Oxygen Therapy: In the Absence of Evidence

BY RALPH BLUM

Since Mark and I published, Invasion of the Prostate Snatchers, I have been getting a surprising number of questions about the use of oxygen therapy as a vigorous anti-cancer technology. Based on all the inquiries one would think there must be evidence of a widespread belief that oxygen therapy acts to retard or even halt the spread of prostate cancer.

I regret to say that, as of this writing, that is almost entirely untrue, or at best, unproven, except in one situation: Hyperbaric treatment is used to accelerate healing of tissue damaged by radiation therapy. Available scientific evidence does not support claims that increasing oxygen levels in the body will kill or even inhibit the growth of cancer cells.

How is Oxygen Therapy Promoted for Use?
Different varieties of oxygen therapy are effective for treating multiple conditions, including carbon monoxide poisoning, certain kinds of wounds, injuries and skin infections, delayed radiation injury and certain bone and brain infections. However, the FDA sent a warning letter to at least one manufacturer about promoting  oxygen treatment for unproven uses such as certain types of cancer, asthma, emphysema, AIDS, arthritis, heart and vascular diseases, multiple sclerosis and Alzheimer’s disease.

Proponents of oxygen therapy claim that cancer cells thrive in low-oxygen environments. They believe adding oxygen to the body creates an oxygen-rich condition in which cancer cells cannot survive. They also claim that a high oxygen environment increases the efficiency of all cells in the body, increases energy, promotes the production of antioxidants and enhances immune system function.

Other oxygen aficionados believe that immersing an affected body part can cause tumors to separate from the body so that a cancer can be “wiped away.” There is little evidence that this is the case. And yet, a considerable number of men are committing to a variety of oxygen treatments. And that concerns me. So I will give you a brief survey of the oxygen therapy field.

What is the History of Oxygen Therapy?
The history of putting oxygen-releasing substances into the body follows several tracks. Interest in ozone dates back to the mid-1800s in Germany, where it was claimed to purify blood. During World War I, doctors used ozone to treat wounds, trench foot and the effects of poison gas. In the 1920s, ozone and hydrogen peroxide were used experimentally to treat the flu.

One of the earliest accounts of the medical use of hydrogen peroxide was a short article by I.N. Love, MD, in 1888 in the Journal of the American Medical Association. Dr. Love recommended using hydrogen peroxide as “a stimulator of healing." Unlike most current articles, the 1888 report in that prestigious journal did not include details that would be required today, such as whether patients treated with peroxide lived longer than those receiving placebo, or whether there was any solid evidence that peroxide caused cancers to shrink or disappear.

During the 1930s, Otto Warburg, MD, a winner of the Nobel Prize in 1931 for his research on respiratory enzymes, discovered that cancer cells have a lower chemical respiration rate than normal cells. He reasoned that cancer cells thrived in a low-oxygen environment and that increased oxygen levels might therefore harm and even kill them. Many of the beliefs held by oxygen therapy proponents are based on Dr. Warburg’s theories concerning cancer, even though technical advances have since offered a great deal more information about how cancer cells really use oxygen.

Negative Reviews
According to Dr. Stephen Barrett, who writes about health fraud, reviewed a researcher from the Dominican Republic who claimed that his clinic used ozone gas to cure thirteen people with cancer. An investigative news group later learned that two of the patients died of cancer, three could not be found, two refused to be interviewed, three were alive but still had cancer, and in three cases it was not clear if the patients actually ever had cancer.

Furthermore, a 1993 review article found some evidence that too much oxygen in the body’s tissues may damage genetic material and promote abnormal growth. And a 2001 review of ozone therapy concluded that "… few rigorous clinical trials of the treatment exist. Those that have been published demonstrated no evidence of effect . . . Until more positive evidence emerges, ozone therapy should be avoided."

Conclusion
Although oxygen therapy has its benefits, it is the subject of a great deal of controversy, and I could not find credible evidence that it either halts or slows cancer growth. Nor does depriving tumors of oxygen stimulate their growth.  Nevertheless, oxygen therapies continue to be widely promoted as alternative treatment for cancer and other serious illnesses, and are offered at clinics in Mexico, the United States and Europe. These clinics are attracting men with prostate cancer, men hopeful that the therapies provided will benefit them.

