I come across numerous smaller articles of interest related to prostate cancer. Rather than summarizing them in separate blog posts, I’d like to send this short list of four. Hopefully, one or more will be of interest to you.
1) On June 5th, 2013, the Johns Hopkins Health Alerts published a short article entitled “What We Can Learn by Measuring PSA Velocity.” It addresses the role of the rate of PSA change in prostate cancer diagnostics, progression, treatment and outcomes.
2) The Prostate Cancer Foundation (PCF) has published a free pamphlet entitled “Questions to Ask Your Doctor About Prostate Cancer.” The pamphlet also contains spaces to fill in the answers to such important questions. See the following link.
3) Xofigo (alpha-radin, radium-223 chloride) was approved in 2013 to treat men with metastatic prostate cancer which had spread to the bone. Results from a recent study demonstrating improved survival and better quality of life were published in the New England Journal of Medicine with an accompanying video describing the drug. See the following link to the July 31st issue of the Prostate Cancer Foundation NewsPulse.
4) Nanoparticles are chemical species which can serve as a targeted delivery system for drugs, proteins and other therapeutics. The drug to be delivered is contained within the nanoparticle whose surface is then coated with targeting moieties such as antibodies. The overall result is the delivery of a specific drug directly to the cancer cells thereby allowing for higher localized doses and minimized systemic side effects. This type of delivery system for docetaxel (taxotere) is given as an example in a video and accompanying article from the July 31st Prostate Cancer Foundation (PCF) NewsPulse. Docetaxel is a chemotherapy used in metastatic, hormone-refractory prostate cancer patients. While it is efficacious, it also can produce serious side effects. It is also limited in the amount of drug which can be administered intravenously. Therefore, nanoparticle delivery can be much more efficacious.
I was watching my usual TV news channels when a story was presented citing a recent study from the Fred Hutchinson Cancer Reseach Center in Seattle and published on-line in the Journal of the National Cancer Institute. The study results seemed to conclude that taking fish oil supplements or eating too much fatty fish, thereby producing higher serum levels of omega-3 fatty acids, may be linked to an increased risk of prostate cancer. Every TV news story included commentary from the news organization’s resident “medical expert” who unanimously concluded that they would now recommend limiting a man’s input of fish oil and fish itself even though health benefits from essential fats like the omega-3 fatty acids from fish and fish oil and the omega-6 fatty acids from olive oil etc. are well known. However, the benefits of excessive omega-3 supplementation was now being called into question. While fish oil does indeed have an anti-inflammatory effect, the study researchers could not offer a biological reason for this link with prostate cancer and called for more studies. The study analyzed levels of omega-3 fatty acids found to a larger degree in some fish in the blood levels of 834 men who had developed prostate cancer and compared these blood levels to 1,393 men with respect to age and race who had not developed cancer. Men who had the highest levels of omega-3 fatty acids had a 43% increase in risk for prostate cancer and a 71% increase in risk for high-grade prostate cancer most likely to be fatal. The highest blood levels of three omega-3 fatty acids (EPA, DPA and DHA) were consistent with taking fish oil supplements or eating at least three servings of fish per week. The men with the highest levels were the most likely to eventually be diagnosed with prostate cancer. These studies are far from clear and a biological basis for these findings is being sought. Earlier, similar studies in a large trial called SELECT had found that taking vitamin E supplements actually increased the risk for prostate cancer. There is another side to this story which did not appear on my TV news channels. The Prostate Cancer Research Institute (PCRI) recently summarized the comments of three well-known prostate cancer researcher-physicians who unanimously differed in their interpretation of these study results. The physicians include Dr. Anthony D’Amico of Harvard and Brigham and Women’s Hospital in Boston, Dr. Mark Moyad and Dr. Charles Myers. The accompanying link also contains a summary of the original study as well as the physicians’ specific comments and critiques. I suggest that you read their comments, and discuss them with your personal prostate cancer physician before making any changes in your dietary and nutritional habits. The opposing viewpoints were not presented on any of the major news channels to my viewing knowledge.
