Modern Taxotere Chemotherapy for Prostate Cancer

BY MARK SCHOLZ, MD


In prostate cancer, the word “chemotherapy” is essentially synonymous with Taxotere (docetaxel). Taxotere is by far the most common chemotherapy medicine for prostate cancer. Taxotere is an active agent that is also employed for the treatment of breast cancer and lung cancer.  Jevtana, which has many similarities to Taxotere, more than any differences, is the second most commonly used type of chemotherapy. Taxotere (and Jevtana) are administered intravenously every three weeks in a cyclical fashion.

These agents are typically used to treat advanced metastatic prostate cancer. Men with preexisting bone pain usually notice significant improvement within a week or two of starting therapy.  Another sign that the Taxotere is working is PSA levels decline.  If the PSA does not decline immediately, Taxotere should still be continued for at least two or three cycles before concluding the treatment is not working. An initial increase in PSA for 30-60 days is not an indication to stop Taxotere because on occasion men have a bump upward in the PSA, a “flare” from the dying cancer cells.  However, if the PSA continues to rise after three cycles, it indicates that the Taxotere is not working.

Cancer response rates can be further improved by using Taxotere in combination with Carboplatin.  Carboplatin is also administered intravenously and can be conveniently administered at the same time as the Taxotere. In patients who have normally functioning bone marrow and normal kidney function, a small dose of Carboplatin, say 200 mg, can be safely administered along with full-dose Taxotere.  Carboplatin is well-tolerated though occasional side effects include low-grade nausea, numbness in the hands or feet and tiredness.

Taxotere administered in combination is with Avastin and Revlimid is another very active combination that will induce a cancer response in most men. Avastin, which is FDA-approved for colon cancer but not prostate cancer, is an angiogenesis inhibitor given intravenously every two weeks.  It is generally well-tolerated but requires concomitant blood thinners due to a higher risk of blood clots.  Avastin can also cause slow wound healing and can't be used before or after surgery. Revlimid oral agent that is FDA-approved for a type of bone cancer called myeloma.  Like Avastin, it also functions by blocking new blood vessel growth. When using Revlimid in combination with Taxotere and Avastin we typically limit the Revlimid dosage to 5 mg daily.  Side effects at this dose range are rare though occasionally platelet counts can be suppressed.

A study using these three agents in combination that showed very high response rates was published by Dr. Figg from the National Cancer Institute.  This same study also reported a high frequency of fairly notable side effects including numbness of the hands and feet as well occasional cases of jaw damage, a condition called osteonecrosis.  Despite these significant problem, Dr. Figg reported that the vast majority of the men achieved significant remissions and that the remissions tended to be quite long lasting.  

Aggressive combination protocols like these require various supportive measures to be successful.  Defending against low white blood cell counts with an immune stimulator such as Neulasta should be considered routine. Neulasta is a powerful medicine that stimulates the bone marrow to manufacture white blood cells more quickly and in greater numbers. Side effects are rare but occasionally, serious but transient episodes of lower back pain can occur.

Another bone marrow stimulator, Aranesp, can defend against the development of progressive anemia. Anemia is a common in men with prostate cancer and can be due to hormone therapy, chemotherapy, or even from the prostate cancer invading the bone marrow. Symptoms of anemia are shortness of breath and fatigue. Timely and appropriate use of Aranesp helps to maintain normal red blood cell counts and can reduce the need for blood transfusions.

Taxotere usage has been greatly postponed in men with metastatic prostate cancer ever since the FDA approval of Xtandi and Zytiga. These agents induce meaningful remissions with far fewer side effect than Taxotere.  However, patient tend to have a rapid and virulent progression of the cancer after Zytiga and Xtandi stop working.  Taxotere, possibly in combination with Carboplatin should probably be implemented quickly in most cases. 