The lack of randomized clinical trials makes it difficult to judge the value of oxygen therapy for many of its claims, and we need to expand our knowledge on the effect and mechanisms behind tumor oxygenation.  Meanwhile it continues to be big business south of the border.

But let the buyer beware.

Prostate Cancer: Starting at the Very Beginning

BY MARK SCHOLZ, MD

Yesterday I sat down with a new patient, Sam, a charming man who, unfortunately, was just found to have a prostate nodule and a PSA of 50. When I asked Sam why he had not visited a doctor for over 10 years or undergone any PSA testing, he responded, “I have always enjoyed perfect health. Why see a doctor?” Sounds sort of like a stupid response, but judging by his healthy appearance, (looking more like a 70 year old than an 80 year old), one would have to say that until now his policy has been pretty successful.

However, if Sam was going to participate intelligently in further discussions about the selection of optimal treatment, his prostate cancer knowledge would need a major upgrade. Since my instruction had to begin at a very elementary level, I thought I would use this blog to share the main themes of our almost two-hour meeting together.  Focusing on the basic first steps seems an appropriate theme for this, my first blog of the New Year.

Not All Cancers Are the Same
Many patients introduced into the cancer world fail to understand that lung cancer, breast cancer, brain cancer and prostate cancer are each a distinct illness, each with more differences than similarities. These different cancers are as different as kidney stone disease is different from pneumonia. Therefore, preconceived notions coming from personal experiences with one type of cancer occurring in family members or friends are frequently misleading.

Prostate Cancers are a Mixed Bag
It’s fairly easy to see why dissimilar cancer types, such as bladder cancer and skin cancer for example, behave differently; it may be harder to understand that prostate cancer itself comes in many different and distinct subtypes. Part of this varied behavior can be explained by the disease stage: No one is surprised by the fact that cancer diagnosed at an early stage has a different outlook compared to cancer diagnosed after it has metastasized.

However, beyond the issue of variable stage, when comparing two different prostate cancers of exactly the same stage, what we call “prostate cancer” can be extremely variable. Consider the following: In 2014, 70,000 men were diagnosed with a type of prostate cancer considered to be so harmless that experts universally agree it is best managed with active surveillance only. However, at the other extreme, also in 2014, a very different type of prostate cancer led directly to 28,000 deaths.

Prostate Cancer in the Bone is Not Bone Cancer
A common misconception that needs to be rectified is that cancer that originates in the bone, i.e bone cancer, is a totally different entity than prostate cancer that has spread to the bone. Primary bone cancer grows quickly, often spreads to the lungs and does not respond to hormones. Prostate cancer that spreads to the bone tends to grow much more slowly, only rarely spreads to the lung and usually regresses radically with hormone therapy. Prostate cancer in the bone and primary bone cancer are two separate and distinct illnesses that should not be confused with each other.

Doctors and Patients, the Human Factor
The human factor further complicates the selection of optimal treatment. Doctors who treat prostate cancer come from different schools of thought. Not only are urologists, who are surgeons, trained differently from radiation specialists, the true cancer specialists, the medical oncologists, are practically never involved with early-stage prostate cancer. Differences among patients—age, fitness, prostate size for example—can also radically influence treatment selection.

Sam’s Situation
With a PSA of 50, Sam is going to need a bone scan. He may have already developed metastases. His initial color Doppler ultrasound shows a rather vascular tumor (about an inch and a half long) with some early extra-capsular spread. A targeted biopsy, a single core of the tumor, is scheduled for next week and will let us know the Gleason score.

If the scans turn out to be clear, and if Sam was ten years younger, radiation and hormone therapy would give him the best chance for cure. But in an 80-year-old, the possible side effects that can result are more problematic. Also, we don’t know anything yet about the pace of his disease. Might it be feasible for Sam monitor to the situation for a while? Alternatively, radiation alone or mild hormonal therapy alone (with Casodex) could be considered. Sam and his wife left our meeting with a copy of Invasion of the Prostate Snatchers promising to read it in preparation for our next meeting.

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.

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:  

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 Relapses
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

• 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.