New research has identified several ‘biomarkers’ or genetic fingerprints that report the underlying biology of a tumor. Combinations of these biomarkers can aid clinical management of prostate cancer by: 1) allowing accurate diagnoses; 2) establishing whether a patient’s cancer is aggressive or indolent; 3) deciding if repeat biopsies are needed; 4) aiding clinical decisions on therapeutic options (drug combinations for maximal patient benefit); and, 5) evaluating whether a patient’s cancer is responding to therapy or not. For an excellent review article describing many of the diagnostic (including genetic) tests currently available or in the developmental pipeline, see the March 29th, 2013 Prostate Cancer Foundation (PCF) NewsPulse and the articles contained therein. Many of these biomarker-driven diagnostic / prognostic tests nearing clinical use are in the final stages of clinical validation and are listed in table form in the Newspulse article. The New York Times recently published a feature article discussing many of these new tests. These latest prostate cancer tests evaluate blood, urine or prostate biopsy specimens for the presence of either an abnormal gene activity pattern, or specific chemicals that are released by cancer cells. For example, the GenProbe test currently evaluates urine samples for the expression of PCA3 (prostate cancer antigen) DNA. It is anticipated that the GenProbe test evaluating both PCA3 DNA and expression of the TMPRSS2-ERG gene fusion will soon be approved for use. The abnormal TMPRSS2-ERG gene fusion is present in 50 percent of all prostate tumors, and PCA3 is expressed at high levels in 95 percent of prostate cancer patients, therefore the combination of these two tests has a high probability of accurate diagnoses. Testing these biomarkers in urine samples holds potential due to the non-invasiveness of urinalysis, ease of collection, and the fact that prostate cells are directly released into the urethra through prostatic ducts after a digital rectal exam (DRE) or prostate massage.
I would like to share a small example which I believe illustrates God’s timetable and daily provision for circumstances in our lives. While this narrative might seem relatively insignificant, the principle it demonstrates is a major one. Just as we rely on God’s help and provision for serious issues such as prostate cancer, He also makes His presence known in more routine ways of daily life. During the summer months, temperatures along the sun-drenched southwestern Florida Gulf of Mexico coast consistently range into the mid-90’s accompanied by intense humidity. But civilization functioned here long before the advent of climate-controlled air conditioning. A few days ago my wife and I experienced to a small but realistic degree what it would have been like to live here without such modern conveniences. It was a hot, rainy evening at midnight when our 20-year old air conditioning unit finally expired. It would take days to replace it. As we try to consistently do, we prayed that God would enable us to accept our circumstances with His peace and tranquility. To our pleasant surprise, the next few days became mostly cloudy and rainy with temperatures only in the mid-80’s, thereby negating Florida’s hot intense sunshine heating our home. It made our circumstances very bearable and made us appreciate all the more how people thrived without the modern conveniences of air conditioning. God did not alter the weather patterns to conform to our immediate need but we believe He arranged the timetable such that when our need arose, He made the circumstances quite bearable. Our earthly bodies are subject to illnesses and various less-desirable conditions, yet when we release them to the Lord, He carries us through often in ways we could never have anticipated and even guarantees it in His Word. Two examples follow. “Therefore, let us draw near with confidence to the throne of grace, so that we may receive mercy and find grace to help in time of need,” according to Hebrews 4:16. From the Old Testament, Lamentations 3:22-23 states “the Lord’s lovingkindnesses indeed never cease, for His compassions never fail. They are new every morning; great is Thy faithfulness.”
In an attempt to identify younger men who are at risk for prostate cancer, researchers at Johns Hopkins in Baltimore, MD studied 94 men who had been diagnosed with prostate cancer when they were 55 years old or younger or who had close blood relatives with prostate cancer. Past research led the investigators to suspect that one particular region of the human chromosome, known as 17q21-22, might be the location of one or more prostate cancer susceptibility genes. The team analyzed 200 genes located in this region. They found that four of the 94 men had a mutation on a gene known as HOXB13, which plays an important role in the development of the prostate. These four men were also found to have a total of 18 close male relatives with prostate cancer. Blood tests revealed that every one of these men had the HOXB13 gene mutation — powerful evidence that it might be linked to hereditary prostate cancer. In a larger study of 5,100 men who had been treated for prostate cancer, it was found that 72 of them had the same mutation on the HOXB13 gene. In addition, these men were highly likely to have been diagnosed with prostate cancer at a young age or to have one or more relatives with the disease. For comparison, the team studied 1,400 men who didn’t have prostate cancer. Just one man had the HOXB13 mutation. “This study, which was published in the New England Journal of Medicine, found that men who carry the HOXB13 mutation are up to 20 times more likely than non-carriers to develop prostate cancer. It is important to keep in mind that the mutation discovered on the HOBX13 gene is rare and explains only a small number (between 2%-5%) of prostate cancer patients but it is an excellent example of the use of an individual’s personalized genomic information as a predictor of future health issues.