I Am Not a Urologist

BY MARK SCHOLZ, MD

In February, while attending the tenth annual GU-Oncology meeting, I was surprised to see my name listed on large posters around the meeting hall (along with about 30 other physicians).  The hosts of the meeting were honoring a very small group of doctors who have attended every single American Society of Clinical Oncology Genitourinary (ASCO-GU) meeting since the meeting’s inception 10 years ago.

A Prostate Cancer World Populated by Surgeons
It’s not surprising that at a meeting of 2,500 attendees, only 30 doctors were honored. This was not a urology meeting, as is typical with most prostate cancer meetings. This meeting was hosted by the American Society of Clinical Oncology*, an association of medical oncologists. Only 30 doctors were on the list because medical oncologists who consistently attend meetings focused on prostate cancer are rare. The prostate cancer world is run by urologists, who are surgeons. Urologists have dominated prostate cancer for 100 years, dating back to when surgery was the only effective cancer treatment available.

What is a Medical Oncologist?
I tend to assume that all my patients know that I am a medical oncologist, not a urologist. However, when I speak to patients, I frequently discover that men fail to understand the difference. The following short list might be help helpful.

Medical Oncologists:  

1.    Take leadership of a medical team comprised of medical doctors from various specialties

2.    Are trained to manage all types of cancer

3.    Supervise multimodality therapy (surgery, radiation, immune, hormonal and chemotherapy)

4.    Are board certified in internal medicine as well as medical oncology

5.    By observing patient outcomes, learn through first-hand experience which surgeons and radiation doctors are the most skilled

6.    Are trained in how to administer multiple different types of medications—both for cancer treatment and for overall health needs—safely, in combination

7.    Have no innate preference for surgery over radiation, since they perform neither

Urologists:

1.    Are trained first and foremost as surgeons

2.    Are trained to care of numerous noncancerous maladies of the genitourinary tract (kidney stones, erectile dysfunction, bladder infections, prostate enlargement, vasectomies, repair of congenital anomalies, urinary leakage, etc.)

3.    Have no internal medicine training

4.    Have a rudimentary understanding of cancer treatment (outside of doing surgery)

Let’s take up the issue of leadership. In this complex modern era, good medical outcomes require a coordinated team effort that maximizes the participation of all the different medical specialties. Five specialties commonly participate in prostate cancer management: urology, radiation oncology, radiology (reading scans), pathology (reading biopsy specimens under the microscope) and medical oncology.  Obviously, any kind of team, medical or otherwise, performs best with knowledgeable and experienced leadership. With almost every other type of cancer (besides prostate cancer) medical oncologists take the lead.

Longstanding Tradition Makes Prostate Cancer the Exception to the Rule
It’s surprising to most people that university medical oncology fellowship programs (like USC, where I trained) offer no training in the management of early-stage prostate cancer. This role has been totally abdicated to the urologists. While advanced-stage prostate cancer patients do transfer their care to oncologists somewhat more frequently, this happens in only half the men with advanced disease.

Studies show that 50% of men with advanced prostate cancer who succumb to progressive disease die without ever consulting with a medical oncologist!  This practice of urologists holding onto their patient to the bitter end may have been defensible back when the effective treatment options for advanced disease were limited to Lupron, Casodex and palliative spot radiation to the bones. However, forgoing oncology consultation in this modern era of Provenge, Zytiga, Xtandi, Xofigo and Jevtana, all of which are proven to prolong survival, borders on lunacy.

Yet despite there being over two million prostate cancer survivors in the U.S., less than a one-hundred (100) medical oncologists who actually specialize in prostate cancer, and almost all of these are in academia doing clinical or laboratory research. Outside of academia less than ten (10) medical oncologists specialize in prostate cancer fulltime. Three of these are in my office in Marina del Rey. The other free-standing medical oncology clinics that specialize in prostate cancer are listed at www.goo.gl/hfFt3F

Practice Makes Perfect
Real day-to-day clinic experience treating large numbers of men with one disease—in this case prostate cancer—improves the skill level of the practicing doctors. Skillful doctors are of great value because new medicines are being approved at an ever faster pace. Familiarity with their use can only be achieved at a high-volume prostate cancer clinic. A fulltime prostate oncologist gains practical experience that takes years to appear in textbooks.

