PCRI Conference Recap

MARK SCHOLZ, MD

Early feedback about last week’s PCRI conference would seem to indicate that it was a resounding success. Close to 800 attended.  More importantly, the overall spirit of the conference was energized by hope as people learned about the many new treatment options. Also, we were blessed by one of the finest speaker lineups ever.  PCRI invited the world’s most eminent prostate cancer doctors to share information in their specific area of expertise.  

We also encountered real enthusiasm about the SHADES campaign.  I loved one comment from a conference sponsor, “It is truly imperative that we eliminate the shades of gray and replace it with SHADES of Blue.” It seems our message about prostate cancer not being a single disease is finally being heard.

For those of you unfamiliar with SHADES, PCRI has changed the technical names: Low-Risk, Intermediate-Risk, High-Risk, Relapsed, and Advanced disease each into a different SHADE of Blue: SKY, TEAL, AZURE, INDIGO AND ROYAL.  “Prostate cancer” is merely a broad umbrella term encompassing an immense spectrum varying from harmless to potentially life threatening. In this vast and confusing marketplace, SHADES help men distinguish between the different types of prostate cancer so they can be wise shoppers. Optimal treatment depends on correctly matching individual characteristics to appropriate therapy.

“Patient Empowerment” was the theme for the conference. The PCRI wanted to provide a place for patients to interact closely with experts and connect with other patients. Cancer care is advancing so rapidly that it takes a team effort with physicians and other patients to achieve the best care. For the average patient it’s too overwhelming to try and analyze the latest clinical studies, journal articles, and protocols.

The conference program opened with an update on active surveillance from Dr. David Krasne, a pathologist from St. John's Hospital in Santa Monica. Dr. Krasne discussed how imaging may be superior to using random needle biopsies for ongoing monitoring. Dr. Anthony Zietman, Associate Director of Radiation Oncology at Harvard Medical School presented the latest information about radiation therapy for intermediate and high-risk disease.  Dr. John Mulhall from Memorial Sloan Kettering discussed state-of-the-art science on preserving sexual function. My presentation was on relapsed prostate cancer. Dr. Mark Moyad moderated all the talks and gave a typically entertaining presentation on diet and supplements. During the Sunday breakout sessions patients and experts interacted with each other on a full spectrum of prostate cancer related topics.

No one can learn all about prostate cancer in a weekend; it’s too vast and confusing. Our job was to get patients started in the right direction.  Awareness is critical.  Now that treatments are becoming more effective, the stakes are much higher. No one wants to miss out on getting the best treatment.

PCRI strives to be an excellent resource by empowering patients, family, friends and support groups. PCRI also wants to foster a spirit of teamwork and cooperation that can make Shared Decision Making between patients and doctors a reality. We believe that the conference was able to successfully exemplify this spirit. DVD’s from the conference will be available soon and can be preordered at www.PCRI.org

A Closer Look into the Book

MARK SCHOLZ, MD, prostate expert and medical oncologist and Ralph Blum, living with prostate cancer for over 20 years, co-authored "Invasion of the Prostate Snatchers:  Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency."  Written for newly diagnosed men - do research before you take the next step, rather than rushing forward.  They present a closer look into the book with these three videos CLICK HERE

KNOW YOUR OPTIONS

RALPH'S JOURNEY

DOCTOR MEETS PATIENT

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.

Combidex the Detective: Where has the Cancer Spread?

MARK SCHOLZ, MD

In our book, Invasion of the Prostate Snatchers, Ralph Blum and I devoted a chapter to the heartbreaking story of how Combidex, a revolutionary way to detect cancerous lymph nodes, was shot down by the FDA.  Detecting cancer in the lymph nodes is the Holy Grail of cancer scanning because the lymph nodes are the first place prostate cancer usually spreads if it leaves the prostate.  Standard CT scans fail to detect cancer until the tumorous nodes are bulging with cancer.

The early detection of lymph node metastases has become a much higher priority now that lymph nodes can be safely targeted with modern radiation.  In the past, with older radiation, side effects were excessive due to collateral damage to the intestines.

