According to a recent Canadian study, if your doctor suspects you may have prostate cancer because of an elevated prostate-specific antigen (PSA) level, you might want to ask for a repeat PSA test to confirm the results. It could save you from undergoing an unnecessary prostate biopsy that could entail serious complications. Of 1,268 men who underwent a second PSA test within three months of their first test showing elevated PSA levels, 315 (24.8 percent) had normal results the second time around. As a result of their finding, the researchers recommend that men with elevated PSA levels should repeat the test before undergoing a biopsy. The American Urological Association echoes this recommendation. Elevated PSA levels may result from infection, physical activity or sexual activity. Other studies revealed that only 16 to 56 percent of primary care physicians ordered a repeat test for patients with abnormal PSA results. Most experts agree that PSA screening should be used in conjunction with a digital rectal examination, and additional information such as family history, race, and age to assess the likelihood of prostate cancer being present. The information presented here came from the Mayo Clinic Proceedings, published online in December, 2015 and re-printed in HealthAfter50, Scientific American Consumer Health.
I published a blog on Feb. 17th entitled, “If You Want to Hear from God, Be Still”. This is one of the most important blogs I have written. The post on the website looks fine but when I received an e mail of it, parts of it were too large and missing. Until I resolve the issue, please go to the original site, http://www.Godandprostate.net, and click on the February 17th post on the homepage. I am linking it here. Sorry for the problem.
If you are like me, we often pray to God about our health status, specifically our prostate cancer. It is indeed an amazing privilege to have that personal relationship with God the Father through faith in His Son, Jesus Christ and be able to bring our needs, anxieties, fears and uncertainties, to God Himself and seek His wisdom, healing, love, security, comfort and specific plans for us. But how do we hear His response? If you were seeking advice from a trusted friend, would you simply keep talking without stopping to focus on their response? The answer is found in Psalm 46:10, “be still” or “cease striving” and “know that I am God.” The Hebrew word translated “be still” can also be translated “become helpless”, “collapse”, “cease”, “fall limp” and “relax”. The sense is to stop striving. Personally in my haste to prayerfully communicate my thoughts to God, I have to stop, clear my mind, be silent, shut off external stimulii, and ask God humbly “what would You have me to hear?” The command to “be still” calls us to totally silence ourselves and listen to God often in the face of great turmoil. In Psalm 46:1, we are also reminded that God is “our refuge and strength, a very present help in trouble.” When we learn to practice silence before God, we position ourselves to listen carefully to Him. We purposely quiet ourselves so that we are in a listening mode. We turn away from the constant chatter of our minds and digital world in order to grasp the mysterious ways God speaks to us when we turn our attention fully to Him.
But what of we are not sure if we even have a personal relationship with God? If I wanted to enter the White House, I’d need to know someone. In a way, we need a “pass” to obtain entry into the presence of a holy God. Not one of us is good enough on our own to do so. He is perfectly holy and righteous and perfectly just in all He does. We certainly are not. But when we accept by faith God’s offer to credit us with Christ’s righteousness, we have a “pass” that allows us to “approach the throne of grace with confidence, so that we may receive mercy and find grace to help us in our time of need” (Hebrews 4:16). We don’t have to worry about earning that grace; Jesus did it once and for all at the cross. Do you really want to hear from God personally? First you need a “pass” and His name is Jesus. Then express your praise, thanks and needs, and “be still” or otherwise translated “cease striving” and “know that He is God.”
Portions of the above were adapted from two February 16th, 2016 devotionals; “Today in the Word”published by the Moody Bible Institute, Chicago, IL and from “Anchor”, a devotional from Haven Ministries, Riverside, CA. The latter was written by a man currently serving a 6-year Federal prison sentence.
Us TOO was founded by—and continues to be governed by—people directly affected by prostate cancer. They are a nonprofit established in 1990 that serves as a resource of volunteers with peer-to-peer support and educational materials to help men and their families/caregivers make informed decisions about prostate cancer detection, treatment options and related side effects. Their website is http://www.ustoo.org/home.
A new Canadian study has concluded that men with organ-confined prostate cancer are more likely to survive if they have surgery rather than radiation therapy. The authors of the study analyzed data from 19 previous studies involving 119,000 men with localized cancer. Findings from fifteen (15) of the studies showed that those who received initial radiation therapy were twice as likely to die from prostate cancer as those who had surgery. Findings from ten (10) of the studies also showed that men who had radiation therapy were 50% more likely to die sooner of any cause, compared to those who had surgery. The results of the study analyses were published on Dec. 14th, 2015 in the journal European Urology.
The authors add however that “prostate cancer treatment is never a one-size-fits-all matter.” There are times when radiation therapy may be more appropriate than surgery so it is vitally important that a patient discusses treatment options with his physician. It is also noted that radiation is still possible as a secondary treatment after surgery. So patients have yet another way of combating their cancer if necessary. In addition, a radiation oncologist pointed out that this review may not have accounted for recent improvements in radiation therapy that could boost patient outcomes. For an additional reference, see the December 29th edition of Prostate Cancer News Today (linked).