A brief description of terms as used in discussions about genes and prostate cancer was recently published in the July 13th edition of the Johns Hopkins Health Alerts. (See link).
Genomic Health Inc., a cancer diagnostics company, recently announced they are now marketing a genomic test for men diagnosed with prostate cancer that will provide better information on how likely it is that their prostate cancer is an aggressive form of the disease needing immediate treatment, or a slow-growing, low-risk form of prostate cancer that can safely be monitored over time for signs of progression. The new assay, Oncotype DX Prostate Cancer Test, will potentially give tens of thousands of men increased confidence that they can safely forego aggressive treatment and instead enter a program of active surveillance, where their tumor is monitored over time, deferring surgery or radiation and potentially avoiding the sexual and/or bowel and bladder dysfunction side-effects that can result from those treatments. The new test—a 17-gene predictive “signature”, measures the amount of ribonucleic acids (RNA) expressed by these various genes, with some genes making large amounts of RNA and others making little. Seven separate studies by Genomic Health Inc., involving over 1,000 men diagnosed at biopsy with prostate cancer have shown that in men whose tumors turned out to be high-risk, those men tended to test positive for this 17-gene “signature.” The Oncotype DX Prostate Cancer Test currently costs about $3,800 and is not covered by insurances at this time. For further information, please see the May 9th and May 31st issues of the Prostate Cancer Foundation (PCF) NewsPulse.
On May 15th, 2013, the U.S. Food and Drug Administration approved Xofigo (previously known as Alpharadin) for use in men with treatment-resistant prostate cancer that had metastasized to bones but not to other organs. Xofigo, administered by injection, will be marketed by Bayer Healthcare Pharmaceuticals who developed the therapy jointly with Algeta, ASA, a Norwegian pharmaceutical company. The drug works by delivering radioactive alpha particles directly to prostate cancer cells that have formed tumors in bone. The radioactive alpha particles from radium-223 dichloride are relatively “heavy” and therefore do not penetrate very far in the body thus limiting the effect of the drug to about a 10-cell radius thereby limiting its toxicity. The drug binds with minerals in the bone to deliver radiation directly to the bones limiting damage to surrounding tissues. In Phase III clinical trials, men given Xofigo experienced a six-month longer timeframe to first complications (fractures or spinal cord compression) occurring as a result of bone tumors, a survival advantage of about 3 months and a higher quality of life. Xofigo also produced a 50% reduction in the risk of spinal cord compression caused by tumors—a complication that can result in paralysis, severe pain, and other loss of functions.
Further information was reported in the May 31st, 2013 issue of the Prostate Cancer Foundation NewsPulse, and a special May 15th bulletin from the Prostate Cancer Research Institute (PCRI). Additional information including a video from Duke University describing the potential role of Xofigo in the overall sequence of prostate cancer treatment was published in the June 28th, 2013 issue of the PCF NewsPulse. Patients who are interested in finding out where and when Xofigo will be available can call 1-855-696-3446 (1-855-6Xofigo) or visit the website http://xofigo-us.com/index.php.