Furthermore, prior to FDA approval, new drugs can only be obtained by participating in clinical trials. But it’s dangerous to conclude that every agent under clinical investigation will provide meaningful benefit. While there is no absolute inside information, most of the prostate oncologists in the country know each other so “inside information” can be learned from a simple phone call or a chance meeting at one of the various prostate meetings that occur throughout the year.

Finally, doctors who are involved in managing large numbers of men with prostate cancer also gain experience with the relative skill levels of other physicians on the medical team; the surgeons, pathologists, radiation therapist and the radiologists. Improved patient outcome is not simply the result of picking the right treatment.  You also have to select a doctor with special talent to administer it.

Conclusion
Don’t make the common mistake that urologists and medical oncologists are inter-changeable.  Having a highly trained and skilled surgeon can be lifesaving—when surgery is truly indicated.  However, in this modern era, radical prostatectomy should be the first choice in relatively few men. And even when surgery is the preferred approach, having a surgeon as the overall leader of your team is no longer ideal.

P.S. My apologies for radically digressing from the exciting information shared at the meeting.  My frustration with a world dominated by urologists clearly got the best of me.  I’ll take up the meeting highlights in my next blog (and in even greater detail in the next issue of PCRI Insights).

* As an aside, the acronym, ASCO, in Spanish means nausea, a name some consider apropos since oncologists are the main purveyors of chemotherapy.

The 2013 PCRI Conference, How to Handle So Much New Information

MARK SCHOLZ, MD

Every year, it seems, the enthusiasm and excitement at the conference grows. Why?  Certainly Dr. Mark Moyad who moderates the conference, and the PCRI staff and I, who organize it, have grown from our experiences over the years. We are fine tuning and improving the agenda over time. But this isn’t the primary reason.

The prostate cancer world is changing, and changing quickly.  In the early years of putting a conference agenda together, I used to spend a lot of time “scrounging around the basement” to find content with high enough quality for presentation.  Back then the main treatments for early and advanced prostate cancer were surgery and chemotherapy respectively. Now for these same stages we have active surveillance and immunotherapy.

So the problem now – it is insufficient to do justice to all the new information in a two day conference. Nathan Roundy, one of our helpline volunteers, who recently returned to the PCRI from sabbatical, came up to me after the conference and said, “I can’t believe how much things have changed in just the last six months!”

The introductory comments I wrote in the conference syllabus convey some of these same thoughts about how the PCRI handles the massive overload of new information:

“Knowledge is power. And what you don’t know can indeed hurt you.  However, in this modern information age, the deluge of unfiltered data can be completely overwhelming. How can patients without professional training sort through it all out and distil a sensible plan of action?” 

No one can offer an easy solution.  The prostate cancer world is complex, and there are too many behind-the-scenes conflicts of interest to simply trust the first smiling doctor you encounter.  Although you can’t escape from the responsibility of doing your homework, you can make sure that you are registered ‘in the right classroom.’ 

The field of prostate cancer is vast, so the PCRI breaks the disease down into different categories, which we have termed Shades of Blue.  Failing to recognize the different Shades of prostate cancer is like wandering randomly between classrooms teaching totally different subjects. Is it any wonder there is so much confusion? Patients don’t need more information. They need personalized information—unbiased resources that are tailored to their specific disease category.”

Even though cancer is a serious subject, we had a lot of fun as well.  Ryan O’Neal came and shared his personal experience of having undergone focal cryotherapy with Dr. Duke Bahn. Dr. Mark Moyad and Ryan had a hilarious exchange culminating with Ryan giving Mark a kiss on the cheek.  Jerry Peters, our Grammy Award winning board member, along with his twelve-piece band, hosted a rocking evening at our Gala dinner Saturday night. Dr. David Hung, the CEO of Medivation, the manufacturer of Xtandi, gave a strikingly inspirational presentation concerning the acceleration of new drug development in the pharmaceutical world.