Apparent Locally Recurrent Disease

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

 

The INDIGO Shade of Blue

BY MARK SCHOLZ, MD

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

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

Less common signs of relapse are:

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

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

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

 

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

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

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

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

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

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

Treatment for INDIGO

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

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

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

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

Side Effects of Treatment—INDIGO

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

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

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

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

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

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

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

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

The SKY Shade of Blue

BY MARK SCHOLZ, MD

The worst mistakes are to believe that prostate cancer is just one disease and that it will always need treatment. The entire physician community has stumbled into this terrible blunder by assuming that every tiny little spec of cancer being found through needle biopsy is equivalent to the long-familiar, deadly metastatic variety.  It was the invention of the spring-loaded needle biopsy gun, not just the discovery of PSA that launched the modern prostate cancer industry as we know it today.

Tragically, over the last twenty years, millions of men have had their sex lives ruined by unnecessary surgery or radiation. Only recently has it come to light that the Gleason six type of prostate cancer is harmless, that it never metastasizes.

Yet to this day, practically all men with Gleason six are still being treated. Justification is that since it’s called “cancer” we need to be safe and remove the gland. While many men and their doctors continue making this tragic mistake, now that we know how to differentiate between the harmless and dangerous types of prostate cancer, you can be spared.

Blue is the color for prostate cancer as pink is the color for breast cancer. So the PCRI has labeled the major subtypes of prostate cancer with different Shades of Blue. The five shades are Sky, Teal, Azure, Indigo and Royal.

Sky is the first and most favorable shade of blue, the type that can be safely monitored without treatment. Men in the Sky shade category are defined by having the following four characteristics:

1.       A PSA less than 10

2.       A Gleason score under 7

3.       A tiny nodule on digital rectal or no nodule at all

4.       Color Doppler ultrasound or multiparametric MRI scans showing no extra-capsular extension

Treatment for Sky

Studies show that initial observation, termed Active Surveillance, is a safe way to manage favorable forms of prostate cancer like Sky. In a ten-year observational study at Johns Hopkins out of1,000 carefully selected men it was reported that not a single man died of prostate cancer.  In fact there was not even a single case of metastasis.

Observation is preferred because even with the most skilled doctors, standard therapy with surgery or radiation is frequently associated with permanent impotence and incontinence.

A typical Active Surveillance program consists of PSA testing three or four times a year, a digital rectal examination once or twice a year, and periodic random prostate biopsy every one to three years. Bone scanning is not recommended.

Recently, the policy of performing routine random biopsies is being reconsidered. Biopsy is unpleasant and can occasionally be dangerous. Certain centers, those with access to quality imaging, are substituting an annual multi-parametric MRI or color Doppler ultrasound.  Biopsy is reserved only for the men whose imaging shows a new or growing lesion in the prostate. And rather than doing 12-core random biopsy, one to two targeted cores are used.       

|+| Dr. Scholz will be periodically emailing regarding the topics of Imaging, Active Surveillance, the dangers of prostate biopsy and the existence of safe alternatives.

Subscribe to our mailing list

* indicates required

Email Address *

First Name

Last Name

Fifteen Days and Counting

RALPH BLUM

It’s now been three weeks of IMRT—that’s fifteen radiation treatments. The procedure is simple enough, which is somehow reassuring. I arrive Monday through Friday afternoon at the Arizona Avenue Emergency Entrance of St. John’s Health Care Center. If possible, I find a parking place on the street. Otherwise, it’s Valet Parking, with Fernando smiling broadly, “Don Rafael!” and a five-dollar deduction if I have my parking ticket stamped in the treatment center.

Making my way to the radiation unit was a challenge. On my first visits, I used my cane to hobble down a corridor lined with photographs of previous Directors of St. John’s, and stretching most of the way from Arizona to Santa Monica. Then I took an elevator down to the Garden Floor (No “Basements” here). Then another long trek, passing beneath a Commemorative Tablet honoring Vasek Polak, the prostate cancer patron (his money built the IMRT unit). Finally I arrived at the “PRESS HERE” electronic door into the Radiation wing.

With my bad knees, even using a cane, it was a long haul. And since I’ll be making it for 44 days in all, I reckoned it was time for a change. I remembered seeing a clutch of black canvas-backed, metal-framed wheelchairs just inside the door from Valet Parking. So I appealed to “Transportation.” After only a few minutes, a blue-smocked, gray haired lady volunteer arrived, settled me into a wheel chair, and wheeled me down to Radiation. And so it would continue—someone to wheel me down, someone to wheel me back, for the remaining treatments.