I recently learned of a good friend who has asymptomatic but metastatic prostate cancer which was being controlled by intermittent androgen deprivation (hormonal) therapy. One of the potential side effects of such therapy is the risk of osteopenia and the more serious condition, osteoporosis. Osteoporosis and the processes involved in breaking down bone (resorption) by cells called osteoclasts and generating new bone from osteoblasts are described clearly and briefly in the April 6th, 2013 issue of the Johns Hopkins Hospital Health Alerts. Patients on hormonal therapy are advised to have annual bone density tests known as dexa scans wherein bone density is measured in the lumbar spine and the hip femoral neck. Such patients also usually take bisphosphonates such as Boniva or Fosamax among others to minimize the bone depletion which often accompanies hormonal therapy. Since bisphosphonates also have some potential side effects coinciding with their long term use, my friend was advised not to take bisphosphonates (specifically Boniva) for a year and observe any effect on his bone density. After one year, the dexa scan showed a dramatic and very significant reduction in his bone density especially in the lumbar spine. He was then placed on a relatively new medication called Prolia (formerly called denosumab) which had been approved in 2011 by the U.S. Food and Drug Administration for use in prostate cancer patients whose cancer had not yet metastasized to bone in addition to other cancer patients.
Prolia works differently from the class of bisphosphonates such as Boniva by specifically binding to RANKL, a transmembrane or soluble protein essential for the formation, function, and survival of osteoclasts, the cells responsible for bone resorption. Prolia thereby prevents RANKL from activating its receptor, RANK, on the surface of osteoclasts and their precursors. Prevention of this RANKL/RANK interaction thereby inhibits osteoclast formation, function, and survival, thereby decreasing bone resorption and increasing bone mass and strength. Prolia is administered as a 6-month. sub-cutaneous injection.
The moral of this anecdote is that prostate cancer patients undergoing androgen deprivation (hormonal) therapy need to consistently monitor and maintain their bone densities using appropriate medications such as bisphosphonates or Prolia and should also engage in regular exercise regimens to maintain bone strength.
This communication is long overdue. Recently, this website has surpassed 115,000 hits. Two years ago, I would have never imagined I would write this blog post, but I write it with an overwhelming sense of gratitude to God, to my physicians, to my supportive and loving wife and to those of you who have visited this site. How did I get to this point? Please allow me to review highlights as it unfolded. In addition to writing this post for website readers, I also write this to myself as a remembrance and review of past challenges, blessings and lessons learned.
In 1994, at the age of 53, I was experiencing typical middle-age BPH problems usually associated with an “enlarged” prostate gland. My PSA consistently ranged between 3.5 and 4.5. A biopsy in 1994 showed no cancer. However, an ultrasound showed that my prostate was not enlarged. It occurred to me that a medium-smaller prostate gland would be expected to produce less PSA but my gland seemed to be producing too much PSA for its size and that troubled me. About that time, I learned that a measurement referred to as PSA density (the amount of PSA per unit volume of the gland) was being used as one criterion for performing biopsies. My PSA density of 0.23 led to a second biopsy at Johns Hopkins Hospital in October, 1995. The biopsy revealed cancer on the right side only. So in December, 1995 at the age of 54, I underwent a successful radical prostatectomy. My Gleason score was 6 (3+3) and my stage was T1C. Margins and lymph nodes were negative for tumors. Physicians informed me that my cancer was detected so early that “if they couldn’t cure me, they couldn’t cure anybody.” I was fortunate to have very few resulting side effects from the surgery which I found I could easily live with. In the intervening years, I had been anointed with oil for my healing (according to James 5:14-15), and had experienced the most dramatic personal experiences with God and Jesus Christ which are described in the January 11th, 2004 and March, 2005 entries on my website narrative. And so life continued for seven (7) years until November, 2002 when the PSA no longer became “undetectable” indicating some cancer still resided in my body. Subsequent radiation therapy in 2004 did not eradicate all of the cancer. Following the course of radiation, my PSA doubled every three months or so, a factor which still troubles my physicians and seems to indicate an aggressive perhaps genetically-modified cancer. Since 2006, I have been on intermittent hormonal therapy which eventually decreased my PSA to undetectable levels while resulting in very manageable side effects. The return of the cancer was devastating and shook the foundations of my faith but intervening events have resulted in a spiritual maturation which could not have occurred by other means. It is noteworthy that the Bible states that the purpose of trials is to “perfect” our faith. My day-to-day spiritual journey prompted my surgeon to suggest I chronicle them in a book about spirituality and prostate cancer but after keeping a diary of my experiences, God had other ideas and the website was born. At the beginning of this journey, I could anxiously anticipate becoming resistant (refractory) to hormonal therapy, followed by chemotherapy and its notorious side effects and then a painful death. However, the last years have produced a dramatic change in this potentially unpleasant scenario with the availability of new treatment regimens resulting from the approval of a number of therapeutic agents such as Zytiga and Provenge among others which has brightened my personal outlook and those of other prostate cancer survivors overwhelmingly.
