December 2016 – God And Prostate

Two-drug combination boosts survival in patients with metastatic, hormone-sensitive prostate cancer

Patients with newly diagnosed metastatic, hormone-sensitive prostate cancer gained a dramatic survival benefit with simultaneous initiation of two drugs, rather than delaying the second drug until the cancer began to worsen, according to results of a clinical trial recently published in The New England Journal of Medicine (2015; doi:10.1056/NEJMoa1503747).

Patients who underwent six cycles of treatment with docetaxel® (taxotere) along with a hormone blocker survived for a median of 57.6 months, more than 1 year longer than the median 44-month survival for men who received only the hormone-blocker. The immediate combination also prolonged the period before the cancer began to worsen, to a median of 20.2 months vs 11.7 months with the single agent.

The multicenter, phase III trial, involving 790 patients, “is the first to identify a strategy that prolongs survival in men [with] newly diagnosed with metastatic, hormone-sensitive prostate cancer,” said Christopher J. Sweeney, MBBS, of Dana-Farber’s Lank Center for Genitourinary Oncology in Boston, Massachusetts. He said the results of the multicenter phase III trial should change the way doctors have routinely treated such patients since the 1940s.

Sweeney had reported initial results of the trial in June 2014 at the annual meeting of the American Society of Clinical Oncology (ASCO), and they were so favorable that the new regimen has been adopted by some physicians. Since then, confirmatory data from the STAMPEDE trial were presented at the 2015 ASCO meeting, and those results, along with the new publication in the New England Journal of Medicine, are the final pieces “required for treatment guidelines to be updated around the globe,” Sweeney said.

The standard practice for decades has been to treat this group of prostate cancer patients with hormone blockers; chemotherapy is withheld until the hormone blockers become ineffective, which they do, on average, in approximately 3 years.

The new trial was designed and conducted by the ECOG-ACRIN Cancer Research Group to test Sweeney’s hypothesis that adding chemotherapy to hormone treatment from the start would impair the tumor cells’ ability to repair damage, delaying the development of resistance.

An Excellent Review of Current Imaging and Positron Emission Tomography (PET) Scanning and Their Use in Managing Recurrent and Advanced Disease

This website initially posted a review of positron emission tomography (PET) scanning on March 9th, 2015.

More recently, the Prostate Cancer Research Institute (PCRI) November Insights contained an updated and very informative review of the latest PET imaging techniques for managing recurrent and advanced prostate cancer. Their major utilities, advantages and their limitations are discussed clearly. The review was written by Dr. Fabio Almeida, Medical Director of Phoenix Molecular Imaging in Arizona. Rather than summarize the entire readable review, I will merely mention the various sections herein and provide the following link to the entire review.

In the November article, conventional types of imaging such as ultrasound, CT scans and prostate MRI and their uses are discussed initially. A section describing detection of bone metastases using Technetium-99 and sodium fluoride PET/CT scans follows. Carbon-11 acetate (available at Phoenix Molecular Imaging, Arizona) and C-11 choline (available at the Mayo Clinic, MN) are lipid metabolism PET agents both of which are useful for detecting recurrent disease and PSA relapse. In both cases, detection rates were dependent upon PSA values and doubling times.

Axumin (18F-FACBC) is a fluorine-18 radiolabeled synthetic leucine amino acid was has been recently approved by the FDA for detection of recurrent cancer in men with rising PSA after previous surgery or radiation. Amino acids are absorbed into cancer cells because of the increased metabolic demands of the growing cancer. In cited studies, optimal detection rates were seen when PSA levels were above 1.78. Direct comparison with C-11 choline scans indicated better performance for Axumin. For additional information on Axumin, see the website blog dated May 30, 2016.

The prostate-specific membrane antigen (PSMA) is a transmembrane glycoprotein that occurs much more commonly in prostate cancer cells compared to benign prostate tissue. One of the PSMA agents under development is 68-gallium-PS-MA-11, which has demonstrated a higher diagnostic efficiency compared to C-11 choline. Detection rates were dependent on PSA values. For example, a 93% detection rate was observed when the PSA was over 2.0 but only 50% when the PSA was 0.2-0.5. There are limitations to PSMA-targeting agents. Not all prostate cancers exhibit PSMA overexpression. In one study, about 8% of prostate cancer patients did not show PSMA overexpression. Benign lesions and several other types of cancers may also exhibit increased PSMA expression. False positive celiac lymph nodes have frequently been noted in the upper abdomen and detection of small locally-recurrent lesions and lymph nodes in the lower pelvis is challenging.

There is still no perfect imaging methodology with 100% accuracy. However, PSMA-targeted agents are becoming the major focus of future attention and development. “Despite some limitations, PSMA-targeted imaging appears to provide high sensitivity and specificity and is likely to become part of the routine evaluation and management of men with prostate cancer in the near future.”

For an initial review of PET imaging, see this website post dated October 9th, 2012.

