20, or, Gleason of 7, or digital rectal exam with a “biggish” nodule confined to one side of the gland.
Since men in TEAL have a small but real chance of cancer spread, staging scans of the bone and body are needed. In addition, a multiparametric MRI or a Color Doppler Ultrasound should be done to check for spread around the gland just outside the capsule. If extra-capsular disease is seen, the shade changes from TEAL to AZURE.
Treatment for TEAL
The list of treatment options for TEAL is long. While occasionally men are candidates for active surveillance— particularly those who are older—one of the following treatments is usually administered: Robotic surgery, open surgery, intensity modulated radiation, temporary high-dose seed radiation, permanent seed radiation, a combination of seed radiation and IMRT, proton therapy, Cyberknife, focal therapy or testosterone inactivating pharmaceuticals (TIP). Sometimes a short course of TIP is combined with radiation.
Focal therapy “focuses” treatment on the cancer itself rather than the whole gland. Typical tools used for focal therapy are cryotherapy, HIFU or laser. In general, skillfully administered focal therapy is thought to be associated with a lower risk for side effects and only slightly higher risk of future cancer relapse. However, focal therapy is very new and there are relatively few studies accurately describing long-term results.
Another option is to use TIP. TIP causes the cancer to shrivel up. Typically TIP is continued for six to twelve months after which men are placed on active surveillance.
One general principle is that treatment success depends just as much on the skill of the administering doctor as it does on the type of treatment selected.
The second general principle is that cure rates with most of the different treatments are so close that for comparison purposes, they should be considered identical. Of course, the truth of this principle is predicated on the assumption that all treatments are administered by equally skilled experts.
Side Effects of Treatment
The prostate gland is so close to other critical organs it becomes very difficult to target the gland without damaging surrounding structures. The most common side effects, therefore, are persistent difficulties with sexual, urinary or rectal function. For example, after radiation in an average 65-year-old, about 75% of men will recover back to their normal pretreatment level of urinary function. About 50% will recover back to their normal pretreatment level of sexual function. After surgery, about 50% of men have urinary function that is restored but only 20% describe their sexual function as recovering back to baseline.
Predictions about the incidence of side effects after focal treatment are less than certain because this technology is so new. Overall, assuming that the treating physicians are skillful, one would expect somewhat better potency rates and somewhat lower cure rates compared to standard surgery or radiation.
Comparing TIP with others options is even more difficult. Cure rates are certainly much lower. However, the good news is that permanent side effects are rare. The three most troublesome side effects during therapy are low libido, weight gain and fatigue. Weight gain and fatigue are partially counteracted with diligent diet and exercise. Low libido only resolves after TIP is stopped. Other common side effects such as hot flashes, calcium loss from the bones, mood swings, breast growth and erectile dysfunction can be prevented with medication.
Final Thoughts
Men in the TEAL Shade of Blue, compared to men in the other shades, face the biggest challenge—making a therapeutic choice. First, there are so many options. Second, none of the options are attractive. The “best” choice is only relatively better than the others; it’s never something you want to do. Making the best choice for yourself requires good comparison shopping skills, and that requires extensive homework. There are no shortcuts. Third, the biggest differences between the options are not related to the cure rates, it’s the concern about permanent side effects that needs the most attention.
Therefore, my recommendation for selecting treatment is to create a list of all the reasonable choices and study them closely, especially in term of the potential long-term side effects. The “worst” choices should be eliminated one by one. The last option left on the list will probably be the best treatment for you.
Tuesday, October 1, 2013
Stress Management
BY RALPH BLUM
Shining a light on stress from a different angle always yields new insights. The very term “stress management” is like a suitcase you can unpack layer by layer.
There can be no doubt that emotional factors influence biology. Some studies indicate that stress plays a role in causing the occurrence and recurrence of prostate cancer. In fact, most major illnesses have been linked to chronic stress.
Receiving a diagnosis of cancer, and living with cancer, can cause an enormous burden of stress. While experiencing feelings such as depression, despair, anger and fear is totally understandable, if those feelings are not recognized and “managed,” they put endless wear and tear on the body until eventually the immune system—our most powerful defense against cancer—is no longer capable of performing its job efficiently.
The body has its own stress inhibitors. Consider cortisol. Known as the “stress hormone,” cortisol is synthesized from cholesterol, produced in the adrenal cortex, and secreted during a stress response. Among cortisol’s primary functions are: to aid in fat and protein metabolism, and to redistribute energy to those regions of the body that need it most; for example, to the brain and major muscles during a fight-or-flight situation. Most important, cortisol helps to regulate the body’s inflammatory response to stress, which it does by increasing blood sugar through the process known as gluconeogenesis. However, during long periods of chronic stress, cortisol is over-produced, and when cortisol levels are too high, the result is a disruption of its anti-inflammatory function.