Current tests to initially detect prostate cancer rely on biopsies. Scans such as bone and CT scans, and choline-11 and acetate-11 PET scans are used to identify sites of cancer metastases. Researchers at Thomas Jefferson University have now developed a new imaging technique to detect prostate cancer cells and malignant lesions. Their technique is both highly accurate and more effective than current detection methods. Details of their imaging technique (see link) entitled “VPAC1 Targeted 64Cu-TP3805 Positron Emission Tomography (PET), were recently published in the journal Urology. The novel copper-peptide (small protein) imaging agent 64Cu-TP3805 attaches itself to VPAC1 receptors on the surface of cancer cells. The TP3805 peptide portion of the agent hooks on to the cell receptors and the copper-64 radiation-emitting peptide allows their detection by PET-CT scanning. The technique was tested on 25 prostate cancer patients undergoing radical prostatectomies. Compared to conventional biopsies, this technique found 105 out of 107 cancerous lesions in the removed prostates as well as nine lesions not found by conventional pathology. Positive and negative lymph nodes, cases of benign prostatic hyperplasia (BPH), and cysts were also identified. Larger studies are planned.
The following is an excerpt from a January 12th, 2016 blog called Prostate Snatchers by Mark Scholz, M.D.
The latest craze in medical technology is genetic analysis of tumor cells (GAT). “The scientific progress that has been made with GAT in my opinion is the second most exciting area of advancement in medical technology today (see below for more about the first most exciting area).” GAT technology is already being commercialized for use in the medical marketplace in products like Prolaris and Oncotype. (For a review of both, see Godanprostate.net November 27,2015 post). These technologies are able to predict the aggressiveness of prostate cancers, enabling us to differentiate between the men who need immediate treatment and those who can postpone treatment safely.
“The predictive power of GAT is certainly exciting, but there is already an effective form of genetic testing available that has been around for more than 40 years, the Gleason scoring system. The Gleason system relies on the visual appearance of cells under the microscope to draw conclusions about their inner genetic makeup. In the medical world, using the visual appearance of the cancer cells is called phenotypicanalysis. GAT is genotypicanalysis.”
“So how can Gleason score draw conclusions about the underlying genetic potential for tumor aggressiveness simply by looking at the appearance of cells under a microscope? The answer is to do a comparison of the visual appearance of cancer cells with the appearance of normal prostate cells. Normal cells in the prostate perform varied functions but still work together as a team. Specifically, healthy cells form into definable structures called glands. In these glands some cells manufacture prostatic fluid, a complex liquid comprising the ejaculate for the sperm to swim in. Other cells organize to form ducts, a piping system to drain the fluid from the outer periphery of the gland and channel it into the middle of the prostate so that a large quantity of fluid can be expelled through the urethra at just the right moment. All of these different cells work as a team and coexist in the prostate functioning together in a structured glandular arrangement.”
“When a trained pathologist looks at tumor cells under the microscope he grades them by the degree of cellular disorder. He is asking himself the question, ‘How much do these cells retain the normal glandular characteristics of the prostate gland?’ If a cross section of the tumor looks like an unbroken sheet of uniform cells, the cancer is high-grade; the cells have lost their ability to cooperate with each other and form glands. The cancer cells have been honed down into little race cars with only one mission, to aggressively pursue its own replicative destiny. When tumors have this appearance they are graded as a Gleason 9 or 10. On the other hand, if the appearance of the tumor shows residual glandular components, it is less aggressive, perhaps a Gleason 7.” Gleason 6 cancer looks almost like normal prostate gland tissue.
“Predicting future tumor behavior is obviously very important. How fast will it grow? Is it likely to spread? How well can it be expected to respond to treatment? As a result of decades of experience, doctors have learned to use the Gleason scoring system to accurately predict the long-term outcome in individual patients. The new GAT tests represent an important additional refinement, further enhancing our ability to predict the future behavior of an individual cancer. GAT holds one even bigger promise. In the future we believe GAT testing will be a powerful aid in the selection of targeted therapy, i.e., picking cancer treatments with anticancer activity tailored to individual tumor types. This hope, however, will have to be postponed until our limited armamentarium of effective treatments is further expanded.”
“Now, what is it that I” (Dr. Scholz) “consider to be the most exciting area of medical progress? Since I am an impatient type of guy, someone who is looking for quick results, I find immunotherapy more exciting than GAT. To fully exploit the potential of GAT we will need to invent new pills for each of the myriad of genetically different tumor types. Immunotherapy on the other hand comes with its own ‘built-in’ GAT system that enables it to target the unique genetic signature of individual cancer cells. The immune system is so smart, all we have to do is ‘flip the switch on’ and starts cranking out genetically targeted anticancer therapy. Recent developments in the field of immunology are truly mind-boggling and hold promise for a big revolution in cancer therapy within the next 5-10 years.”