How to Find an Expert Prostate Surgeon

Radical prostatectomy can be a very difficult operation. The very best urological surgeons specialize in the prostate gland. They do a lot of these procedures annually. How do you find the right surgeon? The Prostate Cancer Foundation has published a checklist of things to consider before choosing the right surgeon.

1) First, locate a high-volume center that performs a lot of these procedures. Often this is an academic center. Not only are surgeons involved but supporting teams e.g. nursing, specialize in caring for prostatectomy patients. Websites that can help locate such high-volume centers include the National Cancer Institute’s website namely http://www.cancer.gov/research/nci-role/cancer-centers/.

The National Comprehensive Cancer Network (NCCN) also has a useful website for all types of cancer including prostate. See the following web address, https://www.nccn.org/patients.

2) Look for a place where different specialties work together in multi-disciplinary teams such as urology, radiation oncology, medical oncology and pathology. Since prostate cancer is not a “one size fits all” condition, one can get opinions from a team of experts who may recommend treatment modes other than surgery.

3) Ask the surgeon about his patient results. Does he keep results of his many patients regarding their outcomes, side effects such as incontinence and/or impotence, cancer recurrences, etc? Come prepared with a list of questions to ask as well as a detailed description of your specific condition and hopes.

4) Ask the surgeon to provide you with names of his patients who have agreed to speak to other patients about their experiences. If possible, contact some of them. This is helpful in demonstrating that the surgeon has many “happy” patients who comprise a support network to help prospective patients decide what’s best for them. Also check the prostate cancer support groups in your area and ask these men about their experiences and specific surgeons.

5) How many radical prostatectomies has the surgeon performed? The answer should be in the hundreds. If it’s something like “quite a few”, seek elsewhere.

6) Ask more than one doctor to recommend the best prostate surgeon in your area. Some doctors are in practice groups and therefore recommend the specialist in that group. That’s why it is good to ask different doctors in different practices.

7) Beware of the reviews or ads on the internet. The internet is full of false accusations or glamorization of surgeons, and specific hospitals and departments. One urologist said that online reviews are totally unreliable. This is not “Angie’s List of plumbers.” Medical groups or individual physicians may have ulterior motives or “good urology friends” who may or may not be the best choice for you.

8) Don’t worry about offending the doctor with questions or by getting a second opinion. Don’t be rude or disrespectful but don’t feel intimidated either. Do your homework. It’s your prostate and your recovery and your life. You don’t want to be one of those men who say afterward “I wish I had listened to good advice; my surgical experience was not as good as I had hoped.”

The Trap of Discouragement

St. Mark's Church, Petersville, MD Photo BJ Gabrielsen — St. Mark’s Church, Petersville, MD
Photo BJ Gabrielsen

Do you ever feel as if you are stuck in discouragement? Do you feel that you are facing a condition (such as prostate cancer) alone and that God Himself and family or friends truly do not understand your situation? If so, you are not alone. In the Old Testament biblical book of the prophet Habakkuk, the prophet writes “how long O Lord, will I call for help and You will not hear? I cry out to you…., yet You do not save.” (Habakkuk 1:2).

At some point, everyone experiences dashed hopes. Perhaps a PSA test did not produce the result you had hoped for or as in my own case, a cancer detected early and removed surgically returned (a biochemical recurrence) dashing hopes for a quick cure. Disappointment – an emotional response to a failed expectation – is the normal initial reaction. But allowed to linger, it can turn into discouragement, which hovers like a dense cloud. When that’s the case, there is no sense of joy or contentment regardless of what you do.

The circumstances that trigger these emotions may be unavoidable, but how we as men respond to them is a choice. Either we can let sadness overwhelm our soul or we can face the situation with courage and bring it before the One who can help.

Living in discouragement will divide the mind, making it hard to focus on anything besides our pain, apprehension and dashed hopes. Then as anger becomes habitual and desired results do not happen, we may blame ourselves or God Himself.

Frustration and disappointment that isn’t handled well may develop into despair, which in turn can estrange us from those around us who do not enjoy the company of someone who is bitter and defeated. Finally, in the fog of discouragement and isolation, we can make poor decisions, attitudes and actions based on crushed emotions and expectations instead of truth. Obviously, this self-destructive path is NOT God’s best for us.

Though we all face disappointment from time to time in many areas not just those that are health-related, those whose faith is in God and His Son Jesus are not to wallow in it. Instead, God wants us to trust Him with everything – even unmet expectations and deep sadness. Remember to us as God’s children, there is a divine purpose for everything He allows to touch our lives. As Romans 8:28 states, “and we know that God causes all things to work together for good” (even if we don’t see it at the time), to those who love God who are called according to His purpose.” For everything that was written in the past was written to teach us, so that through the endurance taught in the Scriptures and the encouragement they provide we might have hope”. (Romans 15:4).

If you cannot relate to these admonitions, or if you are unsure that you have a personal relationship with God and therefore cannot trust Him, you can know Him intimately. See the following link.

(A portion of the text above was excerpted from the July 11th, 2016 In Touch devotional written by Dr. Charles Stanley.)