 

At Prostate Oncology Specialists we have had reasonably good results imaging lymph nodes with C¹¹ acetate PET scans performed by Dr. Fabio Almeida in Phoenix.  Also, Choline PET scans have been used with success at the Mayo Clinic. However, even with PET scans there needs to be minimum amount of tracer present in the lymph node before it reaches the threshold of detectability. Therefore, PET scans may be unable to detect metastatic nodes until the cancerous nodules are more than 6 mm in diameter.  Studies evaluating intravenous Combidex in conjunction with MRI scanning indicate that normal lymph nodes can be distinguished from metastatic nodes even when the metastases are as small as 3 mm. In one study comparing Combidex with Choline PET scans, Combidex was more accurate at detecting metastatic nodes.

 

I am raising the matter of Combidex in this blog because now, for the first time in years, Combidex has become commercially available again in Europe.  Dr. Jelle Barentsz from the University in Nijmegen has been able to purchase all rights to Combidex along with all the documents and files from the original manufacturer. Unfortunately, as yet there are no sites in the United States that offer Combidex.

 

More than 50,000 men annually develop a cancer relapse after surgery or radiation.  A relapse is indicated by the presence of a rising PSA level in the blood. The rising PSA signals that cancer is present, but offers no indication about the location of the cancer in the body. New scans such as C¹¹ PET and Combidex-enhanced MRI have opened up a whole new realm of treatment possibilities. After all, if the cancer can be located, it creates a possibly for cure by targeting it with radiation.

 

We welcome the renewed availability of Combidex, thanks to the concerted efforts of Dr. Barentsz.

READ MORE ON COMBIDEX

Past Blogs by Ralph Blum
http://prostatesnatchers.blogspot.com/2012/11/life-after-combidex-part-1.html
http://prostatesnatchers.blogspot.com/2012/11/life-after-combidex-part-2.html
http://prostatesnatchers.blogspot.com/2012/12/blog-post.html

Latest PCRI Insights written by Jelle Barentsz, MD
http://prostate-cancer.org/detecting-lymph-node-metastases-combidex/

 

Abstracts from the Meeting of the American Urological Association

BY MARK SCHOLZ, MD

Each year in May the American Urology Association meeting provides a treasure-trove of new scientific information.  As noted in my reviews from earlier scientific meetings, the results of new studies are communicated in 350-word Abstracts which concisely summarize the efforts of a team of scientists working on a specific clinical question.  Several thousand abstracts are published in the proceedings of the meeting, amounting to over a million published words.  On the topic of prostate cancer there were merely hundreds. This year I selected 46 for comment. This blog briefly comments on only a few of these abstracts. Each bullet point is for a separate abstract.

Active Surveillance

·        A large registry in Michigan that tracks prostate cancer treatment reports that about 50% of men with low-risk prostate cancer who are eligible for active surveillance actually undergo active surveillance (the other half get radical therapy). As sad as this sounds, 50% is double the reported active surveillance rates from 3-4 years ago, showing progressively increasing acceptance of active surveillance by doctors and patients. 

·        Laurence Klotz, the father of active surveillance and the lead investigator of the longest study of over a thousand men on active surveillance, reports that after more than ten years of monitoring, 3.6% of patients have developed metastatic disease and 1.7% have died of prostate cancer. Dr. Klotz points out that these statistics are similar to the expected mortality in low-risk patients that get treated with initial surgery or radiation.

Can Gleason 3 + 3 = 6 Metastasize?

·        2500 surgical patients were reviewed to determine if Gleason grade 6 can spread outside the prostate into the seminal vesicle.  In this study not a single case of seminal vesicle invasion was documented when the cancer was exclusively grade 6.

·        Out of 173 men with Gleason grade 6 who had their lymph nodes removed, not a single case of lymph node spread was observed. After an average of five years of observation, no patient has developed metastases.

Metformin and Statins

A number of previous reports have suggested that metformin and statins have anticancer effects. The anticancer effects of metformin have been only studies in diabetics but there is no reason to believe that metformin would be ineffective as an anticancer agent in non-diabetic men. Four abstracts at the AUA elaborate further on this active area of interest.

·        In Denmark, men taking metformin (for diabetes) were at one-third lower risk of being diagnosed with prostate cancer compared to men who were not taking metformin.

·        Men undergoing surgery for prostate cancer who were taking both metformin plus a statin had a reduced risk of cancer relapse—from 30% down to 15%.

·       In Finland, prostate cancer survival was evaluated in 6000 men depending on whether they were taking statins. Statin use reduced prostate cancer mortality by two-thirds.