What a wonderful problem to have - with so many brand new treatments it’s hard to do justice to them in a two day conference.  The key is to recognize your shade of prostate cancer, identify the treatment options available based on that shade, and follow up with more research about those options.  The PCRI website is presently going through a major upgrade and will go live in the next week or so.  Check out www.pcri.org when you get a chance.

Xofigo—A Wonderful New Treatment for Men with Advanced Prostate Cancer

BY MARK SCHOLZ, MD

It’s a special event when the FDA approves a new treatment.  Xofigo, otherwise known as Radium 223 or Alpharadin, is now commercially available.  The FDA approved Xofigo based on the results of a large, prospective, placebo-controlled trial that demonstrated significantly greater survival in Xofigo-treated men compared to placebo-treated men.  The trial also shows a very low incidence of side effects and good relief of bone pain. The treatment is easy to administer, consisting of monthly intravenous injections.

How Xofigo Works
Cancer treatment falls into four major categories. Chemotherapy selectively targets fast growing cells. Unfortunately, since chemotherapy works as a nonspecific cell poison, it frequently causes prominent side effects. Hormonal and targeted agents work by blocking the internal mechanisms of the cancer cell, thus forestalling growth. These treatments tend to have fewer side effects than chemotherapy.  However, by nature cancers are genetically variable, so resistant clones eventually appear. Immunotherapy stimulates the patient’s immune system. New forms of immunotherapy are promising and development is progressing very rapidly but this area of study is still in its infancy. Lastly, there is radiation consists of high energy particles that blast cellular DNA. A cancer cell with disabled DNA can’t reproduce.

Radiation needs to be given in a dosage sufficiently large enough to be effective. However, it also has to be targeted accurately to spare the surrounding healthy tissue. Xofigo addresses both of these demands elegantly. In terms of power, just one of the alpha particles emitted by radium 223 can cause irreversible cell damage because alpha particles are large enough to sever double-stranded DNA (typical beam radiation with photons requires multiple hits on DNA because it only damages one of the two DNA strands).

Xofigo Targets the Bone Metastasis
When cancer invades the calcium matrix of the bone it stimulates the bone to accelerate its rate of calcium uptake.  Radium 223 has structural similarities to calcium so Xofigo is “mistakenly” taken up by the bone cells adjacent to the cancer in lieu of calcium. So after Xofigo is injected, it travels through the blood stream and concentrates in the irritated areas of the bone where the cancer is most active.

Xofigo would be effective against almost any type of cancer since most cancers that spread to the bone increase calcium turnover in the bone cells adjacent to the cancer. However, the manufacturers and distributors, Algeta and Bayer Pharmaceuticals, were wise to seek FDA approval for prostate cancer before pursuing development in other types of cancer. Prostate cancer has an extremely fastidious pattern of spread. Metastases occur almost exclusively in bone. The major organs like lung, liver, kidney or brain are almost always spared. Since prostate cancer spreads almost exclusively to bone, Xofigo targets most if not all of the disease.

Alpha Particles Only Travel a Few Micrometers
To most everyone, the thought of radiation easily conjures up horrible visions of toxicity. The concept of radiation by injection is not new. Strontium and samarium are two radioactive elements that also concentrate in areas of increased bone activity. However, they emit a different type of radiation, beta radiation, which acts over a much longer distance and induces collateral damage to the surrounding cells in the bone marrow, the cells of the all-important immune system. Fortunately, bone marrow toxicity appears to be rare in men treated with Xofigo because alpha particles characteristically dissipate over the distance of a couple of micrometers, restricting the radiation effect to the active area of the cancer where it is invading on the surface of the bone.