But the website is called Godandprostate.net. What does God have to do with all of this? Had God not allowed the cancer to return, I would have never written this website. We must look beyond our own experience to focus on the big picture of what God is going to do. I am not the same physical, mental or especially spiritual being I was in 1995. I also would have not learned many lessons. We just celebrated the Easter season. The most intense suffering ever recorded was that of Jesus in the Garden of Gethsemane. He knew that by bearing the sins of everyone whoever lived and the penalty thereof, He was about to endure a gruesome crucifixion but in addition, He would experience the full force of God’s wrath, anger and separation. Jesus’ most earnest prayer to His Father God was to plead with God that He “take this cup from me”, loosely paraphrasing, “if possible I’d rather not experience the isolation, pain and suffering involved in paying the penalty for the combined sins (past, present and future) of all mankind; but if I must, then “not My will but Thine be done.” May Jesus’ Gethsemane experience be our example in times of trouble as with prostate cancer. May we have that same intimate and personal relationship with God as Jesus did, trusting God fully and accepting His perfect will for whatever the outcome may be.
A Christian bishop visiting the US from Africa was asked to compare the differences between the church in America with that in Africa. He cited the title of a familiar hymn entitled “Blessed Assurance” when he said, “In America you have ‘blessed insurance’ while in Africa, all we have is ‘blessed assurance'”. The deepest knowledge of God comes from those who have had to trust Him the most. As the ancient Job exclaimed, (see Job 13:11-19), “though He slay me, yet will I trust Him.” My own trust journey is still evolving. Instead of placing confidence in plans and medical scenarios of my own making (though I believe that God still heals cancer today according to His will), we are called to be available for God’s purpose (be it a website or other possibilities) and to trust God when He leads. We may never understand why God does what He does, but if we know Him and believe Him, that is all that is necessary. May we learn to know and trust Him for who He is. This trust journey is predicated upon having a personal relationship with God only available through His Son, Jesus who clearly proclaimed “I am the way, the truth and the life, no one comes to the Father but through me” (John 14:6).
Through the years, worry and anxiety have been problematic for me in spite of my memorization of Philippians 4:6-7 (below) which tells me clearly to “be anxious for nothing.” We all have needs, concerns and desires and the Bible teaches that God knows them all. But He commands us not to worry. Consider the following. Would God ever command us to do something and then not enable us to do it? Absolutely not! As Christians, we are called to live a life of faith; believing God’s promises even when our circumstances confound us and troubles surround us. He wants our trust and if we allow Him, He will prove that worry is unnecessary. Therefore we can put our full confidence in the words of Philippians 4:6-7,which admonishes us to “be anxious (careful) for nothing, but in everything by prayer and supplication with thanksgiving, let our requests be made known to God. And the peace of God that passes all understanding shall guard our hearts and minds in Christ Jesus.” We can all bring our anxiety level down by remembering and trusting in the fact that Jesus paid the once-and-for-all price for our sins. Having this assurance and the gift of eternal life, calms our spirits, worries and cares that often plague us. We can now live as if on an island where time and aging are no object. Knowing that our future contains a promise from God of a new cancer-free body, in a new heaven and new earth for a never-ending period of time, we can savor our earthly time with family and friends, enjoying and using it to glorify and praise God in all we do and experience.