·       In a study from Europe, there was a 60% reduction in overall mortality in men with advanced prostate cancer who were taking statins compared to those who were not. Both cancer mortality and cardiovascular mortality were reduced by a similar increment.

 Benefits of Surgery

·       In Denmark, the estimated length of life gained with surgery compared to the general population was only 0.4 years after 10 years of observation.

·       In France within 60 days following surgery, the mortality rate was one in a thousand surgeries. Mortality after surgery was nearly twice as high in hospitals performing less than 10 prostate operations a year compared to more experienced centers.

Treatment of a PSA Relapse

Here I quote directly from two abstracts on the topic of a rising PSA after surgery or radiation:

·        “We found that salvage radiation was associated with decreased use of salvage hormone therapy, as well as lower risks of local recurrence, systemic progression, and death from prostate cancer.”

·        “Approximately 16% of patients with a detectable PSA after radical prostatectomy may have false biochemical failure. Repeating the serum PSA in all patients with a detectable level is paramount before making treatment recommendations, especially if the patient had Gleason score 6, negative margins, and the cancer was organ−confined.”

Accuracy of Prostate MRI

One of the problems with random biopsy is that it finds too much grade 6 disease, leading to too much unnecessary radical treatment. Previous studies have indicated that multiparametric MRI finds high-grade disease quite well, only missing small tumors.  However, multiparametric MRI “sees” low-grade tumors much less, which is a good thing. Below are two new reports on this important new technology.

·       A multiparametric prostate MRI showing no cancer in the prostate is accurate 82% of the time for grade 6 cancer and 98% of the time for grade 7 or higher using a 12-core biopsy as the reference standard.

·       A multiparametric prostate MRI showing no high-grade cancer is accurate 74% of the time when using surgical removal and pathologic dissection of the prostate as the reference standard. The types of high-grade cancers that were missed by MRI tended to be smaller, secondary tumors that were organ confined.

I was encouraged to see so many abstracts on active surveillance at this year’s meeting. Also gratifying were the numerous reports on imaging, which in my opinion is the technology of the future that will eventually supplant random biopsy. All the 46 abstracts I judged interesting have been posted here: http://goo.gl/ZzwmpB

 

Prostate Cancer Clinical Trials

MARK SCHOLZ, MD

Clinical studies are primarily performed on men with advanced prostate cancer (the Royal Shade of Blue). Why?  The FDA.   FDA only approves new drugs when survival is proven to be prolonged compared to similar men treated with a placebo. The FDA’s insistence on a survival endpoint forces pharmaceutical companies to limit their research to men with a short life expectancy. If survival has to be the endpoint and the study participants live a long time, the cost of performing the study goes up exponentially.

Undergoing experimental therapy with a new medication is reasonable consideration when standard treatment is either no longer working or is causing unacceptable side effects.  However, it’s rare for doctors to recommend an experimental medication before other FDA-approved drugs on the market have been tried.  The commercially available treatments already proven to extend survival are Lupron, Provenge, Xtandi, Zytiga, Xofigo, Taxotere and Jevtana.

Getting Involved in a Trial Can Be Challenging

Eligibility requirements for participation can be rigorous. Trials have carefully specified pretreatment and health status criteria: Eligibility may be denied if the patient is either too sick or not sick enough, if there is too much previous treatment or not enough previous treatment. Criteria are pre-specified so that the final results of the trial are not skewed by a lack of uniformity among patients.  Other requirements designed to achieve trial uniformity include stopping all other anti-cancer medications and the use of placebos, both of which at times may be at variance with a patient’s best interest.

An additional challenge is finding the right trial that matches a patient’s need. The clinical trials landscape changes quickly.  New trials are initiated with limited fanfare and close as soon as they have met their pre-specified number of participants. Trials available at one center may not be so at another.  Another difficulty patient’s face is how to determine the effectiveness of a prospective study drug. Is it likely to work or not?  Due to a study drug’s newness, its functional characteristics are often unclear to patients and doctors alike.

There are different types of study designs to consider each with different goals.  Phase I studies, for example, are primarily designed to learn more about a drug’s side effects. Phase I studies sequentially escalate medication dosages up to determine the point of dosage intolerability. Phase II studies treat a group of patients at a fixed dosage to get a preliminary sense of a drug’s response rates. Phase III studies are the final step that leads up to FDA approval.  Phase III trials are the placebo-controlled trials.