Potent, Highly-Targeted Therapy—Just What the Doctor Ordered
Advanced prostate cancer in the bones eventually becomes resistant to other treatments. Historically, external beam radiation therapy has been a potent method for killing cancer cells, particularly to control pain, when the effectiveness of other options seems to be failing. However, beam radiation must be used very judiciously because it also causes irreversible damage to the surrounding bone marrow. Xofigo is likely to rapidly gain widespread acceptance with both doctors and patients because it simultaneously targets multiple metastases yet spares the closely adjacent bone marrow.

All Newly Diagnosed Men Should Be From Missouri. But There Are Limits . . .

BY RALPH BLUM

Missouri is known as the “Show Me State,”  a nickname made popular around 1899 by Congressman Willard Duncan Vandiver, who famously declared, "I'm from Missouri and you've got to show me." Appropriately enough, the state animal is a mule. Newly diagnosed men with prostate cancer, take heed. But also, know when to listen to the experts.

The newly diagnosed men I know who’ve had the best treatment results questioned everything related to the pros and cons of various treatment options. You need to develop the “I’m from Missouri” mindset, so that when an authority figure with a big reputation pronounces, “You need surgery. I’ve got space in my operating schedule next Thursday,” your automatic reaction is not “Whatever you say, doc.” It is “Well, I’m from Missouri and I need to know more before I make that decision.”

 Remember: 90% of us have the slow growing type of prostate cancer. Time is on our side. Second or even third opinions make sense. But—and I am here to tell you there’s a big “But…” Once you have chosen a treatment you had better pay attention to your doctor’s advice. I learned the hard way.

Back in 2002, when my PSA bumped up to 18.3, given my aversion to being sliced open, fried by radiation or poisoned by chemotherapy, it was only logical that I decided to pursue the minimally invasive treatment known as hormone blockade. The objective of hormone blockade is to reduce the production of testosterone—the hormone (androgen) in the blood credited with fueling the growth and spread of prostate cancer—as near as possible to castrate level. But there are some basic rules to follow once you opt for hormone blockage, and I soon began to wish I had taken Mark’s advice about how to avoid some of the adverse side effects that occur in the absence of testosterone. The most talked about one, of course, being no libido.

The protective measures are simple enough: You need to exercise in order to prevent weight gain and muscle wasting—even if, like me, exercise has not been part of your routine. Recommended: 45 minutes of weight training twice a week. Hate it, resent it, but do it. Otherwise? Somewhere down the line, chances are you’ll find your ability to lift, squeeze, steer and reach are all seriously compromised. The truth of “Use it or lose it” becomes painfully apparent. And the longer you wait, the greater the deficit, the harder to repair the damage.  

And then there’s my least favorite adverse side effect from injections of Lupron, which is breast enlargement.Official name gynecomastia. My options were: Either low dose radiation prior to the use of Lupron, or  taking the estrogen blocking drug Femara. I wasn’t keen on undergoing radiation unless it was of critical importance. And somehow I just never got around to taking Femara. Next thing I knew, there they were—my very own set of boobs. A souvenir of my trek through the libido-free zone.

So I’m a living example where ignoring instructions was mulish behavior of the wrong kind. If memory serves, this set of honkers is bigger than those of my first girlfriend. But on the bright side, after months of hormone blockade, my PSA had bottomed out at 0.05, only a breath away from the magic goal line marked “undetectable.” And nowadays, I am only from Missouri on carefully selected occasions.

 

 

 

Let’s Hear Those Treatment Options Again

BY RALPH BLUM

Some things not only bear repeating, they require it. Every year, in spite of all the progress made in the past half century, approxiametly another quarter of a million men are diagnosed with prostate cancer and face the daunting challenge: What treatment, if any, would be best for me? What treatment would be the least likely to put me at risk for side effects more serious than the disease itself?

Choosing a treatment plan that you can live with is an essential part of coping with prostate cancer, it is a tough decision to make.  All too often, there is no clear-cut “best” treatment, and you will get differing opinions from specialists. Your urologist will have a natural bias toward surgery (that is, after all, his specialty), a radiation oncologist’s bias will be toward radiation. Then too, friends and family will have different stories to tell that will further confuse you. Complicating the complex decision making process is the fact that all prostate cancer treatments have significant side effects. One thing is certain: the decision you make significantly alter the quality of the rest of your life.