In a study presented at the January 2016 meeting of the American Society of Clinical Oncology (ASCO), researchers from Harvard’s School of Public Health concluded that “men with prostate cancer who took aspirin regularly after diagnosis had a significantly reduced risk of death.” Taking aspirin more than three times a week was associated with a 39% lower risk of dying from the disease compared to men who reported less frequent aspirin use. The study evaluated data from 22,071 men who took part in the Physicians’ Health Study and who were tracked from 1982 to 2009. Taking aspirin prior to a prostate cancer diagnosis was not shown to be beneficial as “aspirin use did not appear to affect the risk of prostate cancer development or rate of diagnosis. It also did not affect the frequency of diagnosis of high-grade cancer or locally advanced cancer. But it was proposed that in addition to its cardiovascular benefits, “regular aspirin use may inhibit lethal prostate cancer possibly by preventing cancer progression.” Regular use was associated with a 24% lower risk of developing lethal prostate cancer. It was noted that a recommendation to begin aspirin regimen solely for prevention of lethal prostate cancer is not warranted based on this study alone. More work is needed to identify the particular subsets of men most likely to benefit from aspirin and to determine the optimal aspirin dose. It was also learned that the results seen with aspirin did not extrapolate to the use of celebrex. For more details, see the following link.
Developing an accurate prognosis, i.e., predicting how a man’s cancer is likely to behave in the future, is the first and most important step toward optimal care. Future predictions are often looked at with some suspicion. With prostate cancer, however, our power to anticipate future cancer behavior is quite accurate unless there is a lack of thoroughness in gathering information. One system designed to evaluate the risk of prostate cancer recurrence following localized treatment was formulated in 1998 by Dr. Anthony D’Amico. For a summary of the D’Amico system, see this link.
The Size of the Tumor
Tumor size is a universally important prognostic sign for almost all types of cancer including prostate cancer. The method for incorporating tumor size into the Anthony D’Amico’s staging system relies on the degree of PSA elevation, the tumor grade and on how the prostate “feels” with the finger of a trained practitioner. These indicators are useful but don’t incorporate information from modern imaging. Imaging provides accurate information about tumor size and the presence or absence of extracapsular extension. These are very powerful prognostic predictors and it would be foolish to disregard their importance. As things stand presently these indicators are often used to divide the low, intermediate and high risk D’Amico categories into “favorable” and “unfavorable” subcategories, each with a different spectrum of recommended treatment options.
Knowing Past Treatments Tells Something about Future Prognosis
Historically, since the total number of available treatments is relatively limited, practitioners have used a sequential “trial and error” treatment methodology that administers the standard treatment options in a fairly predictable sequence. For example, it is not uncommon for men to start with surgery or radiation. When a relapse occurs, standard hormone therapy (Lupron) is often started and given intermittently or continuously. Hormone therapy usually controls the disease for an average of 10 years. When Lupron stops working, immunotherapy with Provenge may follow. After Provenge, more potent hormone therapy with Xtandi or Zytiga is started. If these two agents prove ineffective, chemotherapy with Taxotere (docetaxel®) or radiation with Xofigo would be considered next. The whole point of presenting the treatment sequence described in this paragraph is to convey the idea that the number of previous treatments communicates important information about that patients’ future prognosis. Having “failed” Lupron, for example, bespeaks of a much more worrisome prognosis compared to the situation where Lupron continues to be effective.
Response to Lupron, The Mother of All Metrics
The quality of the “response” to Lupron is actually one of the most powerful prognostic metrics available. The degree of PSA decline after Lupron is incredibly important. How low the PSA drops after starting Lupron is called the “PSA nadir.” The specific PSA threshold used to determine a “good response” is less than 0.1. Believe it or not, there is a huge difference in prognosis between a man on Lupron for six months who has a PSA of 0.1 versus a man whose PSA levels off at 1.0.
An Established History is also a Prognostic Indicator
Another somewhat obvious prognostic indicator that is often overlooked and almost never discussed in textbooks has to do with the prognosis of men who have been diagnosed years ago — over time it is apparent that things are turning out much better than what might have been expected based on their initial indicators. For example, take the case of a man who started off with a panoply of bad indicators—tumor is in the lymph nodes and Gleason 10—but after aggressive treatment remains in remission for 5 years. The fact that things have gone well for five years counts big-time in his favor going forward. Remember, the original prognostic predictors of a Gleason 10 were just that, predictors. No predictor is 100% accurate. Five years of established history is a stronger predictor than the original Gleason score. The fact that things have gone well for five years, strongly indicates that the future is for that individual is bright. Such individuals may have “beaten the odds.”
The Location of the Tumor in the Body
Another extremely important indicator of prognosis, something that even laypeople anticipate by simple common sense, is the location of the cancer in the body. Location says volumes about how things are likely to progress in the future. For example, consider the following sequence of progressively more serious cancer sites:
•Contained within the prostate
•Extended into the seminal vesicle
•Spread to the lymph nodes
Each of these locations is very important for determining prognosis.
This short blog is just an introduction to some of the “profiling” methods utilized in generating an accurate prognosis. Space limitations preclude discussion here about other known prognostic factors such as the size of the prostate gland, genetic tests and PSA doubling time. The D’Amico risk categories constitute the backbone of useful prognostic information. However, the additional prognostic information beyond the D’Amico risk categories that are discussed in this blog, provide additional useful information necessary for determining an accurate prognosis. An accurate prognosis is the starting point for accurate selection of treatment.