The Business of Clinical Trials

Patients contemplating participation in a clinical trial should be aware that the clinical trial world functions like a business.  It’s funded primarily by the pharmaceutical industry. As such, doctors working in academia are highly motivated to find participants in their research.  If trials are not completed in a timely fashion funding for new trials will be harder to come by in the future.

Participating in a clinical trial has become more attractive over the last ten years as the pharmaceutical industry has made significant strides toward understanding cancer.  Now that they have access to cancer “blueprints” it’s feasible for brilliant biochemists to design “software patches,” new drugs that are far more effective and far less toxic than what has been traditionally available.  However, patients need be careful they don’t mistake a “new” drug for being an “effective” drug.  Despite the tremendous advances in research, most phase I and II drugs still fail to meet minimum standards of clinical effectiveness and never even advance to phase III testing. Sadly, many of the potential prostate drugs that have been tested in Phase III studies over the last ten years have failed to meet the FDA minimum threshold of showing a survival advantage.

Dr. Scholz is the Principal Investigator at Prostate Oncology Specialists - a list of the active trials are found at http://www.prostateoncology.com/clinical_trials

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!

Taking Charge of Your Treatment

BY RALPH BLUM

The condition known as “selective inattention” plagues our understanding:  We hear what we want to hear. I can think of no way around that defect. Some things just have to be repeated. And repeated, until they sink in.

I am now approaching my 82^nd birthday, and my long and often humbling affiliation with prostate cancer began when I was fifty-eight. A slightly elevated PSA and a “lump” in my prostate led to a biopsy that the urologist evaluated as “suspicious for well-differentiated adenocarcinoma.” The intervening years have given me a profound education in taking responsibility (and at times failing to take responsibility) for decisions that have affected not only my health but also my emotional well-being.

If you have just been diagnosed with prostate cancer, you are walking into the middle of what my oncologist and writing partner, Mark Scholz, MD, calls “a medical minefield.”  Choosing a medical team that will lead you safely through the prostate cancer minefield is arguably the most important decision you will ever make.  And taking an active role in your team is the second most important. You are the person who has cancer, and a passive, “Whatever you say, doc,” attitude will not serve you well.

You need to be aware that over-diagnosis and over-treatment of prostate cancer are rampant. There are many reasons that so many doctors over-treat and over-test, not the least of which is that most of them are reimbursed for how much care they deliver. In fact hospitals, doctors, medical equipment manufacturers, pharmaceutical companies—all organizations that derive their revenue from cancer diagnosis and treatments--have a deeply vested interest in the “more-treatment-is-better treatment” paradigm. However, in the great majority of cases prostate cancer is very slow growing, so there is no reason to panic, or to act precipitously. So that for 9 out of 10 men reading this blog, “active-surveillance” should be your first step on this cancer journey as you weigh your treatment options—which must include the possibility of living with prostate cancer untreated.

You also need to be aware of the “Hammer Syndrome:” If you’re a hammer the whole world looks like a nail. To the surgeon the best option looks like surgery. A radiation oncologist will see radiation as the answer. A medical oncologist is more likely to suggest drugs. It can’t be repeated too often: Before you reach any treatment decision take the time to do as much research as possible, and make sure you explore every option. Do not go to just one doctor and say, “Treat me.” Get a second opinion. Ask questions. And don’t be pressured by anyone to hurry a decision.  Weigh all the pros and cons of each treatment recommended, and look carefully at prostate cancer from the potential cure versus quality-of-life perspective. Far too many men rush into radical treatment for what is typically a non-life-threatening condition when their number one priority should be guarding and preserving quality of life.

Few of us have any objective way to judge whether a particular doctor has the medical knowledge, skill and experience to treat our specific case with success.  I have dodged some major bullets over the years, but eventually it was my good fortune to fall into Mark’s compassionate and capable hands. And I can tell you that confidence in your doctor and belief in your chosen treatment are two of the great intangibles in a successful recovery. And guess what? Your successful recovery may include living a long and productive life with a chronic form of prostate cancer. At least, it has worked for me.

So How Are You Doing Otherwise?

BY RALPH BLUM

At times, over these past decades, I have heard myself say, almost flippantly, about the chronic form of prostate cancer that I, and most men with the disease are dealing with, “Don’t worry—we’re going to die with it, not from it.” But in the meantime?

I almost had a bad fall last night. Barely recovered in time.  I notice I am increasingly wobbly. Unsteady. I lose my balance and barely recover to avoid what might have been a serious fall. Suddenly the world is full of sharp edges and uneven paths. What to do?