After your doctor has evaluated the test results and you know the grade and stage of your cancer, there are other factors to consider. The first is your life expectancy, and this, of course, depends on your general health. If you have no other serious health problems and you are likely to live at least ten or more years, chances are your doctor will recommend more aggressive treatment. However, age is also a major factor, and doctors are often reluctant to pursue aggressive treatments with men older than 70 or 75, especially if the cancer is not fast growing. All the more reason to consider possible negative side effects of any treatment you choose.

Unless your PSA is rising fast, or “doubling,” I cannot repeat too often that there is no reason to rush into treatment that you might live to regret. You have to navigate a complex diagnosis, and you need to gather as much information as you can and consider all possible options before deciding which treatment is  the right one for you.

 And here’s something I learned early on: No matter how much you trust your doctor, you should get a second opinion, preferably from a medical oncologist who specializes in prostate cancer. Someone who is familiar with all the available reatments, who isn’t pushing one treatment over others, and who will give you an unbiased opinion.

If you have a low-risk or intermediate-risk cancer, the main treatment options to consider are watchful waiting (also termed “Active Surveillance”), surgery, radiation, and hormone therapy. Each has its risks and benefits and you need to investigate all of them-thoroughly. If, however, your cancer is high risk or more advanced, your treatment plan will be more complicated. Yourr options may well include a combination of these therapies, as well as chemotherapy, immune therapy, and gene therapy.

In a state of major shock after your diagnosis, you may be inclined to accept whatever treatment your doctor recommends. However keep in mind that it is very difficult for doctors who treat prostate cancer regularly not to have strong feelings that favor their own specialty. You are the one who has to live with the results if the treatment doesn’t work out well, and therefore it is you who must have the final say regarding which course to take. Never forget: if you have to get cancer, prostate cancer is the best kind to have because in the great majority of cases it is slow growing, and not only manageable but curable.

In my case, I was convinced that my prostate cancer was the tortoise and not the hare; that it was no more threatening than chronic asthma, and that I would die with it, not from it.  Now almost a quarter of a century has passed. Except for a year of hormone blockade a decade ago, I have stuck with the practice of Active Surveillance.

From everything I have seen and experienced, there are a few questions I would want answered if I were making a treatment decision today. Here they are:

What new drugs and/or treatments are on the horizon? What’s in the testing stage? How promising does it look? How long are we talking about before it comes on line?

Can I reasonably take the chance, given the degree of aggressiveness of my cancer, that waiting will result in my having a better quality of life?

Given the decision I finally make, what are the odds of my being cured?

And finally, if you are thinking about Active Surveillance, here is perhaps least discussed consideration: 

Have I got the temperament to live with even a small  amount of cancer in my body?
 

The answer to that last question is, for most men, the pivot upon which their decision must swing.  So face it. Answer it.  And then, depending on your answer, make your decision.

Prostate Cancer? Newly Diagnosed? Gearing Up for Your Journey (Part 1)

BY RALPH BLUM

You’ve just received what sounds and feels like a death threat. So what do you do? What steps do you take? You may have heard all this before. But we all absorb vital information at different rates, in different ways. Blessed are those of us to whom the Latin proverb applies: Verbum sat sapienti est: “A word to the wise is sufficient.” I know that in my case quite a few repetitions were required to spur me into action.

I’ve written about this subject in “A Strategy for Self-Empowerment,” and yes, now as then, we’re talking about “patient empowerment.” It is vital that you learn all you can about your disease because, like it or not, you are the final authority in making your treatment decisions. And it is equally important not to rush the treatment selection process or allow anyone else—including respected medical professionals—to stampede you into making a decision before you have done your due diligence.

Your 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—whether it is still confined within the prostate gland or has spread beyond the prostate. This information will determine your prostate cancer’s risk factor, and help you decide which treatment option is most appropriate for you.