Led by Sheldon Cohen, professor of psychology and director of the Laboratory for the Study of Stress, Immunity and Disease at Carnegie Mellon University, a teamof researchers found that chronic psychological stress was associated with the body losing its ability to regulate its inflammatory response and fight infection. They found that, over a prolonged period of stress, body tissue becomes desensitized to cortisol and the hormone loses its effectiveness in regulating inflammation. As a result, disease can prosper.
The links between psychological stress and metastatic growth of disease suggest that stress management should be an integral part of cancer treatment—and possibly the treatment of all inflammatory diseases.
After I completed six weeks of Intensity Modulated Radiation Therapy (IMRT) at St. John’s Health Center in Santa Monica, California, part of the post-procedural concern was monitoring levels of inflammation. For that reason I continued to take Avodart, a drug that both inhibits the transition of testosterone to the more pernicious dihydrotestosterone and acts to keep inflammation levels down. At the same time, I began consciously to monitor my own stress levels and mindfully work to diminish them.
Practically speaking, one thing we can we do is to consider the potential benefits of “mind-body medicine,” which embraces such practices as relaxation therapy techniques, yoga, meditation and tai chi, all of which have been found to be useful as de-stressing activities.
For those of you who think of meditation as an exotic eastern exercise, check out Meditation for Dummies by Stephan Bodian (Wiley Publishing). On the other hand, some people respond well to biofeedback or hypnotherapy. Moreover, it seems that just stroking your pet cat or dog for a few minutes each day has a significant calming effect.
At the very least, adding some form of stress management to whatever conventional treatment you elect to undergo will certainly improve your quality of life—and at the same time enhance your chances of recovery.
Shining a light on stress from a different angle always yields new insights. The very term “stress management” is like a suitcase you can unpack layer by layer.
There can be no doubt that emotional factors influence biology. Some studies indicate that stress plays a role in causing the occurrence and recurrence of prostate cancer. In fact, most major illnesses have been linked to chronic stress.
Receiving a diagnosis of cancer, and living with cancer, can cause an enormous burden of stress. While experiencing feelings such as depression, despair, anger and fear is totally understandable, if those feelings are not recognized and “managed,” they put endless wear and tear on the body until eventually the immune system—our most powerful defense against cancer—is no longer capable of performing its job efficiently.
The body has its own stress inhibitors. Consider cortisol. Known as the “stress hormone,” cortisol is synthesized from cholesterol, produced in the adrenal cortex, and secreted during a stress response. Among cortisol’s primary functions are: to aid in fat and protein metabolism, and to redistribute energy to those regions of the body that need it most; for example, to the brain and major muscles during a fight-or-flight situation. Most important, cortisol helps to regulate the body’s inflammatory response to stress, which it does by increasing blood sugar through the process known as gluconeogenesis. However, during long periods of chronic stress, cortisol is over-produced, and when cortisol levels are too high, the result is a disruption of its anti-inflammatory function.
Led by Sheldon Cohen, professor of psychology and director of the Laboratory for the Study of Stress, Immunity and Disease at Carnegie Mellon University, a teamof researchers found that chronic psychological stress was associated with the body losing its ability to regulate its inflammatory response and fight infection. They found that, over a prolonged period of stress, body tissue becomes desensitized to cortisol and the hormone loses its effectiveness in regulating inflammation. As a result, disease can prosper.
The links between psychological stress and metastatic growth of disease suggest that stress management should be an integral part of cancer treatment—and possibly the treatment of all inflammatory diseases.
After I completed six weeks of Intensity Modulated Radiation Therapy (IMRT) at St. John’s Health Center in Santa Monica, California, part of the post-procedural concern was monitoring levels of inflammation. For that reason I continued to take Avodart, a drug that both inhibits the transition of testosterone to the more pernicious dihydrotestosterone and acts to keep inflammation levels down. At the same time, I began consciously to monitor my own stress levels and mindfully work to diminish them.
Practically speaking, one thing we can we do is to consider the potential benefits of “mind-body medicine,” which embraces such practices as relaxation therapy techniques, yoga, meditation and tai chi, all of which have been found to be useful as de-stressing activities.
For those of you who think of meditation as an exotic eastern exercise, check out Meditation for Dummies by Stephan Bodian (Wiley Publishing). On the other hand, some people respond well to biofeedback or hypnotherapy. Moreover, it seems that just stroking your pet cat or dog for a few minutes each day has a significant calming effect.
At the very least, adding some form of stress management to whatever conventional treatment you elect to undergo will certainly improve your quality of life—and at the same time enhance your chances of recovery.
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