I know the rules about exercise. But my body, heading for 82, is noticeably less trustworthy than it was even a year ago. And because my knees and arms are not capable of their former range of exercise (stationary bike, yes, walking and treadmill, no) I can feel the constant ache and low-grade pain as my muscles proceed to atrophy. And while I know there is “armchair yoga,” it isn’t that easy to find a class, and I am less than enthusiastic to try it, so for now I am yoga-less. What to do?

My moaning is muffled. It could be so much worse!  has become one of my mantras, almost a prayer of thanks. I have one old friend, Jack, whose pacemaker, following a stroke, has helped his heart outlive his brain. His loving wife and friend of 43 years, Muriel, is still his aide and comforter, helping him to the toilet, changing his diaper, getting him back comfortably onto the couch, but, but . . .

Anton Chekhov, who died of tuberculosis in 1904, wrote: “Whenever there is someone in a family who has long been ill, and hopelessly ill, there come painful moments when all timidly, secretly, at the bottom of their hearts, long for his death.” The truth is, secretly, and at the bottom of her heart, Muriel would hope for that pacemaker in Jack’s chest to fail.

Which brings me to the troubling issue of American Medical Overdoing. All the advances are functioning to keep Jack functioning. Why? Because they can. Because someone is making money off stents, pacemakers, airport  defibrillators, 911 emergency assistance, insurance that pays for hugely expensive specialists. I can only tell you that Muriel, who has seen too many close friends losing control of their lives and slowly dying, keeps a copy of the Hemlock Society’s Final Exit, underlined in red, on her desk.

The problem is—and it’s the result of medical advances—the number of us who survive health crises that previously would have killed us, is growing rapidly. The eldest of us are the nation’s most rapidly growing age group. And, God help us, nearly one third of all Americans over 85 have some degree of dementia. At least half of them need someone’s help with daily, life-sustaining activities.

What makes my life worth living? Being able to peck out my thoughts on my Mac. Being able to share my thoughts with others who, I hope, will appreciate them. Being able to reach out to friends. To be of some small service to others who find themselves “in the same boat.” And maybe most important, not be too alarmed by death or its not so clandestine approach. As someone put it, “Nobody is really in charge except the marketplace.” And we wait for the bio-ethicists to have some impact on the opposite of over-kill. Maybe “over save-gate?” When does a life cease to be a life, and become a prolonged and agonizing dying? Sick enough to never get better? When indeed?

Prostate cancer and I have been working allies for almost a quarter of a century. Working my way through the thickets of fear and health concerns, having a black belt prostate oncologist, Dr. Mark Scholz as my guide, has left me far more conscious of health maintenance and wise options. I have to confess I am in some ways a healthier and happier man from living all these years with my cancerous prostate.

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

BY MARK SCHOLZ, MD

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

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

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

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

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

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

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

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

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

BY RALPH BLUM

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

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

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

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

The PCRI Conference: Standing in the Gap in a Woeful Medical Situation

MARK SCHOLZ, MD

September is prostate cancer awareness month. Every year the PCRI hosts a three-day educational symposium for patients.  “For patients?”  But people always ask, “What about doctors?”

In the cancer world, prostate cancer is the last bastion of surgeons (urologists).  Surgeons, as it happens, are the primary supervisors of this, the most common type of cancer in men.  Thirty years ago all cancers were managed by surgeons because back then surgery was the only available treatment. While the true cancer specialists of today—medical oncologists—have assumed primary responsibility for every other type of cancer, urologists continue to take primary responsibility of caring for men with prostate cancer.

Therefore surgeons tenaciously hang on to the “way it has always been done,” even though surgery is usually the least effective way to treat prostate cancer. In fact, despite tremendous improvement in other methods of treatment, the reliance on traditional surgery has been on the rise.  The excitement surrounding robotic surgery is probably the reason for the increase. Sadly, numerous scientific studies showing that older surgical techniques work just as well have not changed urologists’ minds.

The theme of this year’s PCRI conference—Quality of Life—naturally emphasizes alternatives to surgery.  Active surveillance, seed implants, IMRT and focal therapy all have survival rates at least as good as surgery, but with far fewer side effects.