Dr. Joseph Stowell, a college president has recently stated that when we look back on our lives, we can all see that it has its seasons depending on our ages, circumstances, health status and abilities. As life’s seasons change and we age, we are often uncertain or fearful as to what they might hold for us. As with every season of life, we have to make a choice. We can waste the season in fearful thoughts or as the apostle Paul says in Ephesians 5:15-16, we should make the best use of the time, “walk circumspectly, redeeming the time because the days are evil.” Regardless of our season, we can count on God’s faithfulness. He says “I will never leave you nor forsake you.” We can confidently say “the Lord is my helper, I will not fear.” (Hebrews 13:5-6.) Because we have God’s protection and provision, we can make the most of our time in every season by following Jesus closely, spending time with Him in His Word and prayer, loving and forgiving more freely than ever before, and serving others with joy and generosity. God has blessed us with our present season of life – make the most of it. If we have a personal relationship with God through His Son, Jesus, then regardless of our present trials or triumphs, we can embrace the following truths as encouragement for all seasons of life. 1) God will be faithful to us because that is His very nature. His “mercy is in the heavens and His faithfulness reaches unto the clouds.” (Psalm 36:5.) 2) God knows all about our situation. We are never alone in any season of life (Psalm 139:7-12). 3) God is omnipotent, so He has the power to meet every single need. He knows how to move us through the various seasons of life. Romans 8:28 promises that “all things work together for good to them that love God, to them that are called according to His purpose.” We will all change with the passage of time and our seasons will change but our wonderful God and His Son Jesus are always the same. God won’t fail us, waver on us and won’t vary- we can fully rely on Him. He will never forget about His own- great is His faithfulness.
So what does my future look like? It has been eighteen years since I was diagnosed with prostate cancer. We humans don’t learn lessons when times are good, but we learn best in times of crisis. Will I outlive my cancer and die of another cause? I pray this will be the case or that Jesus will return as He promised and take His children home. But I can now say with more conviction than ever before “may God’s perfect will be done. I must look beyond my own experience to focus on the big picture of what God is going to do. In fact my recent health checkup revealed that my general blood test results have never been better in my life. Isn’t that just like God???? Lastly, we hear daily of “viral” internet stories and videos which result in millions of “hits”. I am personally overwhelmed and gratified for the interest in the relationship between God and prostate cancer which has led to 115,000 hits for this website. We who have experienced prostate cancer share a special bond. May we continue to “redeem the time” we have remaining in our earthly lives, serving God and those around us with an eternal perspective, focusing on fulfilling, joyful experiences.
P.S. Lots of new medical news; more blogs to be written in the very near future.
For a newly-diagnosed prostate cancer patient, the three most important initial parameters are the blood levels of prostate-specific antigen (PSA) and its rate of increase, the biopsy-based Gleason score that ranks a tumor’s aggressiveness, and the clinical stage of the tumor based on its physical appearance. In the early 1990’s, Dr. Alan Partin, currently director of Urology at the Johns Hopkins Hospital in Baltimore, MD, formulated the Partin Tables using data comprised of the three parameters above as a statistical modeling tool to predict the stage of cancer spread at the time of performing a radical prostatectomy and to assess the chance of a surgical cure. These tables were based primarily on data from men treated in the 1980’s who often were diagnosed with later-stage cancers. The tables have recently been updated with data from over 5,000 men treated at Johns Hopkins between 20o6-2011 and published in the British Journal of Urology International. The revised study found that men treated during this period were more likely to be diagnosed before their PSA had risen significantly and were more likely to have a Gleason score greater than six (6) at the time of biopsy. According to Dr. Partin and his colleagues, the updated Partin Tables show that “surgical cure may be possible for a greater percentage of men especially those whose Gleason scores (such as 8) put them at the high end of intermediate risk.” The updated tables also found that the majority of men who are diagnosed prior to surgery with intermediate Gleason scores of 6 or 7 had a very low (less than 2%) risk of having prostate cancer spread to surrounding lymph nodes. These terms are defined and discussed in more detail in an article published in the January 2013 issue of NewsPulse from the Prostate Cancer Foundation.
The Johns Hopkins Prostate Disorders Health Alerts recently published (Feb. 14th, 2013) a short article defining the terms used in the TNM (tumor, nodes, metastasis) staging system used to define a cancer’s clinical stage or how far it has spread. The TNM prostate cancer staging system is a predictor of the extent of the disease and is useful in choosing the best course of treatment.
A related study describing the effects of exercise on prostate cancer survival was recently published in the Journal of Clinical Oncology and summarized in the January 24th issue of the Johns Hopkins Prostate Disorders Health Alerts. Data was received from 2,705 men followed for a period of 18 years. The study concluded that any type of regular exercise improved overall prostate cancer survival regardless of the intensity of the exercise. However, men who took part in vigorous activity, defined as at least three hours of intensive exercise per week, had a significantly lower (61%) risk of dying from prostate cancer.