Your risk level determines your treatment, and not all prostate cancer requires immediate treatment. If your stage and grade put you in the Low-Risk category, your least invasive choice would be Active Surveillance—simply monitor the situation with regular PSA testing, prostate exams, and periodic repeat biopsies.

If you fit into the Intermediate-Risk category you have many treatment choices, and in order to make the best decision you need to get opinions from multiple specialists with state-of-the-art knowledge, and equipment. You will have already seen an urologist who, if you are a candidate for surgery, is likely to have recommended a radical prostatectomy. If this is the case, don’t be shy.  You owe it to yourself to ask the tough questions: What are the risks? How many procedures has he performed overall, and how many within the past twelve months? Does he perform nerve-sparing surgery, and if so what is his success rate with preservation of potency and continence? You will usually find the most experienced surgeons at university centers. But an urologist who is well trained and does 100 procedures a year—and who you feel comfortable with—is also a good bet.

However, before making a decision, you should consider the other options available to you. Consult a radiation oncologist about brachytherapy (radioactive seed implantation). Learn the pros and cons of Intensity Modulated Radiation Therapy (IMRT), a precisely targeted procedure that delivers high doses of radiation to the prostate and, when necessary, to the seminal vesicles and other surrounding tissue. Once again you need to ask about success rates, and about the possible side effects of both radiation treatments.

Men in the Intermediate-Risk category also need to 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—during which time, less toxic and more effective treatments are likely to become available. Hormone therapy does not promise a cure, but it is a viable, noninvasive alternative to surgery or radiation.

If you are in the High-Risk category, you will usually need two or more different kinds of treatment—probably hormone therapy plus radiation, and possibly chemotherapy. But don’t panic. There are a number of exciting new treatment methods in the pipeline, so even if you fall into this more serious category you are not looking at an imminent death threat!
It goes without saying that there are pros and cons to all prostate cancer therapies. And when selecting a treatment plan, much will also depend on your age, your general health, your life expectancy, and your tolerance for the inevitable risks and undesirable side effects of whichever treatment you choose. I am not suggesting that you back off from a definitive form of treatment because of potentially adverse side effects, but bear in mind that quality of life is also a prime consideration when deciding which treatment is best for you. And remember: In most cases prostate cancer is the tortoise of cancers, and--especially if you are in your seventies or older--you are more likely to die with it, not from it. A word to the wise . . .

Confessions of an Anxious Man

BY RALPH BLUM

Like every man I know who is living with prostate cancer, I’ve had my bad moments. But right at the start, during the phase known as “newly-diagnosed,” I knew the odds were in my favor; knew I could die with it not from it. Now, after more than two decades of successfully and peacefully co-existing with this disease, I am once again feeling anxious and at risk.

I have succeeded in one area: the treatment I have undergone has been minimally invasive: no surgery, zero radiation, no chemo. Only a stint of hormone blockade, aka androgen deprivation therapy, and/or Testosterone Inactivating Pharmaceuticals (TIP). And even then, instead of the conventional triple medication—Proscar, Casodex and Lupron—being a minimalist rather than a fan of saturation bombing, I took only Lupron. Still, since there is no question about prostate cancer being testosterone driven, it was appropriate to choose TIP as the least invasive treatment option and, in my case, reduce my testosterone level to that of a pre-pubescent boy.

           

What else did I do to “fight” the cancer? I confess that my behavior as a prostate cancer patient does not receive high marks:  slovenly attention to weight (I’m 5’9” and weigh 218). Diet? Despite my wife Jeanne’s best efforts, I was only part time successful. Exercise? A stationary bike at my neighborhood YMCA, 20 minutes twice a week; no weights work. I am not proud of my record.

Prostate cancer specialists are now rethinking the validity of PSA monitoring. Still, as it was general practice with the option known as “Watchful Waiting,” I was regular in getting my PSA recorded. And until about six weeks ago, my levels were reasonable for a 79-year-old semi-careful patient of a conscientious, competent oncologist, my writing partner, Mark Scholz.