This year the conference will feature its very first celebrity—actor Ryan O’Neal.  Mr. O’Neal had such excellent results from his focal therapy that he has volunteered to attend the conference and share his experience.  His story will be featured in the next issue of PCRI Insights which should hit the stands next week.  PCRI Insights is a free quarterly newsletter published by the PCRI.  You can sign up at the PCRI website and have it emailed to you.

Back to the question, “Why patients?”  Basically, Dr. Stephen Strum and I founded the PCRI to educate patients because unlike the surgeons, patients are highly motivated to learn and embrace new options in therapy, especially when the new therapy can convincingly be shown to be equally effective and less toxic.  A patient-orientated approach has proven successful, and the popularity of the conference continues unabated.

So far I have only been commenting on treatment issues related to the newly-diagnosed men with early stage disease. What about men with advanced disease?  Believe it or not urologists are still managing the majority of men with advanced disease, even when metastases are present, and despite the fact that in the last few years  five new products—all of which are proven to prolong life—have been approved for use by the FDA to treat advanced prostate cancer.

Do urologists know how to administer these new treatments?  Are they even aware of them? The complexity of managing advanced prostate cancer has increased exponentially due to the availability of these new treatment options.  The question is: How can urologists, who typically manage prostate cancer in their spare time, keep up with all these new developments when they also have to treat so many other serious issues—kidney stones, urinary incontinence, erectile dysfunction, kidney cancer, bladder cancer, testicular problems, urinary infections—in addition to the time they spend in the operating room  performing various types of surgery?

I would suggest that it is not safe to abdicate your health choices to a urologist. To inform yourself about your options, plan to attend the PCRI Conference on September 6^th, 7^th & 8^th at the LAX Marriott.  Tickets can be purchased on line at PCRI.org.

The Leaders of the PCRI

BY MARK SCHOLZ, MD

Recently a donor to the Prostate Cancer Research Institute (PCRI) asked me about the composition of the board of directors. As I was relating details about board members, I noticed my swelling pride in these wonderful individuals who have been so instrumental guiding the management and development of the PCRI.  What follows is a brief bio of the twelve board members who govern the PCRI.

Chester Swenson (President) is the Chairman/CEO of Marketing and Financial Management Enterprises, Inc., a company that has pioneered the development of corporate cause-related marketing programs designed to access the lifestyle interests and activities of targeted customer segments.  He was formerly CEO of College Enterprises, a premier outsourcing provider of ‘on demand publishing’. He has a BA in political science with a minor in economics from California State University Northridge. He is the author of Selling to a Segmented Market: The Lifestyle Approach, as well as numerous articles in the Journal of Business Strategy, American Demographics, Management Review and the Los Angeles Business Journal.

Jerome Seliger, PhD (Vice President) is a Professor of Health Administration and Public Health in the Department of Health Sciences at California State University with experience in ambulatory care, managed care, community-based health services, community mental health services, behavioral health services and grants management. He has authored numerous scholarly articles on community development, health care and methods for training professionals. He is Co-Founder/CEO, Bienvenidos Children's Center, Co-Founder, Health Compliance Systems PPO and Founding Director, Institute for Communication and Professional Studies.  He has a BA from the University of Minnesota and a PhD from USC.

Barry L. Friedman, Esq. (Secretary) is a family law mediator and former member of panels of arbitrators, American Arbitration Association and Los Angeles County Bar Association. He was formerly a member of  the panel of judges pro tem of the Santa Monica Municipal Court, and family law judge pro tem, Los Angeles Superior Courts. He graduated from the University of Pennsylvania in chemistry and economics as a National Science Scholar and Foundation Fellow. He received his law degree from the University of California with honors.

Kent Graham (Treasurer) is the Founder and Chief Executive Officer of Wellness Ideas Network (“WIN”), a private company specializing in designing, delivering and directing customized health and wellness plans to both organizations and individuals. Prior to WIN, Mr. Graham was a senior executive in the financial services industry for 30+ years. He holds a Bachelor of Arts degree from Dartmouth College and a Master of Business Administration degree from Drexel University.

Mark C. Scholz, MD. (Executive Director) is the Medical Director of Prostate Oncology Specialists in Marina del Rey. He received his medical degree from Creighton University and internal medicine residency and Oncology fellowship from USC.  He is the co-author of Invasion of the Prostate Snatchers and has written and produced extensive educational material on the subject of prostate cancer in various medias which include DVDs, blogs, newsletters and pamphlets. He is also an educational speaker on behalf of Amgen, Dendreon and Sanofi-Aventis. Dr. Scholz has authored or co-authored over 90 scholarly articles and abstracts in his area of expertise.