What an improvement! I never thought about wheelchairs before—I was never wheelchair “bound” before IMRT. I learned that the first known “dedicated” wheelchair (called an “invalid’s chair”) was made in 1595 for Phillip II of Spain by an unknown inventor. I bless his unknown memory as the wheels turn and I ride at ease.

The aide parks me just inside the door of the bright comfortable waiting room. There are usually several people sitting in the lounge chairs, reading out of date magazines, waiting for a friend or family member to return from treatment. Or waiting to stretch out and fit into their own treatment mold.

The routine is the same every day. I sit in the waiting room until collected by James or another radiation tech or nurse, who takes me into the changing area and hands me a blue, open–in-the-rear, cotton garment to change into. Then I am escorted through the Ops area (Computer screens frozen on the vast Ion Chamber, charts and graphs, the empty, waiting slide) and into the treatment room with its futuristic cyclorama unit where I am settled into my custom-fitted lower body mold. My three tattoos are aligned with the brilliant green, needle-thin laser beam, followed by my daily MRI. And when all is aligned,  the canned Tchaikovsky starts up, and the whirring of gears announces that the flow of electrons has begun. The zapping itself is surprisingly brief: my prostate is receiving radiation for barely two minutes.

Once a week, Dr. Chaiken and one of the nurses interviewed me: Any pain? Blood in urine? Rectal discomfort? Urinary problems? They each repeat the same questions. Covering the bases twice, just to make sure. I had no unwelcome side-effects. More important, I now believe,  I never felt anxious. Never felt a sliver of doubt. I knew that all would be well.

Only twenty-nine or thirty treatments to go.

Tattooed, Targeted and Zapped

BY RALPH BLUM

Today, at 1:20PM in St. John’s Hospital basement radiation wing, a bright, airy facility managed by friendly, competent techs, nurses and other staff members, I was given the first of 44 doses of Intensity Modulated Radiation Therapy aka IMRT, under the outstanding supervision of Dr. Lisa Chaiken.

 

As explained by the Cancer Treatment Centers of America, IMRT uses advanced software to plan a precise dose of radiation based on tumor size, shape and location. A giant, revolving, computer-controlled machine called a linear accelerator (“Linac” by the techs) delivers radiation in “sculpted” or “carved” doses that match the exact 3D geometrical form of the prostate. In my case, since the cancer is already in the left seminal vesicle, that will also be included in the precisely targeted radiation field.

 

With IMRT, the radiation oncologist can adjust the intensity of radiation beams across the treatment area as required with laser confirmed accuracy. (You can actually see the brilliant green light of the laser emanating in a needle thin beam from the treatment room walls.) This translates as the ability to deliver higher radiation doses than by traditional radiation therapy methods, while minimizing exposure to healthy tissues.

 

What concerned Jeanne most was:  Will I be tired after treatments, so that she should be there to drive me home. Somehow, I just don’t expect to feel excessive fatigue, though we will judge that as the treatments proceed. However, it is worth mentioning that, because the treatment effect is “cumulative,” somewhere around the mid-point (say around 22+ treatments) I may begin to feel fatigue.

 

To prepare me for the procedure, thanks to Jamie, one of the radiology techs, I now have three minute “tattoo” crosses inked right, left and center onto my pelvis, and covered with transparent patches to protect them. The tattoos will serve in the coming treatments to set up and align the path of the Linac.

 

As I settled into the specially tailored plastic body mold, I found myself feeling quite comfortable with the procedure: no anxiety, no dwelling on possible negative side effects (urinary distress, anal irritation up to and including the charming condition referred to in doc speak as “hamburger ass”).

 

When I left the treatment room that housed the 12 foot tall linear accelerator, I was offered a daily treatment time of 9AM for the remaining 43 does of IMRT, However, just to be safe, I rejected that in favor of a regular daily time of 4:20PM. That way, if there is a build up of fatigue, it will not have a negative impact on my entire day.  Anyway, I am ready to put myself in the hands of Dr. Chaiken and her experienced team.

 

Ready to? Seems I already have.

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.