Then, in what might be called “overnight” after two decades of stability, my PSA doubled, vaulted up to 23 and change. And I confess, my sleep is being riven with anxious thoughts. The all but forgotten  “What  if . . .” assault has begin again earnest, with its companion stomach acidity, staring into the darkness, a renewed sense of urgency and, most upsetting, the writing on the wall has become the mirror image of my mantra: Die with it not from it.

However, since my last PSA test, I did undergo a form of heavy duty stress: two surgical procedures for kidney stones. And since surgery—together with heavy lifting, bike riding and recent sexual activity—is known to drive PSA to unrealistic levels, following any of these stressors, you are advised not to be re-tested for a good month or more.

Furthermore, although I was unaware of it for several months, I have been host to a nasty infection known as Proteus Mirabilis (More about that rabid puppy later!). Remembering a previous scare when my PSA suddenly jumped to an alarming level due to infection, I need to undergo a course of antibiotics—in my case Cipro—and then get another PSA test, and a rectal probe with analysis of prostatic fluid to determine whether the infection was actually the cause of my elevated PSA.

Then I will want two essential consults.

First, I need to see Duke Bahn, MD, radiation oncologist, and for my money, the world grand master of the Transrectal Color Doppler Ultrasound for Diagnosis, monitoring with Active Surveillance, and the management of Recurrent Disease.

           

And finally, I will consult with Lisa Chaiken, MD, radiation oncologist at St. John’s Medical Center in Santa Monica, and herself a grand master in the forefront technique of Intensity Modulated Radiation Therapy (IMRT), the only radiation procedure I would feel even provisionally comfortable undergoing.

So first things first: I just came back from my neighborhood CVS Pharmacy with 39 tablets of 500mg Ciprofloxacin HCL. Took the first tab in the parking lot. I’ll complete the two-a-day course of antibiotics; then redo the PSA and get the opinions of the prostate mavens I trust. But whatever the case, I have decided that it is time for definitive treatment—aka cure. Living with low testosterone is downright debilitating.

Enough is enough.

Playing “Chicken:” Sometimes You Both Lose

BY MARK SCHOLZ

I have never seen a real game of chicken where two cars race head on toward each other to see who will swerve first, i.e., who is chicken. However, we are seeing an actual game of chicken being played out before our eyes on the national stage.

In one car in this are the pharmaceutical companies that are charging mind-boggling prices for their new cancer drugs. FDA approval of a new medicine is like hitting the lottery because the insurance companies are legally obligated to pay for the drug. Recouping the cost of developing a new drug is certainly justifiable. Even so, in my recent blog I cited the example of Zytiga (abiraterone), an effective new pill for prostate cancer that retails for $5,000.00 per month.

The other car in this game is the insurance companies, who, to control costs, have begun imposing artificial restrictions on coverage of Zytiga by insisting that chemotherapy be administered first, before Zytiga can be prescribed. By imposing this artificial restriction the insurance companies are getting involved in making decisions about treatment that historically have been left to the doctor. The insurance company’s rationale is that the studies of Zytiga that led to FDA approval were performed in men after chemotherapy, so in theory we don’t know if Zytiga will work before chemotherapy.  What a travesty!  Any cancer expert—for that matter, anyone with common sense—can tell you that starting treatment earlier works better than waiting until the disease is more advanced. 

I really don’t know how this scary game of chicken is going to end.  No insurance company has endless resources. Yet, thanks to effective research being performed by the pharmaceutical companies, many new (and expensive) drugs are coming on the market. Presently in my daily practice, people who meet the criteria—men who have had previous chemotherapy—and have adequate pharmaceutical insurance, are getting coverage for their Zytiga pills. Also, Johnson and Johnson, the manufacturer of Zytiga has a generous program for drug access for people who can’t afford the drug.  Even so, at some point the costs to society are going to become unsustainable. Just like the game of chicken, if both the parties wait too long to take corrective action, we can anticipate a crash.