Duke K. Bahn, MD is the Director of the Prostate Institute of America in Ventura California and is Board Certified by the American Board of Radiology. Dr. Bahn is the preeminent world expert in color Doppler ultrasound imaging of the prostate as well as being one of the original researchers who documented the effectiveness of cryotherapy for prostate cancer, work that ultimately led to Medicare approval for cryotherapy. Dr. Bahn has many academic and professional appointments including Clinical Professor of Urology, Keck School of Medicine, University of Southern California.

Stanley Brosman, MD graduated from Indiana University Medical School. His Urology training was at UCLA where he conducted extensive basic research into the immunology of prostate and bladder cancer. He is a Clinical Professor of Urology at UCLA. He has been involved in numerous studies including the development of the PSA test as well as a variety  of modern therapies currently used in the management of prostate cancer such as Lupron, Firmagon, Casodex, Nilandron, Flutamide, Xgeva, Prolia, Zometa and Zytiga. He is currently practices in Santa Monica and is affiliated with St John's Hospital.

Scott Cohen is CEO of 180 Fusion, a Search Engine Marketing and Search Engine Optimization Company recognized as the leading local SEO Company in North America. Mr. Cohen served in key executive management roles in start-up and high-growth software companies. Most recently, he took PSS Systems from pre-revenue stage to market leader before being acquired by IBM. He currently holds advisory and board member positions at several privately held companies in the technology sector as well as being Co-Founder of TeleHealth America.  He holds a Bachelor of Arts degree from the University of Arizona.

Arthur N. Lurvey MD, FACP, FACE is a board certified internist and endocrinologist, and has been a Medicare Contractor Medical Director for 16 years working for Transamerica Occidental Life Insurance Company, National Heritage Insurance Company and National Government Services; and most recently for Palmetto GBA.  He received his MD from the University of Illinois and had his post doctorate and fellowship training at Los Angeles County-USC Medical Center.  He is a Fellow of the American College of Physicians and the American College of Endocrinology. He is also a CMA surveyor for both the Joint Commission hospital survey program and the CME accreditation program in California.

Jerry Peters is an American songwriter, record producer, multi-instrumentalist, conductor and arranger. He is best known for writing the hit song Going In Circles by The Friends of Distinction. This became his first gold record. Peters also recorded his album, Blueprint For Discovery.  Peters is an in-demand composer, songwriter, arranger and producer. Peters has worked with Earth, Wind & Fire, Aretha Franklin, Quincy Jones, Marvin Gaye, Natalie Cole, The Emotions, The Jacksons, Diana Ross, Deniece Williams, Gladys Knight, Al Green and Lionel Richie.  He won a Grammy for co-writing the “Gospel Song of the Year” with Kirk Whalum, “It’s What I Do.”

Claudia Sangster is an expert in estate, gift, and charitable tax planning having published extensively on topics dealing with ways to prolong family wealth. She speaks extensively at professional conferences and client events, including participation as a panelist at the Milken Institute Global Conference where the discussion focused on philanthropy’s role in improving the lives of global communities.  She has a BA in sociology from Pepperdine University, graduating summa cum laude. She later graduated magna cum laude with a JD from University of Houston Law Center.

Michael L. Steinberg, MD, FASTRO, FACR, FACRO is Professor and Chair of the Department of Radiation Oncology at the David Geffen School of Medicine at UCLA, Director of Clinical Affairs for UCLA’s Jonsson Comprehensive Cancer Center and Chair of the Clinical Chairs of the David Geffen School of Medicine, and also, Chair of the Electronic Health Record Oversight Board (EOB).  He is the founding Chair of the Health Policy Council of American Society for Radiation Oncology (ASTRO) and is currently ASTRO’s Chairman of the Board.   Dr. Steinberg graduated from Occidental College, Phi Beta Kappa, was elected to AOA at University of Southern California School of Medicine, and did his radiation oncology residency and fellowship at UCLA. 

The PCRI board members have wide ranging experience in the healthcare world, charitable endeavors, the arts, as well careers as physician specialists from all the important specialties including oncology, urology, radiation therapy and radiology. Several have had to deal with prostate cancer in their own lives. PCRI is truly fortunate to have such excellent and diverse leadership.